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Neuropsychologia,Vol. 33, No. 11, pp.

1345-1357, 1995
Copyright© 1995ElsevierScienceLtd
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Department of Human Sciences, Brunel University, Uxbridge, Middlesex UB8 3PH, U.K.

(Received 10 May 1994; accepted 11 October 1994)

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.

Key Words: brain damage; imagery; learning; memory; mnemonics; remediation.

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

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
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.


Localisation and lateralisation

Patten [68] considered that the three patients he had tested who had failed to benefit
from mnemonic training had lesions in the midline structures of the brain. Elsewhere, he
proposed that such structures had a generalised function in the encoding of new memories,
so that damage to these regions would give rise to a global memory deficit [67]. In contrast,
structures within the two cerebral hemispheres had a specific role in encoding memories in
each modality; consequently, damage to these structures would give rise to selective
memory impairment which could be alleviated by encoding material instead using the
intact modalities.
More specifically, Patten [68] concluded that "each of the cases in which memory
therapy was successful was able to overcome a verbal memory defect by the strategy of
encoding in the preserved, or relatively preserved visual modality" (p. 31). Clinical
investigations had confirmed that in these cases the brain damage was localised in the left
hemisphere (see Ref. [67]), and elsewhere he argued that these patients had been able to
compensate for this damage by relying upon the intact capabilities of the right hemisphere
for creating mental images [69, 70]. This was indeed a natural conclusion to draw from the
conventional wisdom at the time that the right hemisphere contained the neural substrate
of mental imagery [54].

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.

Localisation and aetiology

The locus of brain damage in neurological patients typically depends upon the precise
aetiology of that damage. Relatively permanent, stable and global impairments of recent
memory may result from damage either to the diencephalon (associated mainly with
Korsakoff's syndrome, thalamic infarction and tumours of the third ventricle) or to the
medial temporal lobes (associated mainly with bilateral temporal lobectomy, herpes
simplex encephalitis and anoxia). A number of case studies have also suggested that
similar (though often less severe) impairments may result from damage to regions within
the frontal lobes (associated mainly with intracranial aneurysms of the anterior
communicating artery) (see Ref. [65], Chapter 7).
Lhermitte and Signoret [55] suggested that there were qualitative differences between the
patterns of impairment produced by diencephalic and temporal-lobe lesions, and there is
now substantial evidence for this point of view [64]. Weiskrantz [100] argued that in many
cases apparent differences between the two categories of patients could be attributed to
uncontrolled variation in the severity of their memory impairment, but it is unlikely that
this would explain all of the differences that have been observed (see Ref. [65], Chapter 8).
Patients with anterior communicating artery aneurysms not surprisingly tend to show
frontal-lobe symptoms, but their memory deficits may be the result of generalised arterial
vasospasm rather than of localised frontal damage [84].
1348 J . T . E . RICHARDSON

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.

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).

Intelligence and education

The role of intelligence in this context is not clear. One study using normal subjects found
that imagery instructions were of benefit only to those individuals who had obtained scores of
110 or higher on the U.S. Army's General-Technical Test [36]. There is nevertheless good
evidence that training in the use of mental imagery can be beneficial even in the educable
mentally retarded [59, 63, 98]. Indeed, a study carried out with college students found that the
effectiveness of imagery instructions was inversely related to their verbal ability; this
apparently reflected the spontaneous use of effective learning strategies on the part of
subjects of high verbal ability even in the absence of specific instructions [60].
In neuropsychological research, educational attainment is sometimes used as a proxy for
premorbid intelligence, or else it can be of interest in its own right. Gasparrini [23]
suggested that training in the use of imagery mnemonics would be useful only to brain-
damaged patients who were high-school graduates. It is true that many studies have been
concerned with patients who were educated to college standard [52]. Nevertheless, given
appropriate testing procedures, even children as young as 8 years can benefit from training
in the use of mental imagery [15, 72, 74].

Motivation and insight

Patten [68] also stressed the importance of motivation and insight. Of the three patients
who failed to benefit significantly from training in imagery mnemonics, he stated that
"none were aware of their memory defect or interested in improving it" (p. 31). The
importance of the patient's motivation is not surprising, given the effortful nature of most
mnemonic techniques. A patient's motivation to engage in cognitive retraining may
depend upon the perceived relevance to the requirements of daily living of both the
learning task that is to be used for retraining and the cognitive strategies that are
recommended in order to achieve it (see below).
Unfortunately, the frequency of memory complaints among patients with brain damage
is sometimes uncorrelated with their level of impairment on objective psychometric testing
[44, 95]. This lack of insight compounds the problem of poor motivation when attempting
to remedy memory deficits [89]. In dealing with head-injured patients, Prigatano et al. [77]
therefore incorporated psychotherapeutic interventions which were intended to develop
"increased awareness and acceptance of the injury and residual deficits" (p. 507; see also
Ref. [78], Chapters 5 and 6).
Motivational factors may well explain two otherwise puzzling findings from my own
research on the effectiveness of imagery instructions in cases of closed head injury. First,
middle-class patients benefited from these instructions but working-class patients did not,
at least when tested by a middle-class psychologist [82]. Second, and independent of this
effect, the benefits of imagery instructions decreased monotonically with age from the
teens to the 60s, at least when the patients were tested by a young adult psychologist [88].
This pattern of results is unlike most effects of ageing on cognitive functioning, which are
normally not apparent until the 50s or 60s, and both findings are more plausibly to be
interpreted in terms of variations in perceived demand characteristics.

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

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.

