Journal of the International Neuropsychological Society (1997), 3, 487–496.

Copyright © 1997 INS. Published by Cambridge University Press. Printed in the USA.

CRITICAL REVIEW

Cognitive Rehabilitation: How it is and how it might be

BARBARA A. WILSON
MRC Applied Psychology Unit, Cambridge, U.K.
(Received October 1, 1996; Accepted March 18, 1997)

Abstract

This paper suggests there are, at present, four main kinds of cognitive rehabilitation programs for brain injured
people. The first attempts to rehabilitate cognitive deficits through drills and exercises. The second uses theoretical
models from cognitive psychology to identify deficits in order to remediate them. The third is primarily a
patient-driven approach that uses a combination of learning theory, cognitive psychology, and neuropsychology to
identify and remediate cognitive difficulties. The fourth is the holistic approach that has, as its basic philosophy, a
belief that cognitive functions cannot be divorced from emotion, motivation, or other noncognitive functions, and
consequently all aspects of functioning should be addressed in rehabilitation programs. Despite some overlap
between these approaches, there are major differences. The two main arguments offered in this paper are (1) that the
first two approaches do not lead to good clinical rehabilitation practice; and (2) that a synthesis of the second two
approaches would result in the best cognitive rehabilitation model. (JINS, 1997, 3, 487–496.)
Keywords: Rehabilitation, Cognitive, Brain injury

The Meaning of the Term “Rehabilitation”
Definitions of rehabilitation abound, and while most would
seem to capture something of what people working in the
field mean by the term, none of them have achieved general
consensus. The term itself comes from “habilitation” mean-
ing “to make able,” so, at one level, rehabilitation means
“to make able again.” However, it is clearly recognized by
rehabilitation workers themselves that it is often impossible
to make brain injured people able again if by this expres-
sion we mean, “to restore them to their former selves.”
As is frequently the case when arguing philosophically,
dictionary definitions at the surface level of language are
unhelpful. The Concise Oxford Dictionary, for example, de-
fines “rehabilitate” as “1. to restore to effectiveness or normal
life by training etc. especially after imprisonment or illness.
2. to restore to former privileges or reputation or a proper
condition” (Allen, 1990, p. 1012). The blanket emphasis on
restoration make these definitions inapplicable to the aims,
practice, or outcomes of cognitive rehabilitation as experi-
enced generally by patients and rehabilitation workers.
Reprint requests to: Barbara A. Wilson, MRC Applied Psychology Unit,
Rehabilitation Research Group, Box 58, Addenbrooke’s Hospital, Cam-
bridge CB2 2QQ, U.K. E-mail: barbara.wilson@mrc-apu.cam.ac.uk.
487
Perhaps a more helpful definition is that offered by the
World Health Organization at a meeting in Finland in 1986
when they stated:
Rehabilitation implies the restoration of patients to the highest
level of physical, psychological and social adaptation attain-
able. It includes all measures aimed at reducing the impact of
disabling and handicapping conditions and at enabling dis-
abled people to achieve optimum social integration. (p. 1)
This definition avoids goals that, given the state of our
present knowledge and abilities, are unobtainable because
they imply restoration of function or recovery. While sug-
gesting more realistic aims that would lead to a reduction in
the impact of disabling and handicapping conditions, it nev-
ertheless recognizes that rehabilitation goals can be set to
achieve the highest levels possible, including optimum so-
cial integration. This definition offers a framework within
which rehabilitation workers can set realistic objectives, prac-
tice effective therapy and achieve attainable outcomes.
One element missing from the WHO definition is any ref-
erence to the involvement of the disabled person. McLellan
(1991) argues that rehabilitation is a two-way, interactive
process. Unlike medical treatment, which is something given
to people to help them recover from an injury or illness, or
to make them feel better, rehabilitation, in order to be effec-
488
tive, must involve the disabled patient. McLellan expands
this point to include others besides the patient and therapist
when he writes: “Rehabilitation is a process whereby peo-
ple who are disabled by injury or disease work together with
professional staff, relatives and members of the wider com-
munity to achieve their optimum physical, psychological,
social and vocational wellbeing” (p. 785).
