It was with some eagerness that I approached this book, which sets its task as an exploration of “the challenges of psychotherapy with the patient with stroke or brain injury”. Despite increased research interest in this field, in the form of a host of single case studies and the occasional randomised trial, there remains a lack of empirical evidence regarding the efficacy of psychotherapy with patients with brain damage and even less information as to how best to adapt our traditional forms of therapy.

The book is divided into four sections: background, history and ethical considerations; emotional factors and defensive functioning; interplay of psychotherapy and cognitive remediation; and specialist treatment applications for specific population needs. Early on, we are offered a guided tour of neuropsychology, in the form of a rather simplistic and associationist tale of two hemispheres. However, we are left in some doubt as to whether any of the cognitive impairments actually make any difference to the psychotherapeutic process which, according to certain of the contributors, could be conducted without regard to aetiology at all.

In subsequent chapters, the importance of distinguishing between emotional and cognitive sources of denial and compromised awareness is repeatedly emphasised, although the authors seem to share the belief that this can be accomplished solely on the basis of a dialogue with the patient. The reader is also left guessing as to how best to adapt standard psychotherapeutic techniques for patients in the light of these and other common cognitive disorders in areas such as memory and problem-solving. Excursions into the rehabilitation of cognitive deficits such as visual inattention, and primitive attempts to incorporate cognitive rehabilitation techniques (such as diaries and calendars) into the psychotherapeutic process do little to answer these questions.

My growing sense of pessimism about this book was alleviated, albeit temporarily, by a chapter on psychotherapeutic issues with members of the family. Frank Padrone presents a comprehensive and eminently readable overview of the stages of coming to terms with loss after brain damage, as well as some of the common defence mechanisms that may disrupt and delay the adjustment process. He stresses the importance of a flexible coping style in adjusting to disability and raises issues such as the meaning of the disability for the patient and the family. He also reminds us that even in adaptive, flexible family structures, there is the potential for misattribution and misperception of neuro-psychological impairments.

In summary, this text suffers from a lack of evidence-based research and a poor grasp of the relevance of certain neuro-psychological impairments to the psychotherapeutic process. The chapters do not hang together as a cohesive entity and, in general, fail to advance our understanding of the key diagnostic and treatment dilemmas in this field.