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

[83]. Seeking to improve memory function in neurological patients in a global manner by

means of mental imagery and other mnemonic devices imposes further demands upon
their already impaired memory for specific episodes and events. Glisky and Schacter [29,
30, 91] have suggested instead that rehabilitation should exploit their residual learning
capacities and prior knowledge to facilitate the acquisition and retention of knowledge
within particular domains of practical significance to patients themselves.
The complexity of the learning task is also important. Baddeley and Warrington [2]
found no improvement in a heterogeneous group of amnesic patients when they were given
instructions to make up mental images which linked together groups of four items.
However, Cermak [5] hypothesised that amnesic patients might be able to benefit from
somewhat less complex images, and he found indeed that imagery instructions enhanced
the recall performance of Korsakoff patients when learning simple paired associates. In
general, the efficient use of mnemonics demands vigilance and planning, and yet it is
precisely this sort of function that might be compromised in brain-damaged patients [91].
Hence, the elaborated learning task should make only reasonable demands upon their
residual information-processing capacity.
These issues have been illustrated by research on memory training in the elderly [71].
Older subjects show less benefit than younger subjects when asked to learn long lists of
words using a more complex mnemonic device such as the method of loci [3, 46, 47].
However, they show as much benefit when asked to learn short lists of words by the same
method [80], and they tend to show more benefit than younger subjects when simply asked
to construct linking images in the context of paired-associate learning [4, 40, 90]. This
might nevertheless require adapted procedures (e.g. longer acquisition and retrieval times)
if older individuals are to benefit from imagery training [97].
Nevertheless, brain-damaged patients do seem to have problems in the spontaneous use
of mental imagery. Normal individuals show an improvement in their memory
performance from the use of either experimenter-generated images in the form of line
drawings or self-generated mental images, and in older adults at least the amount of
improvement tends to be greater in the case of the latter than in the case of the former [40,
96, 97]. In contrast, patients with memory impairment may benefit more when images are
provided by the experimenter (e.g. Refs [11], [39], [41], [62] and [96], but cf. Ref. [51]).
Similarly, brain-damaged patients may need to be prompted or reminded at the time of
recall that they used mental imagery to learn the critical material if they are to show any
improvement in their performance. Jones [41] found that patients who had undergone
bilateral temporal lobectomy appeared to forget that they had previously formed an
imaginal association linking the items to be remembered and so were unable to use these
images at the time of recall. Cermak [7, 8] reported that the Korsakoff patients who had
benefited from imagery instructions in his earlier study [5] had nevertheless had to be
reminded constantly of the specific image they were supposed to be using on each learning
trial and of the fact that they had used that mnemonic at the time of retrieval.
In general, without explicit structure at the time of learning and explicit prompting at
the time of retrieval amnesic patients may show no improvement as a result of training or
instructions in the use of mental imagery. Of course, such explicit structure and prompting
is not likely to be encountered outside the psychological laboratory or the clinical
assessment room. For this reason alone, imagery mnemonics might well be expected to be
of very little value in enabling brain-damaged individuals to respond to the cha!lenges of
everyday life unless they can also be trained to generate their own internal cues or

reminders [87]. This demands a broader-based approach to rehabilitation that integrates

the cognitive and noncognitive modes of psychological processing [38].


Patten [68] made no systematic attempt to follow up his patients' use of imagery
mnemonics in daily life, but in some cases their anecdotal reports indicated that they
continued to use these techniques many months after their original training. Gianutsos [26]
similarly found that one postencephalitic amnesic continued to use mental images or
simple stories as mediating devices to recall word lists for 2-3 weeks after his formal
training had been discontinued. Malec and Questad [56] also found that a mildly impaired
patient with closed head injury learned to use imagery as a mediational device without
prompting from his therapist. However, other researchers have not found convincing
evidence that brain-damaged patients continue to use such devices in similar learning tasks
beyond a few days in the absence of explicit instructions to do so [7, 10, 22, 37, 53, 102].
Apart from the maintenance of imagery mnemonics beyond the period of formal
training, one would also hope that patients could generalise their use to other tasks and
particularly to learning situations in daily life. Crosson and Buenning [10] found that
training a patient with closed head injury to use imagery and other devices to learn short
paragraphs of text had modest benefits for his performance on other memory tasks.
However, other researchers have found little evidence of generalisation of imagery
mnemonics to different tasks in brain-damaged patients, still less of any transfer to
learning in everyday situations [22]. This is not a specific limitation of imagery mnemonics,
since similar problems are encountered in using methods based upon purely verbal
elaboration or mediation [34, 102]. In fact, brain-damaged individuals tend to reject both
verbal and imaginal techniques as being inappropriate or irrelevant to their needs in
everyday life and instead prefer to use external memory aids [10, 27, 28].
One aspect of Patten's [68] original study that has been generally neglected in
subsequent research is the potential noncognitive benefits of training and instructions in
the use of mental imagery. Patten commented that the patients for whom his memory
remediation was successful were able to rely upon their own memory skills rather than
those of others, and that they experienced a marked increase in self-esteem as a result. Of
course, even those patients who do show improved retention may well not experience any
increase in self-esteem if they attach relatively little importance to memory improvement in
comparison with other personal goals. Conversely, it has been argued that having to rely
on external memory aids might rob brain-damaged patients of any sense of ownership
over their own cognitions and generate a profound existential anxiety [61]. This might
explain why patients often fail to use external memory aids in an efficient way [29].


It is quite clear that training and instructions in the use of mental imagery can lead to
improved retention in various groups of brain-damaged patients. These mnemonic
techniques do enable brain-damaged patients to impose some associative structure on an
arbitrary and unstructured domain of information. However, the effective deployment of
these techniques in daily life depends on the patients' "metacognitive" skills: that is, the
patients' awareness of how, when and where such techniques should be used [9, 45, 73].

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

Acknowledgements--I am most grateful to Alan Baddeley, Michel Denis and an anonymous reviewer for their
comments and suggestions.

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