About the Book

• The Lady and the Unicorn: A Psychological Metaphor



• Dreaming�With Eyes Wide Open: Schizophrenic Hallucinations



• Information Processing in Schizophrenia



• Clarification of our Clinical versus Forensic Function: Dual Relationship



• Art Psychotherapy



• Lord of the Rings: A Psychological Metaphor



• Aviation Psychology



• So, You have just been Passed by a Girl! A Holley Carborator may help



• Approaches in Memory Rehabilitation



• Memory Enhancement Module



• Negaunee Center



• The Final Transition



• Is Deinstitution- alzation a Misnomer



• Token System: a Psychiatric Case Study



• A Token Economy System: Inpatient Psychiatric Population



• Insight: An Aspect of Neurocognition

Memory Enhancement Module

You have been referred to attend the Cognitive Skills module by your interdisciplinary team. This training is designed to enhance your memory skills. Over the years, many patients have mentioned that they are bothered by memory various problems. We have never had a program before which addresses these aspects of memory. Our program is special 12 week session for learning some memory techniques and strategies which may help improve your memory recall.

The memory enhancement class will be one hour per day, for 12 weeks. During these session, various techniques for memory enhancement will be discussed and practiced. The format outline is as follows:

An overview of the program will be presented to all participants. Patients will be positively reinforced for their desire to enhance their memory. Session 1: Each individual must be pretested in order to determine the current baseline functioning level of memory recall ability. The following testing will be completed: 1) a list of 10 words; 2) List learning; 3) List recall; and 4) Proses memory. Questionnaires and assessments will be performed to establish a baseline of current memory performance. Skill Area 1:Associations and Imagery

Visual imagery techniques focus upon improving retention and memory recall. The research by Gasparrini and Satz (1979) found significant improvement in recall by using visual imagery techniques in contrast to rote memorization and verbal mediation. Cognitive researchers, such as (Atwood, 1971; Bower, 1970; and Pavio, 1969); and professional mnemonists (Furst, 1944; Gordon, Valentine & Wilding, 1984; Lorayne & Lucas, 1974) have emphasized the utility of imagery techniques as a means of organizing information for subsequent recall. O'Connor and Cermak (1987) stated that "their evidence comes from experimental investigations demonstrating that an individual's memory capacity can be increased dramatically when to-be-remembered items are aligned with an image" (p. 266).

Why this is consistently found is still an object of speculation. One of the most obvious hypothesis is that imagery strengthens the memory event through redundancy. For instance, instead of only a verbal label coding the memory event, an addition of a mental image provide new traces for subsequent recall and association. The sensory integration theory (Ayres, 1972) helps in the explanation of the effect of redundancy with the improvement of learning through multiple sensory processing.

Another stage in information processing of a memory event includes the act of association. Effective memory recall is based on the principle of association. It can take place either actively or passively, although active association appears to be the strongest in terms of duration. One of the fundamental principles of a trained memory is to become aware of exactly what is to be remembered. The process of becoming consciously aware of the memory event and the association can be effortful and place demands upon the attentional system. Deficits in mobilizing this effortful attentional process can be one of the major obstacles in achieving active associations through imagery.

It is easier to remember things that are meaningful to you than to remember things which are not. The term meaningful here really consists of a hierarchical relationship from concrete to abstract, or from sensory to semantic. The process of association to already known or meaningful experiences might be less effortful through the use of elaboration within a previously established associative network. The addition of material to an established memory trace may be less effortful than the process of establishing new learning patterns (Bradshaw & Anderson, 1982). By purposefully associating anything to something you already know is the first step in memory training. Extending this further, complete thoughts may be associated to each other using a similar strategy. In other words, one thought will remind you of the next thought. The process of mental associating will relationally tie two items together. For instance, associating two objects together such as a house with an airplane might be mentally imagining a flying house. This creates a striking image in ones mind and serves as a cue for the retrieval of the memory event.

