Factors influencing the uptake of memory compensations: A qualitative analysis

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Factors influencing the uptakeof memory compensations: Aqualitative analysisVictoria N. Baldwin a , Theresa Powell a & LouiseLorenc ba University of Birmingham , Birmingham, UKb Moor Green, West Midlands Rehabilitation Service ,Birmingham, UKPublished online: 16 Jun 2011.

To cite this article: Victoria N. Baldwin , Theresa Powell & Louise Lorenc (2011)Factors influencing the uptake of memory compensations: A qualitative analysis,Neuropsychological Rehabilitation: An International Journal, 21:4, 484-501, DOI:10.1080/09602011.2011.582378

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Factors influencing the uptake of memory

compensations: A qualitative analysis

Victoria N. Baldwin1, Theresa Powell1, and Louise Lorenc2

1University of Birmingham, Birmingham, UK2Moor Green, West Midlands Rehabilitation Service, Birmingham, UK

In 1996, Wilson and Watson stated that it is not always easy to persuade peoplewith memory impairments to use memory strategies, despite the value of usingthem. To date, there has been no in-depth exploration of what motivates peopleto use memory compensations from the perspective of the individual with anacquired brain injury. In this study eight people attending an out-patientbrain injury rehabilitation service were interviewed. Transcripts were analysedusing interpretative phenomenological analysis. Four master themes emergedfrom the analysis: emotional barriers that need to be overcome beforememory compensations are used; factors that may have a reverse effect onmotivation, such as the strategy being an unpleasant reminder that one is differ-ent; beliefs about memory, such as it is better to use your own memory ratherthan relying on memory aids otherwise it will become lazy; and the final mastertheme “It’s not in my nature”, i.e., it does not fit with the person’s lifestyle. Theresults show that motivation for strategy use depends on complex processesthat include social, emotional and practical factors. This study demonstratesthe importance of adhering to a biopsychosocial approach within rehabilitation.

Keywords: Memory compensations; Acquired brain injury (ABI).

INTRODUCTION

In 1996, Wilson and Watson stated that it is not always easy to persuadepeople with memory impairments to use memory strategies, despite thevalue of using them; “Some feel it is cheating and believe they should not

Correspondence should be sent to Theresa Powell, School of Psychology, University of

Birmingham, Edgbaston, Birmingham, B15 2TT. E-mail: [email protected]

NEUROPSYCHOLOGICAL REHABILITATION

2011, 21 (4), 484–501

# 2011 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business

http://www.psypress.com/neurorehab DOI:10.1080/09602011.2011.582378

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rely on aids, others feel compensatory aids will reduce their chances of naturalrecovery occurring” (Wilson & Watson, 1996, p. 466). Subsequent studiesusing quantitative approaches have explored a range of factors that influencestrategy use, e.g., Wilson and Watson, 1996; Evans, Wilson, Needham, andBrentall, 2003; Patel, 2008; however the personal beliefs and experiencesof those who use memory aids have not yet been explored using qualitativemethodology.

Demographic and injury-related variables have been explored (e.g.,Wilson & Watson, 1996; Evans et al., 2003), however, given that theseare static variables it is also important to examine modifiable variablesthat can be addressed in rehabilitation, such as memory self-efficacy(Aben, Busschbach, Ponds, & Ribbers, 2008; Kit, Mateer, & Graves,2007) and attitudes towards assistive devices (Lund & Nygard, 2003;Parette & Scherer, 2004). A more recent study (Patel, 2008) exploredhealth beliefs, such as perceptions of more serious consequences, greaterpersonal and treatment control, a cyclical timeline and greater emotionalrepresentations and how these influenced memory aid use in those withan acquired brain injury (ABI). It was found that health beliefs accountedfor 56% of the variance in memory strategy use (Patel, 2008). Althoughthis study explains over half of the variance in memory compensationuse, the emotional response that might explain the link between thegeneric questionnaire sub-scales and use of memory compensationsremains unexplored.1

Most of the research is quantitative in nature and, although this researchhas found factors that influence the use of memory compensations there isstill a need to address the issue from the individual’s perspective. Key ques-tions about the reasons why people use compensations, what makes themchoose specific compensations, as well as their experiences of using themneed to be asked. Research that has looked at the patient’s perspective hasbeen undertaken within other populations, such as those with physical ordevelopmental disabilities (Lund & Nygard, 2003; Parette & Scherer,2004) and so these findings can be considered speculative with respect topeople with ABI. Questions therefore still remain unanswered about thefactors that encourage or discourage the use of memory compensationsamongst people with ABI.

