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Towards a comprehensive model

of cognitive rehabilitation
Barbara A. Wilson
MRC Cognition and Brain Sciences Unit, Cambridge
& Oliver Zangwill Centre, Ely, UK

Cognitive rehabilitation is a field that needs a broad theoretical base incorporat-

ing frameworks, theories, and models from a number of different areas. No one
model or group of models is sufficient to address the complex problems facing
people with cognitive problems consequent upon brain injury. This paper
considers some of the models that have influenced cognitive rehabilitation
including models of cognition, assessment, recovery, behaviour, emotion,
compensation, and learning. An attempt is made to synthesise these different
models into a comprehensive model of cognitive rehabilitation.

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: k

Ó 2002 Psychology Press Ltd DOI:10.1080/09602010244000020

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.

What needs to be rehabilitated in cognitive

At the most fundamental level, people undergoing cognitive rehabilitation
require help to remediate, reduce or alleviate their cognitive deficits. Sohlberg
and Mateer (1989) say that “Cognitive rehabilitation . . . refers to the thera-
peutic process of increasing or improving an individual’s capacity to process
and use incoming information so as to allow increased functioning in everyday
life” (p. 3). In a recent book these two authors go on to suggest that the term
“cognitive rehabilitation” is too narrow and it is better to talk about “rehabilita-
tion of individuals with cognitive impairments” (Sohlberg & Mateer, 2001,
p. 3). This seems a sensible suggestion as it implies that people with cognitive
impairment may have additional problems that should also be addressed in
rehabilitation programmes. Ben-Yishay and Prigatano (1990) offer the follow-
ing definition of cognitive rehabilitation, “the amelioration of deficits in
problem-solving abilities in order to improve functional competence in every-
day situations” (p. 395). The important point about this definition is that, like
Sohlberg and Mateer’s view, it focuses on functional competence in every day
life. We have moved on from the early days of cognitive rehabilitation with its
emphasis on drills and exercises to try to reduce basic impairments, to a more
individualised approach addressing the everyday manifestations of these
impairments, i.e., disabilities and handicaps (Wilson, 1997).

McLellan (1991) argued that rehabilitation is not something we do to people

or “give” to people, it is not like surgery or drugs but a two-way interactive
process involving the person with disability, therapeutic staff, relatives and
possibly members of the wider community. So cognitive rehabilitation is a
process whereby people with brain injury work together with health service
professionals and others to remediate or alleviate cognitive deficits arising
from a neurological insult (Wilson, 1996). However, people with cognitive
deficits arising from injury to the brain are likely to have a number of associated
problems such as anxiety, depression, and difficulties with communication and
social interaction. All such additional problems need to be addressed in the
rehabilitation we offer to people with brain injury.
In short, cognitive rehabilitation should focus on real-life, functional
problems, it should address associated problems such as mood or behavioural
problems in addition to the cognitive difficulties and it should involve the
person with brain injury, relatives and others in the planning and implementa-
tion of cognitive rehabilitation.
From this summary it can be seen that no one existing model is sufficient to
address all aspects of cognitive rehabilitation programmes.

Some views on theories relevant to cognitive

In 1987 I argued that three areas from within psychology were important for
cognitive rehabilitation—neuropsychology for helping us to understand the
organisation of the brain, cognitive psychology for providing theoretical
models, and behavioural psychology for providing a number of treatment
strategies that could be modified or adapted to reduce the everyday problems
of people with cognitive deficits (Wilson, 1987). Gianutsos (1989) in the
foreword to Sohlberg and Mateer’s (1989) book on cognitive rehabilitation
said that cognitive rehabilitation came of mixed parentage including neuro-
psychology, occupational therapy, speech and language therapy, and special
education. McMillan and Greenwood (1993) believed that rehabilitation
should draw on clinical neuropsychology , behavioural analysis, and cognitive
retraining together with group and individual psychotherapy. These authors,
together with Diller (1987), understood that cognitive rehabilitation should not
be confined by one theoretical framework or model. In Diller’s words, “While
current accounts of remediation have been criticised as lacking a theoretical
base, it might be more accurate to state that remediation must take into account
several theoretical bases” (Diller, 1987, p. 9).
This contrasts with the view of Coltheart (1991) described above who
appears to believe that the models from cognitive neuropsychology are suffi-
cient to plan cognitive rehabilitation.

