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1345-1357, 1995
Copyright© 1995ElsevierScienceLtd
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0028-3932(95)00068-2
JOHN T. E. RICHARDSON
Department of Human Sciences, Brunel University, Uxbridge, Middlesex UB8 3PH, U.K.
Al~lraet--Training and instructions in the use of mental imagery can lead to improved retention in
patients with memory impairment as the result of brain injury or disease. The amount of
improvement varies inversely with the severity of memory impairment, but is largely unrelated to
either the aetiology or the locus of brain damage. It also appears to depend on the patients'
motivation rather than their intelligence, education or imagery ability. However, brain-damaged
patients may need explicit prompting if they are to use imagery mnemonics successfully and often
fail to maintain their use on similar learning materials or to generalise their use to new learning
situations. As a result, imagery mnemonics will typically be of little practical value in enabling
memory-impaired individuals to respond to the cognitive challenges of everyday life.
INTRODUCTION
Experimental research has demonstrated that instructions and training in the use of
mental imagery lead to consistent, reliable and substantial improvements in memory
performance [81]. This applies both to the use of simple interactive images in verbal-
learning tasks and to more complicated mnemonic systems such as the pegword method or
the method of loci (see Ref. [103]). Deficits in memory performance are a frequent
consequence of brain injury and disease [43]. The question therefore arises whether
instructions and training in the use of mental imagery will alleviate the memory
impairment encountered by patients with brain damage.
This proposal was first put forward by Patten [68], who suggested that "such mnemonic
techniques may be the foundation of a new branch of rehabilitation therapy helping
patients to recover their memories" (p. 26). He taught a variety of techniques to four
patients with verbal memory deficits: two stroke patients, one case with an arteriovenous
malformation and one case of herpes simplex encephalitis. The procedures included a peg-
word mnemonic in which concrete nouns (e.g. tea, shoe) were associated with the numbers
1-10 and then used as mental "pegs" for remembering lists or sequences of words, as well
as the use of more loosely structured interactive imagery.
All four of these patients were able to use these techniques to improve their
performance. Subsequent work confirmed that instructions and training in the use of
mental imagery could often lead to improved retention in brain-damaged individuals (see
Ref. [87] for a review). These include patients with amnesia associated with Korsakoff's
syndrome or encephalitis [5, 6, 26, 37, 39, 49, 50], patients who have undergone unilateral
1345
1346 J.T.E. RICHARDSON
temporal lobectomy [41], patients with closed head injuries [10, 11, 28, 33, 56, 86], patients
with cerebrovascular disease [22, 53, 66, 94, 101,102] and patients with Parkinson's disease
[31].
Nevertheless, there are considerable individual differences in the benefits gained from
such training [29, 52]. At one extreme, Richardson and Barry [86] found that instructions
to use mental imagery raised the performance of patients with minor closed head injuries
to the level achieved by control patients. At the other extreme, a number of studies have
failed to demonstrate any significant improvement at all. Patten [68] himself mentioned the
lack of benefit from imagery training in three further cases: one patient with Alzheimer's
disease, one with a tumour of the third ventricle and one who had undergone surgical
repair of an aneurysm of the anterior communicating artery. Four other studies also found
no enhancement of memory performance in cases of amnesia from various causes [2, 12,
41, 94].
Clearly, if training and instructions in the use of imagery mnemonics are to have any
practical value in the remediation of memory disorders, it is important to understand the
origins of this variability. In the first part of this paper, I shall discuss which characteristics
of brain-damaged individuals appear to be important determinants of the benefits which
they gain from imagery mnemonics. I shall discuss in turn the lateralisation, aetiology and
severity of their lesions and the intelligence, education, motivation and imagery ability of
the patients themselves. I shall go on to consider which properties of the learning tasks
with which patients are confronted influence the efficacy of imagery mnemonic
instructions, and I shall conclude by addressing the practical issue of whether brain-
damaged individuals who are given instructions and training in the use of imagery
mnemonics will continue to use these techniques in their everyday lives.
However, Ehrlichman and Barrett [16] showed that there was actually no reliable
evidence to support this idea. Subsequent analyses based on case reports of the loss of
mental imagery following brain damage [17], on research using medical imaging
techniques [32, 58] and on the findings of experiments with patients who had undergone
cerebral commissurotomy [19, 48] tended to emphasise the contribution of structures
within the left hemisphere to imaginal functioning. Nevertheless, more recently, Farah [18]
acknowledged that the available evidence was not wholly consistent, and Sergent [92]
suggested that the most reasonable conclusion was that both of the cerebral hemispheres
contributed simultaneously and conjointly to the process of image generation.