1 For the purpose of this paper, the term memory compensations will be used to describe

memory aids; i.e., external aids (such as a diary, mobile phone, wall calendar) and internal

aids (such as mnemonics). It is also used to describe memory strategies, for example, something

people think or do to help them remember, such as putting things in key places, and creating

mental pictures or rhymes to help them remember people’s names.

FACTORS INFLUENCING THE USE OF MEMORY COMPENSATIONS 485

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Demographic and injury-related variables

Five studies have explored demographic and injury-related variables includ-ing severity of cognitive deficits, premorbid use of compensatory aids, age,and education. Wilson and Watson (1996) and Evans et al. (2003) foundthat people without additional cognitive deficits and those people who usedmore aids prior to injury were more likely to be using compensatory strategiesafter injury and were also more likely to be independent. However, studiesundertaken by Wright, Rogers, Hall, Wilson, Evans, Emslie, and Bartram(2001) and Wright, Rogers, Hall, Wilson, Evans, and Emslie (2001) foundthat there was no correlation between psychometric scores (memory andother cognitive tests) and the use of an appointment dairy on the pocketcomputers used in their studies. Studies that looked at age and use ofmemory compensations found that being under 30 years of age at the timeof injury and current age predicted the uptake of memory compensations(Wilson & Watson, 1996; Evans et al., 2003). Three studies found thathigher educational attainment was also positively correlated with the use ofmemory compensations (Patel, 2008; Wright, Rogers, Hall, Wilson, Evans,Emslie, & Bartram, 2001; Wright, Rogers, Hall, Wilson, Evans, & Emslie,2001). Similar correlations between educational attainment and strategyuse have also been found in older adult populations (McDougall, 2004;McDougall & Holsten, 2003).

Although such demographic and injury-related variables are predictive ofstrategy use, they account for a small amount of the variance in the use ofmemory aids, for example, Evans et al. (2003) found a positive associationbetween use of aids and the number of aids used premorbidly and attentionlevels, and a negative association with age and years since injury.However, these factors only accounted for 27% of the variance in strategyuse. Although demographic and injury-related variables are clinically impor-tant, it is also necessary to explore other variables that are potentially modifi-able, such as health beliefs and attitudes towards assistive devices, as thesemay further enhance our understanding of what factors influence the use ofmemory compensations in those with ABI.

Health beliefs

A recent study undertaken by Patel (2008) based upon the common sensemodel of self-regulation of illness (Leventhal, Meyer, & Nerenz, 1980;Leventhal, Nerenz, & Steele, 1984), suggested that the strongest predictorsof strategy use were beliefs that treatment can control one’s memoryproblem and the belief that one’s memory problem is cyclical or variable.Patel (2008) suggests it is not surprising that those who hold the belief thattheir condition is controllable use aids more frequently as this belief is

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likely to result in an active, problem-focused approach to coping. In factresearch in people with other health conditions, such as epilepsy, breastcancer and Addison’s disease, demonstrated similar results (Hagger &Orbell, 2003). Similarly, Verhaeghen, Geraerts, and Marcoen (2000), in astudy of older people, found that those with a more internal locus ofcontrol believed they had greater control over their memory abilities andhence applied more efficient coping mechanisms/strategies. However, Kitet al. (2007) did not find a significant relationship between locus of controland the strategies sub-scale of the revised Metamemory in Adulthood Ques-tionnaire (MIA) in people with traumatic brain injury (TBI). The presentstudy might therefore help to resolve such discrepant findings.