There are many other definitions of cognitive rehabilita-
tion to which we could refer, but I would hope that the two
I have quoted are sufficiently all-embracing for the pur-
poses of this discussion. For example, a recent definition by
Ben-Yishay (1996) would sit comfortably within the frame-
work offered by the above: “. . . the rehabilitation of a head-
injured person is, principally, a task of aiding that person to
speak and act in a way which optimizes his or her adapt-
ability and sense of belonging” (p. 341).
So far, we have examined the meaning of rehabilitation
in general, rather than cognitive rehabilitation specifically.
The term “cognitive rehabilitation” gained popularity in the
1980s after Gianutsos and Gianutsos (1980) described this
branch of rehabilitation as “. . . a service designed to reme-
diate disorders of perception, memory and language”
(p. 37). Most of us today would perhaps find this definition
too limiting, although a more recent definition from Wood
(1990) is, I suggest, too imprecise, when he writes: “Cog-
nitive rehabilitation utilises an assortment of procedures to
improve or restore a diverse collection of abilities and skills”
(p. 3). Perhaps more acceptable is Ben-Yishay and Priga-
tano’s (1990) attempt to define cognitive rehabilitation,
which they describe as “. . . the amelioration of deficits in
problem solving abilities in order to improve functional com-
petence in everyday life situations” (p. 395).
My own attempt at a definition has been influenced by
the WHO statement, by Miller’s (1984) book, and by dis-
cussions with Lindsay McLellan. In 1989 I suggested:
The term “cognitive rehabilitation” can apply to any interven-
tion strategy or technique which intends to enable clients or
patients, and their families, to live with, manage, by-pass, re-
duce or come to terms with cognitive deficits precipitated by
injury to the brain. (p. 117)
I extended this in 1996, when I wrote, “Cognitive reha-
bilitation is a process whereby brain injured people work
together with health professionals to remediate or allevi-
ate cognitive deficits arising from a neurological insult”
(p. 637).
A Brief History of Cognitive Rehabilitation
The earliest known document about treatment of people with
head injury is Egyptian, dating from 2,500 to 3000 years
ago, and discovered by Smith and Luxor in 1862 (quoted
by Walsh, 1987). Many techniques used today were antici-
pated by Itard in the 18th century, when he was working
with Victor, the Wild Boy of Aveyron (Lane, 1977).
Boake (1996) says that “neuropsychological rehabili-
tation may be almost as old as neuropsychology itself”
B.A. Wilson
(p. 241). He goes on to describe Broca’s successes and fail-
ures in teaching an aphasic patient to read (see Berker et al.,
1986).
However, rehabilitation that would be more recognizable
as such by practitioners of today probably began in Ger-
many during World War I, as a result of improvements in
the survival rates of head injured soldiers (Goldstein, 1942).
Goldstein stressed the importance of cognitive and person-
ality deficits following brain injury, and touched upon prin-
ciples that could now be called “cognitive rehabilitation
strategies” (Prigatano, 1986).
Jefferson (1942) wrote, “Although it is a new word, re-
habilitation is an old purpose. All medical treatment has
basically no other aim” (p. 296). A further impetus to reha-
bilitation came during World War II, with developments in
Germany, Great Britain, the Soviet Union, and the United
States. An important paper by Zangwill appeared in 1947 in
which he discusses, among other things, the principles of
reeducation, and referred to the following three main ap-
proaches: compensation, substitution, and direct retraining.
In the Soviet Union, during and after World War II, Luria
and his colleagues were active in neuropsychological reha-
bilitation at a time when Luria was responsible for organiz-
ing a hospital for head injured soldiers (Luria, 1979). As
Boake (1989) tells us, Luria noted that over 800 soldiers
who had sustained brain injury from gunshot wounds were
treated in this hospital by 1943. The publications of Luria
(1963, 1970) and by Luria et al. (1969) still provide a rich
source of material for contemporary neuropsychologists in-
terested in cognitive rehabilitation.
