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Introduction
A model is a representation to help us explain, understand and predict related
phenomena. Models range from simple analogies such as comparing memory
storage to storing books in a library (Baddeley, 1992) through to highly
complex systems such as connectionist modelling to explain how a damaged
system might learn new skills (Robertson & Murre, 1999).
In rehabilitation, models are useful in enabling us to conceptualise
processes, think about treatment and explain impairments to relatives and
patients. The working memory model (Baddeley & Hitch, 1974), the dual route
model of reading (Coltheart, 1985), the model of lexical processing (Patterson
& Shewell, 1987) and the face recognition model of Bruce and Young (1986)
have all been influential in helping to explain phenomena, predict strengths and
weaknesses and plan treatment for people with cognitive impairments.
All these models mentioned above originate from cognitive neuro-
psychology. Some believe that this field is the one where we should seek
Correspondenc e should be sent to Professor B.A. Wilson, OBE, MRC Cognition and Brain
Sciences Unit, Box 58, Addenbrooke ’s Hospital, Cambridge CB2 2QQ, UK. Tel: +44 (0)1223
355294, Fax: +44 (0)1223 516630, Email: barbara.wilson@mrc-cbu.cam.ac.u k
models for cognitive rehabilitation. Coltheart (1984), for example, said that
rehabilitation programmes should be based on a theoretical analysis of the
nature of the disorder to be treated. In 1991, Coltheart, went further. He said
that in order to treat a deficit it is necessary to fully understand its nature and to
do this one should have in mind how the function is normally achieved.
Without such a model, it is impossible to determine what kinds of treatment are
appropriate. In similar vein, Caramazza and Hillis (1993) say they are not
concerned with the question of whether cognitive models are helpful in rehabil-
itation for “surely they are, it is hard to imagine that efforts at therapeutic inter-
vention would not be facilitated by having the clearest possible idea of what
needs to be rehabilitated” (p. 218). Instead they are concerned with the potential
role of these models in articulating theoretically informed constraints on cogni-
tive disorders.
The purpose of this paper is to try to demonstrate that one model (or one
group of models such as those from cognitive neuropsychology ) are insuffi-
cient to (1) determine what needs to be rehabilitated and (2) plan appropriate
treatment for cognitive impairments. Models of cognitive functioning are
certainly not the only models to influence cognitive rehabilitation. Rehabilita-
tion is one of many fields that needs a broad theoretical base incorporating
frameworks, theories and models from a number of different areas.
affecting (1) the body, (2) activities, and (3) participation. In practice similar
principles apply to the new model as to the earlier ones, i.e., rehabilitation
efforts are directed at reducing limitations and increasing activities and
participation.
A model/theoretical framework for understanding compensatory behav-
iour. Compensation is one of the major tools for enabling people with brain
injury to cope in everyday life. Wilson and Watson (1996) described a frame-
work for understanding compensatory behaviour in people with organic
memory impairment. The framework was developed by Bäckman and Dixon
(1992) and further modified by Dixon and Bäckman (1999), it distinguishes
four stages in the evolution of compensatory behaviour, namely origins, mech-
anisms, forms, and consequences. Wilson (2000) went on to use this frame-
work to consider compensation for a variety of cognitive deficits. Evans,
Wilson, Needham, and Brentnall (submitted) investigated factors that predict
good use of compensations. The main predictors appear to be age (younger
people compensate better), severity of impairment (very severely impaired
people compensate less well), specificity of deficit (those with widespread
cognitive deficits appear to compensate less well than those with more specific
deficits), and premorbid use of strategies (those using some compensatory aids
pre-morbidly appear to compensate better).
This is an area where further work is required. If we can predict who is likely
to compensate without too much difficulty, we can target our rehabilitation to
help those who are less likely to compensate spontaneously.
Errorless learning. Errorless learning has, in recent years, become an
important aspect of memory rehabilitation although we do not yet know
whether this is the best method of learning for those with cognitive problems
other than memory.
As the name implies, errorless learning involves learning without errors or
mistakes. Instead of learning by trial and error, information is presented in such
a way to avoid or significantly reduce mistakes. First described by Terrace
(1963, 1966) in work with pigeons it was soon adapted for people with develop-
mental learning disabilities (Cullen, 1976; Sidman & Stoddard, 1967; Walsh &
Lamberts, 1979). A second impetus to errorless learning came from research
into implicit learning from cognitive neuropsycholog y (Baddeley & Wilson,
1994). In the 1990s research showed that people with severe memory deficits
learned better if prevented from making mistakes during the learning process
(Baddeley & Wilson, 1994; Clare, Wilson, Breen, & Hodges, 1999; Evans et
al., 2000; Glisky, 1995; Squires, Hunkin & Parkin, 1996; Wilson, Baddeley,
Evans, & Shiel, 1994; Wilson & Evans, 1996).
Baddeley and Wilson (1994) believed that errorless learning was effective
because it capitalised on the intact implicit memory skills of amnesic patients;
Squires, Hunkin, and Parkin (1997) argued that it capitalised on the residual
104 WILSON
appropriate environment, the person with brain injury, family members, and
rehabilitation staff should all be involved in the negotiating process. The main
goals may attempt to improve impairments, disabilities or handicaps. Although
there may be times or stages in the recovery process where it is appropriate to
focus on impairments, the majority of goals for those engaged in cognitive
rehabilitation will address disabilities and handicaps.
There is obviously more than one way to try to achieve any goal. Sometimes
we try to restore lost functioning, or we may wish to encourage anatomical
reorganisation, help people use their residual skills more efficiently, find an
alternative means to the final goal (functional adaptation), use environmental
modifications to bypass problems or use a combination of these methods.
Whichever method is selected, one should be aware of theories of learning.
In Baddeley’s words, “A theory of rehabilitation without a model of learning is
a vehicle without an engine” (Baddeley, 1993, p. 235). Evidence for the success
of these approaches also needs to be taken into account. The final question is
how best to evaluate success or otherwise. Consider Whyte’s (1997) view that
outcome should be congruent with the level of intervention. If intervening at
the disability level then outcome measures should be measures of disability and
so forth. As most rehabilitation is concerned with the reduction of disabilities
and handicaps, outcome measures should reflect changes in disability and
handicap. For example, how well does someone who forgets to do things, now
remember to do things? There are studies that directly assess such changes. For
example, a recent study evaluating the use of a paging system for reducing
everyday memory and planning problems (Wilson, Emslie, Quirk, & Evans,
2001), measured success in achieving everyday targets before, during, and after
the provision of a pager. This study demonstrated convincingly that pagers can
reduce the everyday problems of people with memory and planning problems
following brain injury. The final message of this paper is that it is possible to
combine theory, scientific methodology, and clinical relevance.
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Manuscript received January 2002