Interestingly, Patel (2008) found that the more cyclical or variable theperson saw their memory as being, the more likely they were to use strategies.Given that memory failures caused by ABI are not traditionally considered tobe cyclical, this is a curious finding. Patel (2008) suggests that those peoplewith an unpredictable memory may feel the need to use memory compen-sations even more, in order to avoid the problem, especially if they believecompensations are effective. Nevertheless, this finding might be furtherelucidated by a qualitative study.

Perceptions about memory abilities can change after a brain injury result-ing in low memory self-efficacy (MSE: belief in one’s memory abilities) anddepression (Kit et al., 2007). It is reported that the use of memory strategiesmediated the relationship between traumatic brain injury (TBI) anddepression (Kit et al., 2007), suggesting that the need to use memory compen-sations may further reinforce the idea that memory abilities have changed.This may help explain why people with an ABI do not use memory compen-sations. A qualitative study might provide greater clarification of this conceptfrom the individual’s perspective.

Attitudes towards assistive devices

Attitudes towards assistive devices have rarely featured in studies of peoplewith ABI, although they have been studied in other populations. Olderadult research presents favourable attitudes towards the use of compensatoryaids and assistive devices such as walking frames, electric wheelchairs, andbath seats (Roelands, Van Oosta, Buyssea, & Depoorter, 2002). However,less positive attitudes have been found in people with disabilities. Paretteand Scherer (2004) report that: family expectations of assistive technology,perceptions of increased visibility or attention when using assistive devicesin public settings, device aesthetics and the perceptions that children usingassistive technology will not attain important developmental skills if theybecome reliant on them, impacts on the decision whether or not to implement


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devices such as mobility aids and communication devices (Parette & Scherer,2004).

A qualitative study that explored how people with disabilities (e.g., spinalcord injury, multiple sclerosis) experienced the meaning of assistive devices(mobility aids and aids for self-maintenance) within their occupations foundthat social consequences outweighed functional adequacy when making thedecision whether to use an assistive device or not (Lund & Nygard, 2003).Addressing people’s experiences of using memory compensations followingABI may reveal similar findings and so prove helpful to rehabilitationtherapists.

This study employs a qualitative approach using Interpretative Phenomen-ological Analysis (IPA) in order to expand on our current understanding offactors that influence the use of compensatory aids and strategies. A betterunderstanding of this area may explain some of the associations describedin the literature to date, and also provide guidance to therapists on how toencourage people with ABI to use memory compensations. Furthermore,this approach is in keeping with the philosophy of increased consultationwith service users which is now central to the development of services(Department of Health, 2008).

METHOD

Participants

Purposive sampling was employed in order to gain a closely defined group forwhom the research question was important (Smith & Osborn, 2008). Keyworkers at an out-patient interdisciplinary brain injury rehabilitation servicewere asked to approach people who met the inclusion criteria (i.e., partici-pants should have an ABI and should self-report everyday memory difficul-ties that cause significant problems to daily living). Severity of memoryimpairment was confirmed through formal testing using the List Learningsubtask of the Adult Memory and Information Processing Battery (AMIPB;Coughlan & Hollows, 1985) and the extent of everyday memory problemswas confirmed by asking participants to complete the Everyday MemoryQuestionnaire (28 item) (Sunderland, Harris, & Baddeley, 1983). Partici-pants’ key workers also noted that they had memory difficulties whichcaused significant disruptions to daily activities. Key workers were alsoasked to nominate people who were willing and unwilling to use memoryaids. Use of memory aids is a major focus of the programme and, althoughparticipants may have had other cognitive problems, key workers would beaware of who would need to use aids that would specifically addressmemory problems. Eight people were approached by their key workers and


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all eight agreed to participate in the study. Of these, three could be describedas having mixed views about using memory aids, three had positive views andtwo could be described as having negative views about the use of memoryaids.