In the USA those people influential in the development
of cognitive rehabilitation programs were Aita (1946, 1948),
Granich (1947), and Wepman (1951). After the Second World
War and its immediate consequences, things were quiet, in
a worldwide sense, until the publication of two conference
proceedings (Walker et al., 1969; Hook, 1972). The Israeli
wars prompted further development of rehabilitation pro-
grams, such as those described by Najenson et al. (1974)
and Ben-Yishay (1978). At the same time, greater numbers
of survivors from road accidents probably prompted the
growth of specialist rehabilitation centers in the USA, such
as the Rancho Los Amigos Hospital in California (Malk-
mus et al., 1980). The first program to call itself a “cogni-
tive rehabilitation program” was probably that of Diller in
New York in 1976 (see Diller et al., 1977, for a description).
A more detailed history of neuropsychological (includ-
ing cognitive) rehabilitation can be found in a special issue
of the journal Neuropsychological Rehabilitation, edited by
Boake (1996).
Impairments, Disabilities, and Handicaps
Using the World Health Organization’s (1980) conceptual
framework, we can classify the sequelae of brain injury into
impairments, disabilities, and handicaps. Impairments can
be regarded as damage to physical or mental structures (for
example, temporal lobe damage), disabilities refer to the par-
Cognitive rehabilitation
ticular problems caused by the impairment (for example, a
patient forgetting to take medication), and handicaps can be
seen as problems imposed by society because of someone’s
disability (for example, a person in a wheelchair is handi-
capped in a building without wheelchair access but not in a
building with wheelchair access).
Figure 1 illustrates how impairments, disabilities and
handicaps might result from a head injury or stroke.
Cognitive neuropsychologists typically treat impair-
ments, identified by scores on tests, rather than disabilities,
which are the ways impairments manifest themselves in the
form of everyday problems encountered by the affected per-
son, or handicaps, which are experienced by the patient be-
cause of social or environmental inadequacies.
How is the effectiveness of a program that treats impair-
ments to be evaluated? Whyte (in press) argues that the sim-
plest way is to use congruent outcome assessment, whereby
the outcome measurement is congruent with the level of in-
tervention. That is to say, if one is treating impairments, the
outcome measure should be a measure of impairment, and,
if one is treating a disability, then the outcome measure
should be a measure of disability.
Fig. 1. An illustration of pathology, impairment, disability and handicap, and how a person with head injury and a
person with stroke might be affected (adapted from Whyte, in press).
489
Given that rehabilitation is concerned with the treatment
of disabilities, it follows from the above argument that the
effectiveness of any particular rehabilitation program will be
measured in amounts of reduction in disability experienced
by the patient (for example, by how much has a particular pa-
tient who forgets to take medication improved his or her abil-
ity to remember to take medication). The information thereby
gained will be of importance for the patient, who may now
be benefiting from improved performance in taking medica-
tion, and the carers (who may include therapists and family),
who will be sharing in the improved situation arising from the
better performance in taking medication.
It also follows that the effectiveness of a particular cog-
nitive rehabilitation program, as practiced by a cognitive
neuropsychologist, which, as we pointed out previously, will
focus on impairments, will be measured by a reduction in a
particular impairment, such as inability to name objects as
indicated by a particular naming test. Now this information
may be of little consequence to the patient or the patient’s
family, and may mean very little to staff treating the patient,
unless there has been a subsequent and measurable improve-
ment in everyday language skills.
490
The cognitive rehabilitation program may of course treat
impairments in the hope, or even expectation, that disabil-
ities will also be reduced, but there is little evidence in fact
that such reduction occurs. Although Diller and Gordon
(1981) found that teaching stroke patients to carry out block
design tasks resulted in improved dressing skills, it is hard
to find evidence that this approach works for patients with
multiple impairments, such as those who form the majority
of brain injured people. Furthermore, Whyte (in press) points
out that there are no data to support the view that cognitive
impairment is related to cognitive disability. Taking mem-
ory as an example, dysfunction is usually identified by per-
formance on memory tests that assess impairment. The
Wechsler Memory Scale–Revised (Wechsler, 1987) is con-
sidered to be a reasonably good test of memory impair-
ment, but it does not correlate with memory performance in
real life (Wilson, 1991a). In other words, the WMS–R does
not measure disability, and does not therefore address reha-
bilitation issues. The Rivermead Behavioural Memory Test
(Wilson et al., 1985), on the other hand, measures disability
in that it includes analogues of real life tasks. Thus it re-
flects real life problems (Wilson et al., 1989) and is a good
predictor of both independence (Wilson, 1991a) and em-
ployment (Schwartz & McMillan, 1989).