Basically, when a mental image is formed and one item is integrated with another, an unusual association is formed. These unusual associations can be created in various ways. Exaggeration of something, making it usually small, very large or out of proportion to normal, is a technique that will make the association more prominent in your mind. Another technique is to give the associative image an action characteristic (i.e., running, skating). Ordinary items tend to slip from our memory whereas unusual and novel items seem to stay in the memory much longer. Imagines do not have to be bizarre, but in many cases where two distinctly different objects are associated together, they may appear so. The major point here is to emphasize that memory is enhanced through the use of mental images.

The purpose of this class is help enhance your memory. To begin our session I would like you to close your eyes and take three deep breathes. This will help you relax. Closing your eyes and relaxing will lower the amount of external visual stimulation and distractions. Images and associations seem to appear in better quality and longer duration if you are relax and concentrate on forming the image? Participants will practice forming mental images utilizing the following procedures:

Now, imagine a small point of white light in your mind. The point of white light will slowly grow larger until it encompasses your whole visual field. This white field is a movie screen on which images or words can be placed vividly in your mind. Now, imagine a triangle made of heavy black lines. Does everyone have that image? Now imagine the word MEMORY. Imagine a book on the screen. Imagine a car on the screen. Does everyone have that image?

This concept of image formation is an important component in memory enhancement techniques. Over these following sessions, I will be asking you to imagine a number of different items, objects, words, and pictures. I will want you to learn certain images and these images will be associated with other images in your mind. It is thought that one image will help you remember other images, words, and memory events.

Let's practice forming these images. Lets try to form an image of an elephant. Does everyone have that image? Now can you tell me what your elephant looked like. Group Discussion. Now lets form and image of your ward. Now what image were you able to generate? Group Discussion. How about tooth paste. Group Discussion.

One major technique is to be able to form images. Images are formed more easily if it is a concrete object. For instance, it is more easy to form and image of an airplane then peace. But all words you want to remember do not come in the form of concrete objects that are easily imaged. In some cases we must use other techniques to form images. For instance, does the word sound like another word which is a concrete object. The word "Art" might be referring to a painting but it might also be associated with a friend whose name is Art. This was an easy example but more difficult words can be remembered by using this sounds-a-like techniques. An emerald sounds like an could be associated with an emery board.

Creating your own associations has been found to be better than any other means of forming associations. Since it is not normally done you will need some practice to get good at creating images. Everyday I will give you a list of words to practice on in forming images.

Training in mnemonic peg word strategies is another popular technique which has been used for memory rehabilitation purposes (Harris, 1978; Lorayne & Lucas, 1974; Pressley & Ahmad, 1986; Wood & Pratt, 1987). In terms of the visual imagery techniques, this strategy utilizes "peg-words." The technique of using a peg-word mnemonic system is to associate images of object with items to be remembered. This peg word technique asks the subjects to visually associate a list of objects (e.g., teapot or a radio) with the numbers 1 through 10.

This type of technique is viewed as an internal strategy (Harris, 1978), which is used to organize and/or encode information so that it can be more easily remembered. Solhberg and Mateer (1986) have defined this as transforming a unit of information into some alternative form for integration into an organized scheme. Patten (1972) utilized the 'peg system' for memorization with patients who had verbal learning deficits associated with dominant (usually left) hemisphere lesions. Solhberg and Mateer (1986) gave an example of rhyming numbers (i.e., one is a bun, two is a shoe, three is a tree...). After learning the items to be remembered they can then be paired with the a list of numbers.

Another technique is to substitute words which sounds-a-like the item to be remembered. This technique is useful in remembering more abstract material which is difficult to imagine. You can recall something that has a clear image mentally and sounds like the item your want to remember. For learning a list of numbers, a person can learn rhyming words which sound like the number to remember. In this way we are learning a "sounds a-like" principle as well as creating an vivid associative image.

Session 2: The memory enhancement group will be explained the importance of memory recall ability and its impact upon learning and higher cognitive processing. They will be introduced to the concept of utilizing cognitive techniques for improving the efficiency of memory recall. The first technique will be rhyming and the use of peg words for improving memory recall. This will be demonstrated and explained that the words rhyme with numbers 1-10. These numbers serve as cues for future word list.