Participants ranged from 19 to 58 years of age with a mean age of 37 years(SD ¼ 13.61). Their time since injury ranged from 9 months to 27 monthswith a mean of 17.5 months (SD ¼ 5.97). Six participants scored wellbelow the 5th percentile cut-off (z score of –1.65 or lower) on the AMIPB.Two participants scored above the 5th percentile cut off but were acceptedas they self-reported memory problems on the EMQ. The mean EMQ scorewas 1.53 (SD ¼ 0.68) similar to Royle and Lincoln’s sample of peoplewith memory problems caused by stroke (Royle & Lincoln, 2008). Five ofthe participants were male, two of whom were White British, one wasWhite Canadian, one was British Asian and one was Black British. Allthree female participants were White British. Four participants had sustaineda TBI, three had suffered a vascular injury and one had a viral infection. Atthe time of injury three participants were unemployed, two were in full-timeeducation, one was employed as a nursery nurse, one as a manual labourer andone participant was a supervisor for a substance removal company. Sixparticipants were living at home with their family and two lived alone butreceived help and support from family members. All participants had agood command of spoken English. Fortunately, the resulting sample washeterogeneous in terms of age, which was felt to be important as it mighthelp to provide an understanding of how this issue impacts on attitudestowards memory aids.

Data collection

Before each interview commenced the interviewer introduced the topic ofthe interview by rereading the main sections of the Participant InformationSheet. This was to ensure that the participants understood what was going tohappen and what the interview was about, i.e., having memory difficulties,what things people found difficult to remember, and using memory aids/strategies. At this point the interviewer made it clear that for the purposeof the interview a memory aid could be a physical device (the interviewerlisted a number of memory aids that people may use, e.g., diary, calendar,mobile phone, post-it-notes), or something that someone did (the inter-viewer listed a number of things that people may do, e.g., putting thingsin the same place or key locations) in order to help them rememberthings. Participants were then asked if they had any questions about theinterview process.

Interviews consisted of a series of open-ended questions centring aroundthree broad areas:


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. How they perceived and felt about their memory problems.

. Whether they used memory compensations.

. How they felt about memory compensations and reasons for using or notusing them.

Each interview lasted approximately 60 minutes and was audio-taped andtranscribed verbatim.

Data analysis

Initial analysis was carried out on the first three interviews so that any unex-pected and interesting themes introduced by participants could be incorpor-ated into subsequent interviews. Interpretative phenomenological analysis(IPA) was conducted, following the process outlined by Smith and Osborn(2008). IPA aims to explore the meanings particular experiences evoke forindividuals in order to understand how those individuals make sense oftheir world (Smith & Osborn, 2008). The initial analysis, which was under-taken by the first author, involved reading each individual transcript whilstmaking preliminary notes; this was followed by a more detailed reading inwhich the meaning of the text was examined and statements of similarmeaning were grouped into clusters for each individual. These clusters thusformed superordinate concepts for individuals. The first author thengrouped individual superordinate concepts into clusters of similar meaningacross participants and the first two authors clustered these superordinateconcepts into higher order clusters to create “master” themes that reflectedthe whole group.

To ensure validity of the resulting themes, triangulation was achieved inthree ways. Firstly, an independent researcher who had no experience ofbrain injury and who was not part of the research team analysed a sampleof the transcripts. She reviewed two transcripts which had been annotatedby the first two authors, comparing their analysis to hers and noted anysimilar or differing themes that emerged. This process was to ensure thatinterpretations were not overly influenced by the main researchers whoboth had experience of brain injury (one had assisted survivors of ABIback to employment and one had 20 years’ experience in a regional braininjury service). She was in agreement with the emergent themes created bythe researchers. Secondly, the initial master and sub-themes were developedthrough a process of discussion and negotiation between the first two authors.Thirdly, as recommended by Yardley (2008), respondent validation wasachieved by feeding back the master and sub-themes to a group of four ofthe original participants. Each participant was given a description and accom-panying quotes that reflected each master theme and sub-theme and the groupwas asked whether the themes and their interpretation accurately represented


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their experiences. Overall the group agreed with the interpretation but someof the sub-themes were rearranged. For example the master theme, “It’s notin my nature”, was initially divided into two sub-themes, however the feed-back group felt that this was not necessary.

Ethical considerations

Ethical approval for this study was obtained from South BirminghamResearch Ethics Committee.

ANALYSIS

Following analysis of the transcripts four master themes emerged and are pre-sented with their sub-themes in Table 1. Table 1 also demonstrates how manyparticipants are represented within each theme.