As far as cognitive rehabilitation is concerned, we should
be attempting to remediate disability rather than impair-
ment or, at least, demonstrate that treatment of impairment
results in reduction of disability.
How is Cognitive Rehabilitation
Carried Out Today?
In Europe, North America, and Australasia, there would ap-
pear to be four main approaches to cognitive rehabilitation:
1. those focusing on cognitive retraining through drills and
exercises;
2. those based on models from cognitive neuropsychology;
3. those combining theory and practice from neuropsychol-
ogy, cognitive psychology, and behavioral psychology;
4. those using a holistic approach by addressing emotional,
motivational, and other noncognitive aspects of function-
ing, in addition to cognitive aspects.
The cognitive retraining approach
The assumption behind this approach seems to be that it is
possible to remediate underlying cognitive deficits (or at least
to teach patients how to deal with their cognitive problems)
by exercise, practice and stimulation. It is therefore akin to
the “mental muscle” approach (Harris & Sunderland, 1981),
which assumes that appropriate cognitive exercises can im-
prove cognition in the same way that physical exercise can
improve physical well-being and muscle tone. Such pro-
grams typically involve the presentation of patients with a
cognitive exercise regime to work through. The exercises
B.A. Wilson
are often computerized. Gianutsos (1980) described one such
treatment for a woman in her 40s who had memory, percep-
tual, and reading problems following a meningioma and a
stroke. Gianutsos reported that, in total, 23 cognitive reha-
bilitation sessions were conducted with this patient, both
before and after discharge from the hospital to her home.
The sessions lasted from 45 min to 2 hr, and occurred within
a 2-month period, except for a follow-up session 5 months
later. Cognitive retraining was organized around two tasks:
(1) memory for short lists of three unrelated words, with
varying amounts of interference in the recall interval; and
(2) oral reading and recall of paragraphs.
Many American programs seem to follow the exercise,
stimulation, and practice model, including the original Diller
(1976) program, in which patients were taken through a se-
ries of training models to improve, for example, visual in-
formation processing or spatial awareness. Others who use
a retraining exercise approach include Parenté et al. (1989),
who developed an “iconic memory scanning” training to im-
prove “iconic retention”; Adamovich et al. (1985) and Sohl-
berg and Mateer (1989), who describe a range of exercises
for improving various cognitive deficits; and Lynch (1982),
Bracy (1986), Gianutsos and Kiltzner (1981), and others,
who describe computerized cognitive retraining programs.
What is wrong with the retraining through
exercises approach?
The main problem with this approach is connected with a
distinct lack of evidence of its effectiveness. Miller (1984)
found little evidence of success for the stimulation, exer-
cise, and drilling approach. Wilson (1982) reported no ef-
fect of exercise on memory functioning, a finding supported
by Glisky (1995). In a fairly comprehensive review of com-
puterized cognitive rehabilitation, Robertson (1990) found
no evidence of significant changes in memory, visuopercep-
tual, or visuospatial functioning as a result of computerized
training. Language training programs for highly specific dis-
orders fared a little better, although there was no published
evidence of more general effectiveness of computerized lan-
guage training. Only in attention training were there some
positive results, although even here the results were contra-
dictory, with some studies reporting positively and others
negatively.
Since Robertson’s (1990) review paper, further comput-
erized attentional training programs have appeared in sup-
port of the tentative evidence available in the 1980s. Gray
et al. (1992) found that, on a number of outcome measures,
a group of brain injured patients receiving computerized at-
tentional retraining were marginally better than a control
group of brain injured patients receiving recreational com-
puterized training. However, 6 months later the experimen-
tal group did significantly better than the control group on
two tests of attention. Sturm and Willmes (1991) gave com-
puterized training to right and left hemisphere damaged
stroke patients. Right hemisphere damaged patients showed
more pronounced impairments of sustained attention and vig-
Cognitive rehabilitation
ilance, whereas left hemisphere damaged patients were worse
on choice reaction tasks. Both groups improved with train-
ing on a number of attention functions, but not for vigi-
lance. Moreover, the training effects were less pronounced
for the right brain damaged group. Just as Robertson re-
ported in 1990, Sturm and Willmes (1991) also found no
evidence of generalization to more general cognitive func-
tions or to real life tasks.