Session 3: Again the group will verbally practice the rhyming strategy. The concept of imagery will be also be practiced. The examiner will ask each participant to produce and image of the rhyming words in their mind. The examiner will also draw the 10 rhyming words and the draw the pictures they represent. Participants will be encourage to formulate their own images based upon experiences they currently possess. It will be explained that their own images will be better than any other images they can use. Participants will be encouraged to form their own associations. Associating new material with memories they currently possess is better and easier than trying to learn new material.

Another technique to improve you memory is to rhyme the word with something that is easily imagined. For instance, lets try to rhyme words with the numbers one through ten. Group discussion. Now I have a list of words that rhyme and many of you had the same words. Let's try to remember this list. 1=Bun,...10=Hen. Do you understand that the number one sounds like bun. Let us learn these associations. 1=Bun, 2=Shoe...10=Hen.

Now, I want you to imagine a Bun, what type of bun do you envision. Group Discussion. In my case, I see a hamburger bun. Can everyone see a bun? This bun is a concrete object and relatively easy to envision. Another technique is to make the bun very large or very small. What do you see? Group Discussion. This is the same as making something out of proportion. Sometimes it is easier to remember something which is unusual or different then something very ordinary. Most things you will attempt to remember are ordinary such as items from a grocery list. But you should try to imagine them just a little differently, if they are different then they may stand out more in your mind and assist you in remembering.

Now that we have all memorized the list of rhyming words with the numbers one through ten. Lets try to look carefully at each image. What I want you to do is to imagine another item associated with the hamburger bun. Group Discussion. What was that object or item. These objects seem to go together with a hamburger. Well this is the act of making an association. Let's try the following words. Can you imagine a book and a hamburger bun. What images did you get. Group discussion. Some saw a hamburger bun setting on a book; others saw a hamburger bun along side of a book. Another technique is to have the objects interact or touch in some way. For instance, you may see a book inside a hamburger bun. In this way, you are creating a striking and unusual image. This may stand out more clearly in your mind because it is unusual. Almost anytime you associate one object with another especially if they are different you will get an unusual image. One object will help you remember another object. Let's go through the entire list of words.

Session 4: Participants will again practice forming mental images as well as begin drawing these images. The examiner will encourage by asking questions of the images more detail. This will encourage elaboration of the images and subsequent more clear images of the ten objects. Participants will be asked to practice forming these images and told they will be utilizing these images in the future. The examiner will explain to the participants the possible use of these images in remembering lists of items. Discussion among the participants in describing their images will be encouraged. This discussion will assist in determining whether certain individuals are having any difficulty in forming images.

Session 5: The participants by this point are able to recall all ten objects though utilization of the rhyme. Images should be formed for the ten objects and drawn by the participants. After the 10 objects are drawn, the examiner will give the participants 5 words and ask to draw these objects touching the images 1-5 they have already drawn. This will provide the examiner with information about the clarity of the two images and their interaction. Assistance will be given to the participants to form images based upon their own associations with these objects. The examiner will make sure the two objects are clearly identified and not hidden or to small to see in the drawing. The examiner will explain that one can make the images out of proportion and by doing this you can make the new item bigger then the other image. The examiner will also encourage the participants to make an mental image of the two objects together.

Session 6: Again practice drawing and making mental images will be encouraged. New item will be given to the participants. The examiner will encourage and explain that to improve memory purposeful attention must be given to what is to be remembered. Also that this purposeful attention must also be utilized in forming images. Ask the participants to have the images blend together in their mind by picking the most important or most obvious characteristic of the images. The participants will be explained that the most salient characteristics is most likely the one to be remembered best. Participants will be reassured that any objects can be associated with the images they had previously learned. Sometimes these objects don't go together and when they are imaged together they form and unusual association. This association does not have to be bizarre but it may be unusual. Unusual associations become novel and novel experiences are sometimes easier to remember than ordinary events.