TABLE 1Master and sub-themes reflecting participants’ experiences of using memory

compensations and the number of participants who represent each theme

Master themes Sub-themes

Number of participants

representing each theme

Emotional barriers preventing

acceptance of memory

compensations

Not wanting to appear to need

help

3

Feeling embarrassed/thick 5

Feeling different 5

Reverse effects You have to know what it’s

like

3

Style of reminding 4

People doing too much for

you

2

“It would make me feel as if I

have got a problem”

1

Beliefs about memory Needing something to “bring

it home to you”

6

Belief in memory improving 3

Belief that rehearsal/repetition helps

3

“Use it or lose it” 2

“It’s not in my nature” 5


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Emotional barriers preventing acceptance of memorycompensations

The first master theme and one of the richest themes, was the notion thatseveral emotional barriers need to be overcome before people would usememory compensations. The following statement was echoed by a numberof participants, “They’ll do it when they’re good and ready and I thinkuntil that point I don’t think you’ll get anywhere with them ’coz theywon’t do it to be honest.”

The potential barriers to acceptance fell into three sub-themes, two ofwhich related to the potential for negative evaluation by others. In thefirst sub-theme, participants described their concern that using memorycompensations might be an indication of needing help and this mightmake people “think less of them”. Occasionally, a more negative globalview of others was also expressed, for example, “. . .some people can bequite nasty aren’t they or some people have got horrible attitudes orhaven’t got time to have an understanding or anything”. In the secondsub-theme participants described several sources of embarrassmentrelated to using aids, including the possibility that people might “thinkyou’re a bit thick. . .they don’t want to be given that label,. . .they want tothink themselves that they’re bright. . .” It was possible to see how theinferences made by one man led him to feel he would be completelyrejected if he used a notebook:

“. . .you say wait a minute and pull out a book for notes, that’s when theygoing to think you’re bit stupid if you can’t remember it, everyone willthink you’re dumb, that your thick. . .what’s the point in me talking toyou no more, I don’t want to talk to you that’s what people will say,they won’t say it to your face.”

For one person the source of embarrassment was related to age and so theyheld the belief that only older people should need to use memory compen-sations “because am so young it’s not right if I go, oh I can’t rememberI’ve got to do things differently.”

However, participants also gave examples of helpful cognitions that wereassociated with overcoming embarrassment and therefore a willingness to usememory compensations, for example:

“. . .once you’ve got used to it you use it and expect it and think ’sodeverybody else’ and do it for me. . .People who can’t understand itthen or give time to understand it then they’re not really worth botheringwith are they.”


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Also, some participants described how they limited the impact of theproblem by remembering it’s just “their memory’s not there” and that youyourself “are not thick, that you are intelligent”.

It should be noted that in order to encourage some participants to talk moreopenly, a few of the above statements were obtained by asking what mightinfluence other people’s decisions about whether to use memory compen-sations. This was a small element of the interview and it should also benoted that when asked about their perceptions of using memory compen-sations people often talked in the third person using the term “people”when describing their views.

In the third sub-theme “feeling different” people described how using anaid made them feel not quite themselves. One woman explained that usingmemory compensations initially made her feel upset because it gave herthe feeling “this isn’t me”. Another woman explained:

“I don’t know. . .it’s ’coz before the accident I didn’t look at it befor-e. . .it was never in my routine to look at my diary I never used towrite things down before so I just used to remember, I don’t knowyou just change.”

Reverse effects

The second master theme consisted of factors that might intuitively beregarded as helpful or positive but participants described how they eithermade them less likely to use memory compensations or the approacheswere unhelpful. For example, participants repeatedly said that someone“who knows what it’s like” should promote the use of aids rather than thera-pists, e.g., “. . .I’d try to use myself perhaps as an example and show how ithelps me, how it works for me. . .”

Similarly, in the second sub-theme seemingly helpful reminders byothers could have a reverse effect on motivation, depending on howreminders were delivered. One man said about his mother’s style ofreminding:

“. . .with Mum trouble is ’coz she’s like that she’ll go on, it has to beevery five minutes, have you remembered that, have you rememberedthat, every five minutes and I’m like, yeah. . ., and then I admit I doget a bit annoyed at times ’coz it does just get too much, least withmy strategy I have just one reminder, so when I need it I make sure Iget it done not every five minutes making sure I get it done ’coz whatI do so I find is with that I get so tired of being reminded that I justdon’t want to do it any more.”