Despite the lack of evidence, there are still those who be-
lieve in the exercise–drilling approach. Gianutsos (1992),
for example, said, “restoration as a goal” should be pursued
“even when that goal might be remote” because patients view
it as appropriate (p. 29).
Other problems with the retraining through exercising ap-
proach include the following:
1. It fails to address the functional manifestations of cog-
nitive problems as experienced by brain injured patients
in real life; that is, it tackles impairments rather than dis-
abilities. Learning lists of words or identifying particu-
lar stimuli on a computer screen is not of any particular
concern to brain injured people.
2. The approach fails to address generalization problems.
The only point to “cognitive retraining” would be if im-
provements on the training tasks generalized to real life,
but to date, we have no convincing evidence of this. Fur-
thermore, without such evidence, it would seem wrong
to build in unnecessary steps for brain injured clients,
who typically have problems learning, especially when
they could be taught directly the information or skills
they require for real life functioning.
3. Emotional, social, and behavioral sequelae of brain in-
jury are ignored, yet these can be just as handicapping as
cognitive difficulties (McKinlay et al., 1981; Thomsen,
1985). Patients and families are sometimes in danger of
exploitation through unscrupulous companies, selling
computers and software to people desperately hoping for
some improvement in their daily lives.
4. This approach lacks any theoretical underpinning.
Cognitive neuropsychological
theoretical approaches
These approaches use a cognitive model, typically of lan-
guage or reading, to identify the specific deficit of an indi-
vidual patient. The deficits are often very precisely identified
by the models. The underlying rationale would appear to be
that, once a deficit can be identified, it can be treated. In the
words of Coltheart (1991),
One needs to have in mind a model of how naming is normally
achieved before one can begin to seek to understand impair-
ments of naming consequent upon brain damage; and one needs
this understanding before one determines what kinds of treat-
ment could be appropriate. (pp. 216–7)
In the United Kingdom and some other European coun-
tries this approach is held in high esteem. The eminent pro-
ponents are Coltheart (1991, 1994), Riddoch and Humphries
491
(1994), Seron et al. (1991), and Mitchum and Berndt (1988,
1995). A typical rehabilitation program within this ap-
proach would involve a careful assessment (following one’s
particular model) to identify the component(s) of the model
that are dysfunctional. Having carefully analyzed the defi-
cit “the treatment is selected specifically to fit in with the
theoretical interpretation of the functional impairment”
(Mitchum & Berndt, 1995, p. 7). The treatment itself, how-
ever, is typically practice at the damaged component of the
model. Although we saw earlier that practice is not a good
rehabilitation strategy, it would be argued by cognitive neuro-
psychologists engaged in rehabilitation that the drilling, prac-
tice, and exercising approach fails because it fails to identify
the damaged component precisely enough.
Even among cognitive neuropsychologists there are crit-
ics of this approach. Caramazza (1989) remained uncon-
vinced of the value of models for rehabilitation. Wilson and
Patterson (1990) claimed that the recent interest in treat-
ment on the part of neuropsychologists has been almost en-
tirely for the benefit of the scientist rather than the patient.
Baddeley (1993) suggests that cognitive neuropsychology
has learned a great deal from the study of brain damaged
patients over the past 20 years, but it is by no means clear
that brain damaged patients have benefited from cognitive
neuropsychology.
What is wrong with the theoretical cognitive
neuropsychology approach?
One of the major problems with this approach is that, while
cognitive neuropsychological models are extremely useful
in identifying the nature of the deficit, and for explaining
observed phenomena, they provide little or no information
on ways of treating the deficit (Wilson & Patterson, 1990).
In other words, they tell us what to treat but not how to treat.
Or, putting it in the terms we have been using in this paper,
this approach can be extremely good at identifying the im-
pairment, but has little or nothing to offer when it comes to
treatment of the disability, which, as I have previously ar-
gued in this paper, is the business of rehabilitation.