Session 7: Again the participants are asked to practice and form images. The examiner will the participants to generate a list ot ten to twenty items which are easily imaged. This list should be concrete objects, since concrete objects are more easily imaged than abstract items. Practice with this will constitute the remainder of this session. Every participant will be asked to recite the list of items. The list of items will be gradually increased beginning at five objects and ending at ten items. Difficult remembering the list will be handled by having the participants draw the associations and again encourage them to use their mental images. The participants will be assigned to bring back a list of 10 objects the following day which they may want to remember when they leave the hospital: 1) Common grocery items; 2) Common household shopping goods; 3) Bills from companies; 4) Similar items and related categories; 5) Random items.

Session 8: These lists will be used for practice in forming images and associating them with numbers one through ten. A new linking technique will be introduced which will involve their apartment or home. Imagine walking up to your house and look at the front yard, now look at the front door, imagine turning the door nob, and walking into the hallway, look into the living room, look into the dining room, look into the kitchen, look into the bathroom, look into the bedroom, walk to the back yard. What we have done is to take a mental walk through our house. We have passed ten different locations on this walk and these locations are linked together in sequential order. We have chosen our own house because we already have a good mental association with what the house and rooms look like. To remember a list of objects using this method simply place one object at each location. Let's practice this method. Be careful in forming the images so that they stand out and are prominently seen at each location. For instance, and object this white will not stand out clearly if it is placed next to a white door. An object that is very small might not be noticed in a large room, so try to make the object bigger or smaller and this will create a better and more novel impression.

Session 9: Some of the most common verbal techniques are: chaining or linking, first-letter cuing and semantic or phonetic elaboration. Link system is applying a link from one item to another and forming a memory association. It is difficult remembering anything "word for word", you could simply link the points you want to remember together in a sequence and tag each with perhaps one word which will form the link between thoughts. This one word is considered a key word which will guide you to the next thought. You can also use this technique when listening to another person because not only are you listening to the thought they are trying to express but you are listening for a key word which will remind you of that thought. Thus, in effect you are increasing your attention span by listening very carefully to what is being said. This technique has been helpful in remembering lists of items (Higbee, Clawson, DeLano and Campbell, 1990). Using the technique of chaining or linking, items are then organized into a list, which successively links items together so that one item leads to the next item. Through the practice of rehearsing and elaborating on these associations will form solid memory association for these items to be recalled later. Using the linking system, a sequence of associations is being formed one following the other. In practice, one item might be used to remind you of another one. Wilson (1987) presented a series of procedures for using this technique as follows:

This time, when I read the words, I want you to make a picture in your mind of the first word. When I tell you the second word, try to imagine the first and second words interacting in some way. Then link the second with the third, the third with the fourth, and so on. The first word is injection. Have you got a picture of that? Now imagine injection with milk. have you go that? Now link milk with potato... potato with ox... ox with rubber... rubber with table... table with candle... candle with armadillo... armadillo with newspaper... newspaper with candle... candle with earring. Earring is the last word. Ready? Now tell me back as many of the words as you can. you can start at the beginning or the end, or anywhere you like. (p. 213) One manner of accomplishing this is by making up a story with incorporates all the items together (Bellezza, 1981).

Session 10: Elaboration and making a group of words into a story, is another method used in remediation of memory recall deficits in both normal and braindamaged subjects (Crovitz, 1979; Goldstein, McCue, Turner & Spanier, 1988; Higbee, 1977). Winograd and Simon's (1980) research with the elderly found that remembering more words was facilitated when the interaction between the words was imagined. Crovitz (1979) developed a story method using what is known as an 'airplane list'. This airplane list used 10 words which were to be remembered by embedding them in a story. For example, Wilson (1987) offered the following procedures

The first word is 'umpire', you can remember that any way you like. The second word is 'nose' because the umpire was hit on the nose by a ball. The third word is 'iceberg',because the umpire crashed his nose into an iceberg. The fourth word is 'vase', because an ancient Egyptian vase was balanced on the iceberg. The fifth word is 'elephant', because an elephant picked up the vase with his trunk. The sixth word is 'refugee', because a refugee was escaping on the elephant's back. The seventh word is 'skylark', because a skylark was flying round and round the refugee's head. The eight word is 'imp',because a mischievous imp trapped the skylark in a net. The next word is 'tree', because the imp climbed up a tree to hide. The last word is 'yak', because a yak came up to the tree to scratch his back. (p. 210)