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Another person described his reaction to his mother telling him what to doin comparison to his sister’s more “subtle” approach:

“They tell me one once and that’s it and I’ll tell them be quiet, be quiet,walk away and that’s it. . . With my sister she calms me down or gets meto say what I’m doing tomorrow or what day I have to go to do that. . .”

These sentiments also link with timing, in that reminders that were giventoo early, for example by other people, were not helpful “. . .she says, ’Whathave you got to do tomorrow?’ and then I’ll go and look and well but I won’tremember in the morning.”

The third sub-theme “people doing too much for you” was initially difficultto position in relation to a master theme but the feedback group suggested itbe placed in “reverse effects”. The essence is that people think they are beinghelpful to the person with the memory problem but the consequence is thatmemory compensations become unnecessary when, as one young womandescribed it perceptively, “I use my mum as my diary”.

In the final sub-theme in this section a participant described how thememory aid itself could be experienced as aversive and they were thus lesswilling to use it, e.g., “. . .it just shows the problem, it reminds you thatyou’ve got a problem, and I, I don’t like to think that I’ve had a braininjury, it’s horrible to like think it.” Although this sub-theme is derivedfrom one respondent’s view, the notion that using memory compensationswould be an unpleasant reminder of her memory problems was mentionedvery frequently and so was a major concern.

Beliefs about memory

This master theme consists of a collection of beliefs held about memory andmemory compensations that influenced the likelihood of participants usingthem. The first sub-theme describes how real-life events tended to “bringhome” the need to use compensations. For example, one person describedhow forgetting where she had put her house keys and having to have thedoor locks changed made her realise that she could not continue in thesame way and needed to instigate a strategy.

In the second sub-theme in this section participants explained that if theyhad a sense that their memory was improving they would reduce the use ofaids. However, the notion of improvement might be a hope or wishful think-ing rather than the reality. “I tend to think that I am getting better in mymemory and that I don’t need to do that but I do.” Thus, in the absence ofgenuine improvement this would be an unhelpful belief.

The final two sub-themes consist of mistaken beliefs about memory andmemory compensations. There was a very strong belief that rehearsal/


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repetition of information is generally an effective memory strategy. Seven ofthe eight participants stated that they used repetition/rehearsal in order toremember information; in fact one participant cited this as his primary strat-egy and stated he would only write information down if, after severalrepetitions, he still did not remember it. The notion of “use it or lose it”,i.e., the belief that one’s memory will become “lazy” and cease to workaltogether if it is not exercised, was also a strongly held belief, forexample, one participant stated, “I thought to myself if I start doing that I’dnever get my memory back. . .”. This sub-theme is also linked with the sub-sequent need to rely on one’s own internal resources, “If I can rely on myown memory that’s one step forward, not by looking at it in a diary. . .”Such sentiments were echoed quite strongly by the feedback group.

“It’s not in my nature”

Some people described how they had never been the “kind of a person” to usecertain memory compensations because they did not suit their lifestyle ordaily routine and participants emphasised the importance of individualchoice.

“That their comfortable in, not being told that you should do that andthat. What they want to do. . .Yeah, like, say, ’Do yourself a diary’. Idon’t want to do a diary ’coz that’s not, am not comfortable doing adiary and that’s not what I want to do.”

General characteristics of memory aids

Comments about the general characteristics of memory aids were notedduring analysis but were not subjected to interpretation. Simplicity seemedto be one of the most important features influencing whether an aid wasused, e.g., “With a booklet you’ll be there. . .for like 10 minutes, pulling itout, getting your pencil out and then your sharpener [laughs]. . .too muchfor me.” One person described how writing things in a diary was too effortfulfor her “whereas I can just stick things on the fridge. . .I probably wouldn’tknow what I was writing. I’d get fed up with that”.