Furthermore, the theoretical cognitive neuropsychology
approach is best suited to patients with relatively pure def-
icits. Indeed, rehabilitationists adopting models from cog-
nitive neuropsychology typically seek out such patients, and
typically report single cases. Of course single cases are in-
valuable for confirming or disconfirming theories (Shal-
lice, 1979), and as Caramazza (1989) wrote, “Experimental
research with brain damaged patients . . . has had as its ex-
plicit goal that of informing theories of normal cognitive
functioning” (p. 384). For many cognitive neuropsycholog-
ists, the raison d’être for their interest in rehabilitation is to
develop, extend, or modify their models. In clinical prac-
tice, the majority of brain damaged patients have multiple
deficits, and for this group, theoretical models have been
less useful.
Because theoretical models tend to focus attention on test
performance rather than ways in which cognitively im-
492
paired people function in everyday life, they are like retrain-
ing models focusing on impairment rather than disability.
Patients rarely want or need to improve scores on tests in
the face of far greater demands requiring them to function
more efficiently in real life; in family, social, and voca-
tional settings. If the subsequent cognitive rehabilitation
offered by the theoretical cognitive neuropsychological ap-
proach were successful in terms of these real life needs of
patients, then I would have one less objection to them, but
so far there is little evidence of this happening. Typically,
improvements on test scores are provided as evidence of
success, rather than some of the more functional measures
such as reading for pleasure, greater confidence in using the
telephone, or engaging more often in conversation.
My opposition is not aimed at the models per se, and
indeed, regarded as tools that have enabled us to come to a
greater understanding of the nature of a number of cognitive
impairments, I am deeply appreciative. Like Caramazza and
Hillis (1993), however, I would argue that understanding
on a theoretical level, although essential, is not a sufficient
requirement on its own to address rehabilitation as con-
ceived of by the World Health Organization (1986), when
they describe it as “enabling people to achieve optimum
social integration” (p. 1). Cognitive neuropsychological
approaches fail to address emotional, social or behavioral
sequelae of brain injury yet, as we noted earlier, these are
often more handicapping than the cognitive if not ad-
dressed properly.
The combined approach: Learning theory,
cognitive psychology, and neuropsychology
This approach is perhaps practiced most in the United King-
dom, and probably reflects British clinical psychology train-
ing. Most British neuropsychologists working in the Health
Service (and therefore in rehabilitation) have been trained
as clinical psychologists who have then gone on to special-
ize in neuropsychology. The clinical psychology training is
generic, with all students spending part of their time work-
ing in adult mental health, child services, and learning dis-
ability. In addition to these compulsory placements, students
choose three of four specialist placements, which may
include neuropsychology. The academic part of the training
would typically include cognitive psychology, neuropsy-
chology, learning theory (and behavior modification),
developmental psychology, psychotherapy, abnormal psy-
chology, statistics, and research design. In many courses,
the basic philosophy is one that recognizes that clinical psy-
chologists are trained to solve health service problems. We
are not allowed to say a patient is untestable or untreatable;
instead, we should use a problem-solving strategy to find a
way to assess or treat, or refer to the right service or depart-
ment. Finally, within this tradition, clinical psychologists
are expected to be research oriented, and to evaluate the
efficacy of their intervention programs.
A behavioral approach is usually incorporated into neuro-
psychological rehabilitation because it provides a structure;
B.A. Wilson
a way of analyzing a problem, of assessing everyday man-
ifestations of difficulties, of evaluating the efficacy of
treatment—and because there are numerous treatment strat-
egies that can be modified or adapted for brain injured pa-
tients (Lincoln, 1978; Wilson, 1987, 1989b, 1991b).
Although formal behavior modification programs are used
in some centers (e.g., Wood & Eames, 1981; Wood, 1987),
many psychologists engaged in cognitive rehabilitation are
less inclined to use the more rigid behavioral approaches of
Skinner (1953) or Kazdin (1975), and more inclined to use
elements such as task analysis and behavioral assessment,
together with other strategies such as anxiety management
and systematic desensitization.