People undergoing rehabilitation rarely have isolated cognitive deficits. Not

only do they have, as a rule, several different cognitive problems, they may also
have emotional, social and behavioural problems. Furthermore, models of
cognitive functioning typically identify impairments (e.g., difficulty under-
standing prepositions) rather than disabilities or handicaps, i.e., everyday
problems. It has already been argued that cognitive rehabilitation should focus
on the real-life functional consequences of brain injury. One final point to be
made here is that these models tell us what to treat not how to treat (Wilson,
In Caramazza’s words, “There is nothing specifically about our theory of the
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.

Other models and theoretical approaches relevant

to cognitive rehabilitation
Models and theories of assessment. Assessments derived from models of
cognitive functioning have been mentioned above. A number of other models
of assessment are also used by neuropsychologist s including those engaged in
cognitive rehabilitation. These include (1) the psychometric approach based on
statistical analysis, (2) the localisation approach whereby the examiner
attempts to assess which parts of the brain are damaged and which are intact,
and (3) the ecologically valid approach in which attempts are made to predict
real-life problems. Although these approaches enable us to build up a picture of

a person’s cognitive strengths and weaknesses they are unable to pinpoint in

sufficient detail the nature of the everyday problems and what problems need to
be addressed, or to tell us how the family is coping or to determine whether the
problems are exacerbated by depression, anxiety, or fatigue. Behavioural and
functional assessments are required to complement the information obtained
from the standardised tests. Wilson (in press a) discusses these approaches in
greater detail.
Behavioural models and theories. Models from learning theory and
behavioural psychology have been used in rehabilitation, including cognitive
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

causing emotional and psychosocial problems after brain injury—those due to

neurological factors, those due to psychological or psychodynamic factors, and
those due to psychosocial factors. An example of the first cause might be
someone with frontal lobe damage leading to loss of control and anger
outbursts. An example of the second cause would be someone with reduced
cognitive abilities and consequent loss of self-esteem together with depression
because of an inability to engage in his or her previous profession. An example
of the third cause might be someone who loses all his or her friends and
colleagues following a brain injury and is thus very socially isolated.
Other models and theories that need to be taken into account are those of pre-
morbid personality, neurological, physical and biochemical models, and other
models of emotional behaviour such as those from cognitive behaviour
Ever since Beck’s highly influential book, Cognitive therapy and emotional
disorders, which appeared in 1976, cognitive behaviour therapy (CBT) has
become one of the most important and best validated psychotherapeutic proce-
dures (Salkovskis, 1996). An update of Beck’s model appeared in 1996 (ibid).
Williams, Evans, and Wilson (submitted) discuss CBT with survivors of trau-
matic brain injury. Analytic psychotherapy is also used in rehabilitation
practice. Prigatano (1999) is one of the best known advocates of this approach
with survivors of brain injury.

The World Health Organisation (WHO). The conceptual frameworks put

forward by the WHO (1980, 1986) have significantly influenced clinical reha-
bilitation in the past 20 years or so. The 1980 framework classified the sequelae
of brain injury into impairments, disabilities and handicaps. Impairments can
be regarded as damage to physical or mental structures (e.g., occipital damage
or damage to object recognition systems); disabilities refer to the particular
problems caused by the handicaps (e.g., inability to distinguish between indi-
vidual people or between particular objects in the home); handicaps can be seen
as problems imposed by society because of the disability (e.g., in an environ-
ment adapted for blind people, the person with object recognition difficulties
may cope well).
Although many neuropsychologist s are primarily concerned with impair-
ments identified by neuropsychologica l tests, most people involved in rehabili-
tation (clients, families, therapists) are more concerned with disabilities and
handicaps. Given that some cognitive rehabilitation programmes appear to be
more concerned with improving test scores than with reducing everyday
problems (Carney et al., 1999), one can only assume that this is done in the
belief or hope that reducing impairments will reduce everyday problems. To
date, however, there is little evidence that this actually happens.
The earlier WHO models are now being replaced by another, rather similar,
framework. This classifies problems resulting from injury or illness into those