For the 24-hour delayed recall, the instructions by Wilson (1987) were as follows:

Yesterday I read five lists, of words to you and asked you to tell me back as many as you could remember. For the first list, I asked you to remember the words without using any particular strategy. Can you tell me as many word from that list as possible? For the second list, I asked you to imagine things in different palaces in you house. How may words can you remember from that list? The I read you a list where the initial letter spelled out a certain word. Tell me as many words as you can remember from that list. Next, I asked you to imagine pictures of the words linked together in some way. Tell me as many words you can from that list. For the last list I made the words into a strange story. Tell me as many words as you can from that lists. (p. 213)

Another technique to remember a list of objects is to make up a story which incorporates all the objects together. Arrange the objects to be remembered in such a way as one object interacts or is connected to the next object. In this way, one object will trigger an association or cue for the next object. Place the images in order, this will help remember the order of recall. One way to place images in order is begin at the bottom and build towards the top. Another way is to begin with a large object which has things inside getting progressively smaller.

Session 11: In this session we are going to make up and unusual story. The story has to do with a man who walking down the street. This man is unusual in how he is dressed. For instance, he is wearing a hat on his head, glasses on his face, a shirt, pants, and shoes. He is walking on a sidewalk and bumps into a mailbox. Out of this mailbox something drops out, it bumps into a car and the car bangs into a building. Here we have a short story with ten possible locations for objects. Lets practice placing 10 objects into this scene.

Session 12: Face and Name-Let's try some name and face associations. Go through all the names of people in the class have everyone give a sound-a-like name association and pick a prominent feature on the individuals face for the association. Another strategy for making associations is to use semantically or phonetically related words as substitutes for more abstract terms. For example, origin might be associated with the word egg or seed (semantic elaboration) and Orange or Oregon (phonetic elaboration) (Bellezza, 1981).

Session 13: Visual imagery is a promising technique for improving recall in memory-impaired adults; verbal methods also play an important role. One method is alphabetical searching. This procedures involves proceeding through the alphabet using a particular letter as a retrieval cue for the item to be remembered. The system of first-letter cueing is relatively simple and used commonly in everyday situations. The technique utilizes the first letter of the word to be remembered as as retrieval cue. For instance, "I knew it began with an A... Apples"). Using this method, could mean searching every word in a category beginning with a letter "A."

Another verbal method for recall is using first-letter cueing. This method is fairly widely used by the general population (Harris, 1980a). An example of this technique would be remembering the saying "Richard of York Gives Battle in Vain" is a first-letter mnemonic for remembering the different colors of the rainbow. In music :"Every good boy deserves favor," for the lines of music E,G,B,D,F. Whereas FACE stands for the notes between the lines. First letter acronyms are another technique and are called encoding operations (Bellezza, 1981). For instance, "Homes" is an acronym in which the letters stand for the names of the great lakes.

However, Harris (1980b) suggested that this method is likely to be successful only when the material to be remembered is well known and is difficult to recall in the correct sequential order.

Wilson and Moffat (1984) have indicated that the first-letter cueing technique is successful due to (1) the chunking of information, and this process has been found to increase recall in some types of information (Brown & Sproson, 1987; Miller, 1956); and (2) it appears to reduce the quantity of competing responses. In addition, cueing through partial information has been found to be effective in improving the recall of amnesic subjects (Warrington & Weikrantz, 1968). First-letter cueing enables people to establish their own retrieval cues for associations. The research by Cermak (1975) demonstrated that verbalmediation techniques assisted Korsakoff patients who were able to learn word pairs, like 'clock-glove', when a verbal mediator (hand) or a visual image (a glove on a clock) was utilized. Cermak (1975) suggested that imagery assists both in recall and recognition tasks, whereas verbal mediation assisted in recall tasks only.