However, behavioral approaches are not in themselves suf-
ficient for our purposes in cognitive rehabilitation. A better
understanding of theory and the organization of the brain
are required; hence the incorporation of cognitive psychol-
ogy and neuropsychology into the programs. Ponsford et al.
(1995) also use this broad approach in their work in Australia.
Wilson (1984, 1987) put forward the case for the com-
bined approach, although Lincoln (1978) had earlier used
behavioral elements in neuropsychological rehabilitation, as
indeed had Ince (1976, 1980). Robertson (1988, 1990) also
comes from this school, although he perhaps emphasizes
the cognitive and neuropsychological aspects rather more
than the behavioral.
The basic principle upon which this approach is based is
that the everyday problems of brain injured patients can be
reduced. If the patient–client fails to learn or fails to change,
it is the psychologist who is at fault for not finding the right
strategy. The main strengths of this approach are perhaps its
emphasis on monitoring, record keeping, and evaluation of
success or failure.
What is wrong with the combined approach?
To the outside observer, the main problem would appear to
be that this approach fails to address the patient’s emotional
needs. Prigatano (personal communication, 1993) says that
the approach does not consider the patient’s feelings. In prac-
tice, this criticism is perhaps more apparent than real, as the
patient’s concerns and anxieties are frequently addressed.
Anxiety management strategies, particularly desensitiza-
tion and relaxation, are commonly employed. In many pro-
grams, patients are involved in setting their own
rehabilitation goals, in monitoring their treatment, and in
taking control of their own therapy. Nevertheless, it is true
to say that patients’ feelings, emotions, and their self-
esteem are not, as a rule, formally seen as part of their cog-
nitive rehabilitation. Furthermore, it is common practice to
focus on one aspect of cognitive dysfunction, such as mem-
ory, attention, or reading, rather than address a broader spec-
trum.
The holistic approach
The holistic approach pioneered by Diller (1976), Ben-
Yishay (1978) and Prigatano (1986) “ . . . consists of well-
Cognitive rehabilitation
integrated interventions that exceed in scope, as well as in
kind, those highly specific and circumscribed interventions
which are usually subsumed under the term ‘cognitive re-
mediation’ ” (Ben-Yishay & Prigatano, 1990, p. 400). Pro-
ponents of the holistic approach regard it as futile to separate
the cognitive, the psychiatric, and the functional from the
affective sequelae of brain injury (Ben-Yishay et al., 1985).
Ben-Yishay’s model follows a hierarchy of stages through
which the patient must work in rehabilitation; namely,
engagement, awareness, mastery, control, acceptance, and
identity.
Major themes of the daily programs include increased
awareness, acceptance and understanding, cognitive reme-
diation, development of compensatory skills, and voca-
tional counseling. The rehabilitation day typically starts with
a morning meeting of staff and patients, with the rest of the
day structured around individual and small group therapy,
together with a further meeting of all staff and clients. The
individual sessions include cognitive training, psychother-
apy, and other specific therapies as required (e.g., speech
and language therapy or relaxation therapy).
Group therapy also covers cognitive therapy and psycho-
therapy, plus special groups as required (e.g., problem-
solving or communication). A relatives’ group is held once
a week, and vocational counseling and work trials are usu-
ally included.
There is increasing evidence that these programs result
in less emotional distress, increased self-esteem, and greater
productivity for participants than is observed in those pa-
tients who do not undergo such treatment (Prigatano, 1986,
1994), as well as evidence that these programs are cost-
effective (Mehlbye & Larsen, 1994).
However, it is harder to find evidence directly comparing
more than one of the four approaches described in this pa-
per, although an interesting study by Rattock et al. (1992)
looked at a comparison of different treatment mixes within
a holistic program. They compared the different intensity of
treatments for three groups of brain injured patients. All
groups achieved the same success rate in terms of employ-
ment at 6 months post follow-up. The groups differed,
however, in that those who spent most time in cognitive
rehabilitation did better on cognitive tasks, those who spent
more time on interpersonal skill training did better on tasks
involving interpersonal skills, and those trained on both im-
proved on both.
What is wrong with the holistic approach?
Clinically, there appears to be little wrong with this approach.