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
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

explicit memory of amnesic patients. Recent work, however, suggests that it

may work through both these mechanisms (Page et al., 2001) Thus, very
severely memory impaired people, with virtually no explicit memory, have to
rely on implicit memory whereas those with some, albeit limited, explicit/
episodic memory, may find that errorless learning benefits both systems.
Errorless learning appears to be superior to trial-and-error learning for
people with severe memory deficits. It is not yet clear whether errorless
learning is superior to trial-and-error learning for cognitive problems other
than memory. Nor is it clear whether it is the method of choice for motor or
other non-cognitive problems. Potentially, this is a powerful treatment method
but further work remains to be carried out.
The SORKC model (Kanfer & Saslow, 1969). This well-established model
from behavioural psychology is still of value in cognitive rehabilitation
because it allows us to incorporate the physical and neurological status of the
individual patient along with motivation, emotion and behaviour. SORKC
stands for Stimulus, Organism, Response, Contingency, and Consequence.
Wilson (1999) describes the use of this model for the treatment of a head-
injured man with cognitive and behaviour problems. It is potentially helpful for
planning and implementing treatment for many survivors of brain injury.
The holistic model. Holistic approaches address cognitive, social,
emotional, and functional aspects of brain injury together because how we feel
affects how we behave and how we think. These programmes are concerned
with (1) increasing the individual’s awareness of what has happened to him or
her, (2) increasing acceptance and understanding of what has happened, (3) the
provision of strategies or exercises to reduce cognitive problems, (4) the devel-
opment of compensatory skills, and (5) the provision of vocational counselling.
All programmes include both group and individual therapy. It can be argued
that the holistic approach is less of a model and more of a series of beliefs, or as
Prigatano (1999) puts it, a series of “principles”. Nevertheless, clinically the
holistic model makes sense and despite its apparent expense, in the long term it
is probably cost-effective (Cope, Cole, Hall & Barkan, 1991; Mehlbye &
Larsen, 1994; Wilson, 1997; Wilson & Evans, in press).

Towards an all-encompassing theory of cognitive

Figure 1 is an attempt to put together many (although not all) of the aspects
to take into consideration when undertaking cognitive rehabilitation. Start-
ing with the person with the cognitive impairments and his or her family,
pre-morbid personality and lifestyle of the brain-injured person (and other
family members) is likely to impact on the needs and desires of these people
and thus on the rehabilitation offered. Consequently, it is desirable to carry
Figure 1. A provisional model of cognitive rehabilitation.

out an assessment of pre-morbid personality either through interview or

through the administration of one of the measures comparing pre- and post-
morbid characteristics. The BICRO (Brain Injury Community Rehabilitation
Outcomes, Powell, Beckers, & Greenwood, 1998) and the EBIQ (European
Brain Injury Questionnaire, Teasdale et al., 1997) both attempt to identify pre-
and post-morbid characteristics.
The nature, extent, and severity of the brain damage needs to be determined.
This information may be obtained from hospital notes and/or the referral forms,
neurological investigations and imaging studies. Neuropsychological investi-
gations may also add to the picture. It is helpful if people are monitored over
time, particularly if a deteriorating condition is suspected. It should be recog-
nised that repeated neuropsychological assessments may not provide reliable
information as improvement in scores may simply reflect a practice effect
whereas no change in scores may mask a deterioration, again because of a
practice effect (Wilson et al., 2000).
Further recovery may need to be considered especially if the person with
brain injury is seen in the early days, weeks, or months after an insult. Theories
of recovery are relevant here. The cause of the brain damage is also relevant.
People with traumatic brain injury, for example, may show recovery for a
longer time than, say, someone with encephalitis (Wilson, 1998).
One of the most important tasks in rehabilitation is the identification of
current problems. There are several theoretical frameworks one can draw on
when assessing these problems. Information from standardised tests that help
us build up a profile of strengths and weaknesses need to be complemented by
the information from functional or behavioural assessments to build up a
picture of how the problems affect everyday life.
Cognitive, emotional, psychosocial, and behavioural problems should
be evaluated more thoroughly through reference to a more detailed model.
Models of language, reading, memory, executive functioning, attention, and
perception can provide details about cognitive strengths and deficits. Models
from cognitive behaviour therapy, such as the one by Beck (1996) mentioned
earlier, contribute to understanding of emotional and psychosocial problems,
while a behavioural model such as the SORKC model of Kanfer and Saslow
(1969) allows better conceptualisation of disruptive or inappropriate
behaviours. While this is not an exhaustive list of the type of problems faced
by survivors of brain injury, other problems such as motor or sensory deficits
are more likely to be treated by physiotherapists or other staff. Neuro-
psychologists, of course, can work together successfully with others and may
need to incorporate models of motor and sensory functioning and recovery in
their work.
Once the problems are identified, one can decide on the rehabilitation strate-
gies. This is likely to involve the negotiation of suitable goals. Given that one of
the main goals of rehabilitation is to enable people to return to their own most

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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