With specific regard to the efficacy of imagery mnemonics, a number of studies have
indeed confirmed Patten's [68] original finding that patients with left-hemisphere damage
may benefit from mnemonic training or instructions [22, 31, 41, 93, 99]. Several of these
same studies have however also shown that patients with lesions restricted to the right
hemisphere do not differ from either normal control subjects or patients with left-
hemisphere lesions in terms of the improvement which they derive from imagery
mnemonic instructions. This indicates that the right hemisphere has no special role in the
generation of mental images.
More intriguingly, there have been several reports that instructions to use mental
imagery improve verbal memory in patients who have undergone cerebral commissur-
otomy [24, 25, 75, 76, 78, 94]. Unfortunately, such reports were inadequately documented
either experimentally or clinically. However, the crucial finding has now been formally
demonstrated by Milner et al. [62] in the case of eight commissurotomy patients, of whom
six were presumed to have undergone a complete section of the interhemispheric
commissures. As a group, these patients showed a significant improvement in the paired-
associate learning of concrete words as a result of both experimenter-generated and self-
generated images. This entails that the surgically isolated left hemisphere is capable of
imaginal encoding.
Patten [70] asserted that imagery mnemonics "are of no value in the rehabilitation of
dementia or other generalised disorders of cerebral function, nor in patients with defective
encoding of recent memory due to bilateral midline lesions" (p. 352). However, most
research studies have not specifically tested whether the efficacy of imagery mnemonics
depended upon the aetiology of the memory impairment to be alleviated. Leng and Parkin
[51] found no significant difference between six patients with bilateral temporal-lobe
damage (associated with encephalitis or posterior cerebral artery occlusion) and seven
patients with diencephalic damage (associated with Korsakoff's syndrome) in the benefits
gained from imagery instructions, although the latter benefited less than the former from
the provision of experimenter-generated images in the form of line drawings.
More recently, Gade [21] compared the efficacy of imagery mnemonic instructions in
four groups of amnesic patients who were broadly similar in the severity of their memory
impairment: 15 patients who had undergone surgery for aneurysms of the anterior
communicating artery; seven patients with diencephalic lesions associated with Korsak-
off's syndrome or a tumour of the third ventricle; six patients with bilateral temporal-lobe
lesions associated with anoxia or with encephalitis; and seven patients with other
aetiologies. He found no significant difference among these four groups and concluded
that the aetiology and hence the localisation of the amnesic syndrome was not a significant
factor in the efficacy of mental imagery.
Severity of impairment
Nevertheless, a previous study reported by Wilson [102] had found systematic variations
in the effectiveness of imagery instructions that were related to the severity of memory
impairment. She classified 36 brain-damaged patients with a variety of diagnoses into
three equal groups on the basis of their scores in a delayed recall test for the passages in the
Logical Memory component of the Wechsler Memory Scale. On a test of paired-associate
learning, the patients who were classified as moderately or mildly impaired showed a
significant improvement in their performance as a result of instructions to use mental
imagery, but the patients who were classified as severely impaired did not. This suggests
that patients with mild or moderate memory disorders can benefit from imagery
mnemonics whereas those with more severe disorders cannot [29].
Accordingly, Gade [21] reclassified his own amnesic patients into three groups in terms
of the severity of their impairment as measured by their performance on an independent
paired-associate learning task, and he similarly found differences in the benefits gained
from the administration of imagery instructions. The magnitude of their improvement was
inversely related to the severity of their amnesia, and in particular the severely amnesic
patients typically showed little or no improvement at all as the result of self-generated
imagery. Hence, the primary clinical determinant of the efficacy of mnemonic training
would seem to be the severity of the underlying memory deficit.
PATIENT VARIABLES
Patten [68] argued that premorbid characteristics of the patients themselves would also
influence the efficacy of instructions or training in the use of mental imagery. He asserted:
"Naturally, low intelligence, poor motivation, and poor imagination interfere with the
application of the mnemonic system" (p. 31).
IMAGERY MNEMONICS IN MEMORY REMEDIATION 1349
Imagery ability
Obviously, any benefit to be gained from the use of imagery mnemonics depends on the
preservation of mental imagery and the patient's premorbid ability to construct and
1350 J.T.E. RICHARDSON
manipulate mental images. Patten [68] claimed that none of his patients who failed to
benefit from mnemonic training was able to form vivid mental images. In fact, the loss of
mental imagery as a result of brain damage is relatively rare and typically not linked with
memory impairment [17, 20]. Conversely, the evidence indicates that severely amnesic
patients are still able to generate vivid and appropriate images, but may gain no benefit in
terms of their subsequent retention of the imaged material [1, 39, 41, 42]. Indeed,
Richardson et al. [87] described one patient with an aneurysm of the anterior
communicating artery who had learned a series of memory aids prior to his disability.
Despite continuing to use these mnemonics in a spontaneous and appropriate manner, he
remained densely amnesic.
