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and permits the simultaneous monitoring and recording of many components
of patients responses for later inspection and analysis. Additionally
and importantly, use of the computer allows for a precise, reliable, and
standardized presentation of materials and is at the same time adaptable
for use across theoretical contexts. This has the potential for promoting
interdisciplinary team consistency and coordination.
Despite the frequency of the disclaimer that the computer is
only a tool, the fact remains that the tool continues to be confused with
treatment itself. When claims are made that certain software can remediate
cognitive deficits of one kind or another, the implication is that the
software itself is the agent of change rather than the organized treatment
program in which it is being used. In a similar way, claims for the efficacy
of psychological tests presume expert use and oversight by a qualified
psychologist. To fail to make this distinction between the computer as
tool versus treatment and to imply that the tool determines therapeutic
outcome is to discourage the thoughtful use of such software and to encourage
and perpetuate unwarranted expectations regarding its efficacy. As Ben-Yishay
and Prigatano (1990) suggest, cognitive remediation is meaningful only
if it is embedded in and systematically coordinated with other neuropsychological
rehabilitation interventions.
RESOLUTIONS:
1. 1 Computer-assisted rehabilitation procedures appear to have a sufficient number of practical advantages and potential benefits to encourage their continued experimental investigation, further development, and empirical validation.
1. 2 Appropriate clinical use of computer software in rehabilitation is dependent upon maintaining a clear distinction between software being properly viewed as a component in an organized treatment program versus being improperly viewed as treatment itself
ISSUE 2: WHAT IS THE EVIDENCE FOR THE EFFICACY OF COMPUTER-ASSISTED NEUROPSYCHOLOGICAL REHABILITATION AND COGNITIVE REMEDIATION?
In order to assess the role of computers in cognitive rehabilitation, it is necessary to consider empirical evidence that bears on the issue. Specifically, we need to know whether there is any evidence that (a) cognitive rehabilitation is effective under any conditions, and (b) use of a computer contributes to or improves the efficacy of a remedial intervention. The answers to these questions depend on the nature and goals of the rehabilitative strategy that is used, and the specific role played by the computer in a particular intervention.
EMPIRICAL EVIDENCE : MEMORY REHABILITATION
Research studies of memory rehabilitation (Gouvier, Webster, & Blanton, 1987) will be considered first. This priority is dictated not only by the fact that more empirical research is available on memory rehabilitation than on other cognitive functions, but also because the paucity of supportive findings for the efficacy of memory rehabilitation suggests an appropriately prudent approach to the efficacy studies of cognitive rehabilitation efforts in other areas of neuropsychological deficit.
Restoration. One possible goal of memory rehabilitation is to restore memory processes to pre-morbid or near-pre-morbid levels through training. In studies in which this has been attempted by exposing patients to repetitive drills and exercises across multiple training sessions, no significant training effects on general mnemonic function have been documented (Batchelor, Shores, Marosszeky, Sandanam, & Lovarmni, 1988; Godfrey & Knight, 1985; Prigatano et al., 1984). The null results are perhaps not surprising since the assumptions underlying the restoration approach are theoretically ill-founded (Schacter & Glisky, 1986). The lack of empirical evidence for the efficacy of restoration approaches does not "prove the null hypothesis", but suggests that attempts to use the computer to administer restoration-oriented memory drills or exercises are unlikely to succeed because the computer has no inherent therapeutic powers, as already discussed under Issue 1. The computer is simply a convenient means of presenting training stimuli (O Connor & Cermak, 1987).
Reduction of Negative Impact. A second approach to memory rehabilitation has explored whether patients can learn to use mnemonic strategies and thereby reduce the negative impact of memory disorders on their everyday lives. Several types of strategies have been investigated, including visual imagery mnemonics (Cermak, 1975; Crovitz, 1979; Crovitz, Harvey, & Horn, 1979; Lewinsohn, Danaher, & Kikel, 1977; Malec & Questad, 1983; Wilson, 1987), verbal organization (Gianutsos & Gianutsos, 1979; Glasgow, Zeiss, Barrera, & Lewinsohn, 1977; Wilson, 1982), and rehearsal (Schacter, Rich, & Stampp, 1985). The general outcome of these studies is that various strategies enhance memory processing, but are not always consistently used by patients on their own in everyday life (Wilson, 1987). The important question of generalization is thus suggested.
Compensatory Aids. A third approach to memory rehabilitation involves providing patients with external aids, such as notebooks, diaries, and alarm clocks, that can serve as helpful reminders and counteract some of the impact of everyday consequences of a memory disorder. There is some evidence that such external aids can be useful in real-life environments (Harris, 1984; Kurlychek, 1983; Parent & Anderson-Parent 6, 1989; Wilson & Moffat, 1984). It has also been suggested that the computer could be used as an external aid for memory-impaired patients (Harris, 1984; Silbeck, 1984). Preliminary evidence exists that patients can use the computer to aid performance of a real-life task (Chute. Conn, Dipasquale, & Hoag, 1988; Kirsch, Levin, Fallon-Krueger, & Jaros, 1987), and further controlled investigations into this possibility should be pursued.
Domain Specific Knowledge and Skills. A fourth approach to memory rehabilitation involves attempting to teach patients domain-specific knowledge and skills that are useful in everyday life (Schacter & Glisky, 1986; Wilson, 1987). Several studies have shown that patients can learn specific new skills, even though memory does not improve in any general sense (e.g., Jaffe & Katz, 1975; Wilson, 1987). The research of Glisky and colleagues (1986 a, b) has demonstrated that memory impaired patients can learn to operate and interact with computers in the laboratory, and also has shown that a severely amnestic patient could be successfully trained to perform a real-world job involving data entry into a computer (Glisky & Schacter, 1987). These results suggest a rather different role for computers in memory rehabilitation than has been considered previously. It may be useful to attempt to train patients for jobs involving certain uses of computers. However, much more evidence needs to be accumulated before it can be determined what kinds of patients and jobs are appropriate for such training.
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