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Neuropsychological
Rehabilitation: An
International Journal
Publication details, including instructions
for authors and subscription information:
http://www.tandfonline.com/loi/pnrh20
Towards a
comprehensive model of
cognitive rehabilitation
Barbara A. Wilson
Published online: 22 Sep 2010.
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
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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.
structure of the spelling system (or the reading system, the naming system, the
sentence comprehension system, and so forth) which serves to constrain our
choice of therapeutic strategy. Merely ‘knowing’ … the probable locus of a
deficit … does not, on its own, allow us to specify a therapeutic strategy. To do
so requires not just a theory of the structure of the system, but also, and more
important, a theory of therapeutic intervention—a theory of the ways in which a
damaged system may be modified as a consequence of particular forms of inter-
vention” (Caramazza, 1989, p. 392).
This is not to say, of course, that models of cognitive functioning are unim-
portant. These models have been hugely important in identifying problems, in
explaining phenomena and in making predictions about behaviour. Take the
models of reading, for example. In the 1970s the neuropsychologica l assess-
ment of reading typically involved asking the person with brain injury to read a
list of words or some short passages. Since the work on models of reading
appeared in the 1980s (Coltheart, 1985) assessment has changed almost beyond
recognition. We now typically assess the ability to read regular versus irregular
words, parts of speech, words acquired at different ages, concrete versus
abstract words, highly imageable words versus difficult to image words and
real words versus nonsense words. These models tell us both where the
problem(s) lie(s) and what the cognitive constraints are on any programme we
wish to implement.
rehabilitation, for a number of years. One of the first to advocate these models
for adults with brain injury was Goodkin (1966, 1969). He worked with people
with motor and language problems. The 1980s saw published reports of these
approaches applied to cognitive problems (Diller, 1980; Ince, 1980; Wilson,
1981). Today the approaches are widely used in rehabilitation including cogni-
tive rehabilitation (see, for example, Alderman, 1996; Wilson, 1999). Behav-
ioural approaches provide a structure, a way of analysing cognitive problems, a
means of assessing the everyday manifestations of cognitive problems and a
means of evaluating the efficacy of treatment programmes.
In addition, these approaches supply us with many existing treatment strate-
gies such as shaping, modelling, desensitisation, chaining, flooding, extinc-
tion, positive reinforcement, response cost and so on, all of which can be
modified or adapted to suit particular purposes, problems and people.
Theories and models of recovery. If further recovery is expected in the
person with brain injury we need to know this before implementing rehabilita-
tion so that we can try to determine whether the treatment or recovery is respon-
sible for any change in behaviour (Wilson et al., 2000). Although natural
recovery can sometimes be ruled out by ensuring there is a stable baseline prior
to treatment, theories of recovery are helpful in understanding what may be
happening to the people we are working with. Recovery in the first few minutes
after an insult to the brain probably reflects the resolution of temporary
dysfunction with accompanying structural damage. Recovery after several
days is likely to be due to the resolution of temporary structural abnormalities
such as vascular disruptia or oedema, or to the depression of metabolic enzyme
activity. Recovery after several years might be achieved through regeneration,
diaschisis and plasticity. For a more detailed discussion of recovery see
Robertson and Murre (1999), Whyte (1990), and Wilson (1998).
Theories and models of emotion. These are becoming increasingly impor-
tant in cognitive rehabilitation. Prigatano (1995, 1999) believes that dealing
with the emotional effects of brain injury is essential to rehabilitation success.
Social isolation, anxiety and depression are common in survivors of brain
injury (Wilson in press, b). Gainotti (1993) distinguishes three main factors
102 WILSON
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
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105
Figure 1. A provisional model of cognitive rehabilitation.
106 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
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