It is hard to find irrefutable evidence of its success but it has
probably been subjected to more research on efficacy than
other approaches (Diller, 1994), and, as Cope (1994) says, “Al-
though none of the outcome research provides definitive proof
of rehabilitation efficacy, the sum of many studies . . . pro-
vides reasonably convincing evidence that comprehensive re-
habilitation does make a substantial difference in outcome of
handicap for TBI (traumatic brain injury) patients” (p. 218).
493
The holistic approach does not come cheaply. There are
usually some 8 to 10 full-time qualified professional health
service staff for 12 to 15 patients but, on the other hand,
Cope et al. (1991) estimated the annual savings in care for
moderately brain injured people was over $14,000, and for
severely brain injured people the saving was above $41,000.
Mehlbye and Larsen (1994) found that in Denmark, where
a holistic program has been in operation since 1985, sav-
ings in health and social care were recouped in 5 years.
Good as the holistic programs are, it is probably true to
say they can be improved. Incorporating some of the posi-
tive aspects from the combined learning theory, cognitive
psychology, and neuropsychology programs mentioned ear-
lier might, for example, enhance their clinical effective-
ness. Careful task analysis, baseline recording, monitoring,
and the implementation of single case experimental designs
should enable us to evaluate more easily the successes and
failures. The implementation of theoretical models to (1)
identify cognitive strengths and weaknesses and (2) explain
observed phenomena should extend the boundaries of
achievement for cognitive rehabilitation programs.
What do we need to ensure effective
and ethical cognitive rehabilitation?
1. In the light of the discussion immediately above, and the
fact that feelings affect how we think and how we be-
have, we need to recognize that cognition should not be
divorced from emotion, motivation, or other noncogni-
tive functions. Consequently, an integrated program
should address not only cognitive functions but also so-
cial, emotional, functional, and affective difficulties.
2. Programs should focus on disability rather than impair-
ment . Effectiveness should not be evaluated by improve-
ments on test results.
3. Cognitive neuropsychologists engaged in rehabilitation
should encourage dialogue with other disciplines. We
typically conduct diagnostic studies or experiments to
elucidate and clarify the nature of impairment. Other re-
habilitation staff are typically concerned with the reme-
diation of real life problems and in helping brain injured
people manage their disabilities. The challenge of those
engaged in cognitive rehabilitation is to develop concepts,
tools, and terminology to bridge these different interests.
4. We need a broader theoretical spectrum on which to base
our rehabilitation programs. Wilson (1984, 1987) ar-
gued for the need to combine theoretical models and
methodology from neuropsychology, cognitive psychol-
ogy, and behavioral psychology. Diller (1987) said,
“While current accounts of remediation have been crit-
icised as lacking a theoretical base, it might be more ac-
curate to state that remediation must take into account
several theoretical bases” (p. 9). More recently, Mc-
Millan and Greenwood (1993) said, “Rehabilitation
should draw on fields of clinical neuropsychology, be-
havioural analysis, cognitive retraining and group and
individual psychotherapy” (p. 352).
494
5. We need to strengthen the interaction between theory and
clinical observation. Theory can sometimes predict which
methods might work, but clinical observation is often re-
quired to tell us how best to implement the theory. For
example, work on errorless learning in the rehabilitation
of amnesic patients (Baddeley & Wilson, 1994) grew out
of theoretical work on implicit memory. The implemen-
tation of errorless learning principles in clinical rehabil-
itation, however, requires behavioral observation and
analysis at an individual patient level (Wilson et al., 1994;
Wilson & Evans, 1996).
6. We need to ensure proper evaluation of cognitive reha-
bilitation programs at both focal and global levels (Whyte,
in press). Given that patients and therapists cannot be
“blind” to treatment procedures, double blind random-
ized control trials are always unlikely to be realized in
neuropsychological rehabilitation. Single blind trials are
sometimes possible (Cope, 1994). Even more possible
are small group or cohort studies, crossover designs, and
single case experimental designs (Wilson, 1997, dis-
cusses research and evaluation in rehabilitation in some
detail).
In conclusion, and to quote a British politician, the late
Sir Keith Joseph, speaking when the first chair of rehabili-
tation was established in the United Kingdom, “An improve-
ment in rehabilitation can mean more to millions of people
than almost any other medical advance” (Joseph, 1973).
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