Participants also recognised that writing notes only “tells you what youneed to remember” whereas an alarm “tells me to do it”, which was afeature that made the mobile phone very popular. In fact the mobile wascited as a useful memory aid on several occasions because of its portabilityand because it was such a well-established routine premorbidly and was unli-kely to be left at home. Other positive advantages of the mobile phone werethat it could be personalised and the alarm signal might be interpreted byothers as an incoming text message and was thus not likely to lead to the


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embarrassment described earlier. The predictive text function could alsoassist with spelling. The nature of alarms was also discussed, in particularthe importance of setting reminders at the correct point in time rather thantoo early which meant the appointment could still be forgotten or rememberedtoo late:

“. . .and then I’ll remember appointment, doctors that day, on whatevertime that day, because an alarm would go off at 6 o’clock and you got 15minutes to go to the doctors, so you got a bit of time in your head. . .”

DISCUSSION

The present study has highlighted a number of previously unexplored social,emotional and practical factors that influence the uptake of memory aids. Italso provides some explanatory links for findings of past quantitativestudies. The most significant master theme to emerge in our study was“Emotional barriers preventing acceptance of memory compensations”.This theme highlighted some of the negative cognitions that might lead to dif-ficulties adjusting to the use of memory aids. It encompassed threat appraisals(Lazarus & Folkman, 1984) in the form of negative social evaluations, e.g.,appearing stupid or in need of help, and led to the avoidance of certainconspicuous memory aids and a preference for universally accepted devicessuch as the mobile phone. Riley, Brennan, and Powell (2004) found thatsimilar perceived negative social evaluations gave rise to avoidance generallyin people with TBI. The need to use strategies also led to the feelings of notbeing oneself, which provides partial support for the proposition by Kit et al.(2007) that a shift in cognitive identity from an efficient to an inefficientrememberer is linked with negative affect. Cognitions that may explain thislink can be found in the sub-theme, “It would make me feel as if I havegot a problem”, which is located in the next master theme “Reverse effects”.

In this theme, supposedly positive influences, such as others trying to helpby providing reminders or the wrong person promoting the use of aids, wasdemotivating. The former has been reported anecdotally in previous studies(Gartland, 2004; Wilson & Watson, 1996), but little focus has been placedon the way in which aids are promoted and is, perhaps an area requiringmore thought in the clinical context.

The next master theme “Beliefs about memory and memory compen-sations” suggests several forums for clinical intervention. The notion thatreal-world memory failures/slips can “bring home” the need to use aidssuggests that careful, sensitive exposure to real-life memory failures mightimprove motivation to use memory aids. Such exposure has been highlightedas an important process of gaining insight generally (Dirette, 2002;


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O’Callaghan, Powell, & Oyebode, 2006). Mistaken beliefs about memorysuch as “Use it or lose it” can be challenged during individual therapy ascan the strongly held belief that repetition is an effective strategy for remem-bering prospective information such as appointments. Implicit within thesestatements is the desire to use one’s own internal resources. Interestingly,whilst such an internal locus of control has generally been viewed as a posi-tive indicator of outcome (e.g., Moore & Stambrook, 1995; Verhaeghen et al.,2000), this may not be the case when it is paired with a mistaken belief, e.g.,the belief that one’s memory problem is controllable, paired with a mistakenbelief that it will become lazy if not used, might result in an unwillingness touse memory compensations.

The idea that people will not use memory compensations that do not fittheir lifestyle is highlighted in the next master theme, “It’s not in mynature”. This theme explains why premorbid use of memory compensationsis an important and strong predictor of post-injury use of aids (Evans et al.,2003; Wilson & Watson, 1996). Adaptive devices must be in keeping withthe person’s desired self-image (Bender Pape, Kim, & Weiner, 2002; Lund& Nygard, 2003) and professionals must take care not to place too muchemphasis on the functionality of a device at the expense of its social conse-quences (Roulstone, 2007).

Practical characteristics of aids, e.g., multiple functions and simplicity ofuse, were also highlighted by participants as important, concurring withstudies in other populations (Capriani, Porter, & Greaney, 2007; Palmer &Seale, 2007). There was a suggestion in the current study that the need tominimise burden and effort outweighed functionality when choosing a strat-egy which may explain the apparent under-utilisation of electronic organisers(Evans et al., 2003).