Session 14: Another visual-imagery technique is the method of loci (location), which has been used for many centuries. Yates (1966) reported that Simonides of Thessaly, of ancient Greece, recalled the names of banquet guests after an accident by remembering where each guest had been sitting. At first glance this would appear as supporting the use of memory by location. Although, Moffat (1984) offered an alternative explanation, in that there was no evidence in this report which suggested that Simonides had visually encoded the position of each person before he was called from the banquet, Simonides may have used location as a simple memory retrieval cue.

Examples of the method of loci were demonstrated by Luria (1968) study of a famous mnemonist, Shereshevskii. The procedures involved forming mental images of items placed at various points along a well-known street, for instance, placed upon a window sill, in a doorway, and by the curb. It should be noted that some difficulty with retrieval using this method occurs when the item was visually similar to the background location (e.g., white eggs imagined by a white door). This method has been studied in nonbrain-damaged subjects by (Ross & Lawrence, 1968; Groninger, 1971; and Higbee, 1977). The method of loci has been used with the elderly population (Robertson-Tchabo, Hausman, & Arenberg, 1976), with some success in an experimental situations. Although it was also found that the elderly did not spontaneously use this technique outside the clinical setting. In another study, Anschutz, Camp, Markely & Kramer (1985) found that elderly subjects demonstrated near perfect performance using this technique to remember a grocery shopping list.

For testing method of loci: Ten locations were used which were familiar to each subject. Wilson (1987) stated that the locations were selected in the subject's own house consisting of the following: "(1) the front door; (2) the kitchen; (3) the dining room; (4) the sitting room or lounge; (5) the bed room; (6) the bathroom; (7) the toilet; (8) the window sill; (9) the hall or passage; and (10) the roof" (p. 210). Wilson (1987) suggests the following were the procedures:

For instance, the first word is pears; imagine a pile of pears by your front door. The second word is; 'umbrella', imagine that it is placed in you kitchen. The next word is 'rice' imagine some rice in your dining room. The next word is 'corned beef' imagine that in your sitting room or lounge. The next word is 'honey', imagine a jar of it in your bedroom. The next word is 'antifreeze'; imagine that in your bedroom. The next word is 'slippers'; imagine them in you toilet. The next word is 'ice cream'; imagine a tub of ice cream on the window sill. The next word is 'nuts'; imagine some nuts have spilled out in you hall. The last word is 'glue'; imagine it trickling over the roof....At the end of the reading of the list subjects were asked to take a mental trip around your house and try to remember what the words were. (pp. 211-213)

Images of locations can be paired with items to be remembered assisting the individual by visualizing a location, such as rooms in their house as cues to help them recall information.

Remembering to do something the next day can be a problem for some people; for instance, to mail a letter. One technique for assisting your memory is to imagine the last thing you usually do before leaving the house. Most of us lock our door on the way out for the day. Now imagine the letter jammed in the lock.

You have just mentally associated the letter with the lock. The act of imagining required that you became actively aware of this association. Thus, seeing the lock the next morning will help remind you of the letter. Using cues, especially if they are unusual images, will help you remember many other things. For instance, you may have something in the oven and you want to remind yourself that the oven is turned on. By making a active mental association between the oven and a teapot and then physically placing the teapot on the living room floor may help remind you the oven is turned on. The fundamental principle of using cues is that one thing will remind you of another. This cue technique is utilizes the concept of "things out of place" can serve as reminders to yourself. As mentioned previously, one of the primary principles of training your memory is to force yourself to pay attention, become aware, and observe the world around you.

When you want to remember a list of items, sometimes they are not from the same category. Categories are groups of items that are related in some way, such as animals, forms of transportation, groceries). It may be helpful to develop an system for remembering a category, for instance remembering transportation, think of someone driving. For animals you may want to imagine a farm yard with all the animals in the yard.

Session 15: In this course we have discussed a number of techniques to improve your memory. Review this material with the class. Can you think of the various uses for these techniques? How can they help you personally? Can you give me any recommendations for improving this course? Posttesting and evaluation of memory techniques will be given.