It is also not clear whether the efficacy of imagery mnemonics varies with individual
differences in imagery ability, as measured, for instance, by Marks's [57] Vividness of
Visual Imagery Questionnaire or by Gordon's [35] Test of Visual Imagery Control. The
evidence for such associations in normal individuals is minimal (see Ref. [81], Chapter 9;
but cf. [14]). The evidence in brain-damaged patients is non-existent.
TASK VARIABLES
It is also important to consider the nature of the learning tasks in which training and
instructions in the use of mental imagery have generally been considered to be beneficial.
Experimental work with normal subjects suggests that imagery mnemonics are more
useful: (a) in remembering past events rather than in remembering to carry out actions in
the future; (b) in acquiring information about specific episodes and events rather than
general knowledge; (c) in recalling concrete objects rather than abstract information; and
(d) in retaining arbitrary lists rather than structured, meaningful material [87].
It follows that the cognitive demands of everyday situations may best be handled using
other strategies or devices such as external memory aids, such as diaries or notepads. In
particular, imagery mnemonics may well be of very little value in learning the names of
other people, in recalling messages and in remembering to do things, which Kapur and
Pearson [44] found were the most important areas of concern for brain-damaged patients
themselves. However, although imagery is less effective for remembering people's names
than for learning paired associates (e.g. Refs [33] and [53]), Wilson [102] found that it
could be used to remember a small set of simple, familiar names, provided that the task
was highly structured. The latter might be an important and legitimate (although relatively
modest) goal in the context of physical rehabilitation.
Imagery mnemonic techniques enable individuals to impose some minimal associative
structure on an arbitrary and unstructured set of information, but they are likely to be of
little practical value in helping patients to incorporate new information into their store of
knowledge about the world. Cermak [6] and Richardson et aL [87] described one
postencephalitic patient who through the use of mental imagery, verbal mediation and
rote memorisation over many months learned to reply "Put on my sweater" in response to
the question "What do you do when you enter the house?" and to reply "Henry Aaron" in
response to the question "Who broke Babe Ruth's record for lifetime runs?" Nevertheless,
he did not learn to put on his sweater when entering the house and replied "Babe Ruth"
when asked who held the record for the most home run hits in a baseball career.
Indeed, one's knowledge of conceptual domains that are pragmatically important in
everyday life is represented in mental structures which are highly organised and integrated
IMAGERY MNEMONICS IN MEMORY REMEDIATION 1351
Researchers studying methods for improving memory function in older adults have argued
that, rather than teaching any particular mnemonic techniques, it would be much more
beneficial to encourage the development of self-monitoring and other metacognitive skills
[13, 71], and this demands the use of somewhat different instructional methods [73].
Until the problems of maintenance and generalisation are adequately tackled, imagery
mnemonics are likely to be of very limited value in the remediation of memory disorders.
Indeed, in contrast to the enthusiastic tone that he had adopted in his earlier writings,
Patten [70] concluded more modestly that "the ancient memory a r t s . . , may have a role in
the rehabilitation of brain-damaged patients" (p. 346). However, he remarked that their
usefulness would also be limited by the substantial amount of time needed to train
individual patients: "The current high cost of a neurologist's time precludes the
neurologist teaching the memory arts since a substantial amount of time is involved and
true mastery of art of memory requires at least an hour's work daily for 6 weeks" (p. 352).
In a similar vein, Schacter and Glisky [91] noted that the average gain per patient
resulting from a cognitive retraining programme described by Prigatano et al. [77] was an
average increase of one item on relevant subtests of the Wechsler Memory Scale as a result
of roughly 625 hr of training delivered by professional rehabilitation specialists. However,
Wilson [102] noted that successful remediation could have very significant benefits in terms
of both a reduced demand upon medical resources and the increased economic
independence of patients' relatives (if not of patients themselves). She also proposed
that routine cognitive retraining could be delivered by unpaid volunteers, but this ignores
the fact that in practice such duties are likely to fall upon the patients' female relatives who
may themselves have other domestic or occupational responsibilities [79].
An equally serious problem is that any benefits from imagery training tend to vary with
the severity of memory impairment. On the one hand, the performance of the most
profoundly impaired patients may simply remain at a floor throughout their training (e.g.
Refs [12] and [41]). It has been suggested that these patients may well benefit more from
external aids and environmental restructuring [102]. On the other hand, the performance
of patients with minor closed head injuries can be raised to the level of normal controls
[86], but in this population the memory impairment is quantitatively slight and typically
resolves within the first few weeks following the injury [85]. Paradoxically, then, any
benefits of imagery mnemonics will be inversely related to the need for memory
remediation.
Acknowledgements--I am most grateful to Alan Baddeley, Michel Denis and an anonymous reviewer for their
comments and suggestions.
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