Limitations

One of the aims of this study was to further investigate Patel’s (2008) findingthat people who viewed their memory as variable and unpredictable weremore likely to use memory strategies. Unfortunately, an explanation forthis did not emerge within the current themes. However, the feedbackgroup suggested that as they were not able to predict whether their memorywould be reliable from one day to another (e.g., on some occasions itwould be worse than on other because they were tired), they used memorycompensations because they could rely on the fact that by using themthings would be remembered regardless of whether they personally felttheir memory was better one day compared to the next day.

Our participants came from a population that is likely to be more informedand potentially more positive about strategies as they were attending a reha-bilitation programme where the use of aids is trained and encouraged.


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To mitigate this, we purposely selected people with both positive and nega-tive views of memory compensations. Nevertheless, we were surprised that,whilst people talked about certain specific positive aspects of memory aids,for example, remembering to attend appointments, they only occasionallyand briefly talked about the general benefits of using memory compensations,such as becoming less reliant on other people or enhancing their self-esteem.This is in contrast to other research that has explored attitudes towards assis-tive devices in people with physical disabilities (Palmer & Seale, 2007) andmay also be because our participants were in the relatively early stages ofrecovery. Thus, unlike people with longer-term disability, our participantssaw memory compensations as “highlighting” their problem rather than asan integral part of themselves. A different view of memory aids might beobtained from people with ABI whose injury was sustained many yearsprior to the interview.

Implications

By tradition, most rehabilitation programmes emphasise a biopsychosocialapproach and this study demonstrates the importance of adhering to thismodel. Clearly, the functionality of a memory compensation (which isoften uppermost in the therapist’s mind), is not the deciding factor for theperson with ABI. There is a need for unhelpful cognitions arising fromperceived negative social evaluation and leading to avoidance to beaddressed, perhaps through cognitive-behavioural therapy or other thera-peutic interventions. When an unwillingness to use strategies is related to alack of awareness of memory problems, it may be necessary to reduce thedegree of support from friends and family and carefully expose the personto the consequences of his or her memory problems.

Mistaken beliefs about memory and memory compensations also need tobe identified and addressed, particularly in those with a strong sense ofpersonal control over their memory problem. It may be that for those individ-uals who possess a desire to use their own internal resources otherapproaches, such as goal management training (GMT) (Levine et al.,2000), may help ameliorate some memory problems, in particular in thosesituations that require planning, organisation and problem solving.However, it may be difficult for people who have limited insight into theirdifficulties to employ GMT techniques, in particular the initial “stop” phaserequires people to be aware of their current difficulties (van Hooren et al.,2007). Therefore careful exposure to memory slips may also help to demon-strate the need for use of memory compensations or techniques such as GMT.

It is also important that memory compensations are customised to suit anindividual’s lifestyle and care should be taken not to overload people with toomany strategies as this simply adds to the effort of coping with the effects of


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the injury. Finally, rehabilitation programmes should perhaps place moreemphasis on an expert patient model with those who have successfullyimplemented aids being instrumental in promoting their use.

Future research might explore the link between control cognitions andunhelpful beliefs and help to clarify discrepant findings relating to locus ofcontrol in previous quantitative studies. The present work could also beexpanded to explore factors influencing the uptake of other cognitive strat-egies, e.g., strategies for executive problems such as problem solving training(Kennedy et al., 2008). This study has also highlighted the need for futurestudies concerning the effectiveness of strategies to report service users’views relating to the acceptability of strategies.

In summary, this is the first qualitative study to explore factors that influ-ence the uptake of memory compensations in people with brain injury. Pre-vious quantitative studies have focused on factors such as age andpremorbid use of aids as well as the type and extent of cognitive problemsfollowing ABI. The findings of this study suggest that motivation to use strat-egies depends on more complex processes that include social, emotional andpractical factors, all of which need to be considered and are potentiallymodifiable.

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Documents

Factors influencing the uptake of memory compensations: A qualitative analysis