Visualizing and Verbalizing: Restoring Reading Comprehension

Restoring reading comprehension means just that: once again being able to comprehend articles and books that you want to or need to read. It doesn’t mean using strategies to simulate reading. It means restored reading.

(Note: Decoding is what traditional rehabilitation refers to as reading rehab. But relearning to decode the symbols, that is, regaining the ability to recognize and decode letters, words, and sentences doesn’t restore comprehension.)

The method used to restore reading comprehension is called, “Visualizing and Verbalizing.” Lindamood-Bell pioneered the method, based on extensive research, in the 1970s. They principally use it for children, but people with brain injury have benefitted enormously from this instruction. After all, restoring a broken brain is a bit like children learning new skills.

Principles of Treating the Brain

Three principles guide most techniques of neurostimulation or brain training. Most take time to see results.

The first principle is to reboot, repair, or rewire the brain.

The second principle is to train the brain to the edge of its ability through intensity and frequency of training over time with rest breaks. When training begins to become easier, increase the difficulty so as to continue to train to the edge of ability. Reassess regularly through feedback and progress discussions with the client and by using the same objective tests at the end of the treatment cycle. Exhaustion is a given, and so build in rest in between brain training sessions. Research shows learning works best with breaks in between.

The third principle is to engage in desired activity during or immediately after neurostimulation in order to stimulate rewiring of the neural networks involved in that activity.

Visualizing and Verbalizing and the Principles

Visualizing and verbalizing follows all three principles. It rewires the brain through conscious learning of a cognitive skill under the guidance of a trained clinician. It trains the brain to the edge of its ability. Every time you meet a goal and the lesson begins to become easier, the clinician will increase the level of difficulty. The training itself engages in the desired activity.

What Is Visualizing and Verbalizing?

Some background first. Lindamood-Bell uses Dual Coding Theory to explain how the brain first decodes text or spoken word and then comprehends them. Symbols are the letters and words seen by the eyes or words heard by the ears. They are the auditory, visual, and language parts of reading. In dual coding theory, the symbols are turned into non-verbal concepts that we can picture. A painting represents a thousand words and all. Wikipedia notes it was the Canadian Allan Paivio who posited dual coding theory in 1971, yet no Canadian brain injury rehabilitation seems to use it to treat reading.

concept imagery is how we understand what we’re reading

Two Primary Reading Weaknesses

Nanci Bell, co-founder of Lindamood-Bell, explains in her video on dual coding that there are two Primary Weaknesses in reading:

Primary Cause of Reading Impairment

But, she notes, there’s one primary cause for both weaknesses:

There’s one primary cause: weakness in the Imagery-Language Connection that’s called Dual Coding Theory from Dr. Paivio.

It is that there’s a non-verbal code and verbal code for all cognition. And obviously, reading is cognition.

And it is the interplay between those two codes that allows us to think, to read, to spell, to do math, and even to decode. . . . [There are] two types of imagery. One enables you to process parts and the other one enables you to process wholes.

Symbol imagery is the ability to image sounds and letters for words. Concept imagery is the ability to image a gestalt or a whole.

When a person has trouble comprehending words on the page or spoken words, that’s brain injury damage to concept imagery.

Note: that what we often think of as reading issues, eg, dyslexia, occurs on the decoding side of the ledger. The comprehension side isn’t usually talked about. It usually doesn’t even have labels like the decoding side does. I personally don’t think labels are always useful, but in our current milieu where everything is labelled, a label gives credibility. I think that’s why when people with brain injury say they have trouble reading yet can read words and use some or a lot of their vocabulary, health care providers, family, and friends don’t believe them. But as Bell says, vocabulary is not comprehension.

Creating Concept Imagery

Visualizing and verbalizing is a method that teaches how to create concept imagery. It restores reading comprehension while increasing reading stamina. The steps are:

1. Learn how to create a mental image.
2. Be able to describe the image out loud. Eventually, this conscious step to verbalize the image is no longer needed.
3. Learn how to add to the image as continue to read.
4. Learn how to build a concept image as you process a greater amount of language in one go.
5. Learn how to create a mental movie.
6. By scanning mentally the image or movie, summarize the text. As you summarize the text, flesh out the image or movie.
7. With mastery, learn to verbalize the main idea of the text by drawing on the concept images and/or mental movies.
8. Be able to answer out loud higher-order thinking questions, such as, “What do you conclude? What do you infer? What do you predict will happen next?” Eventually, be able to ask yourself these questions, at first out loud then silently to yourself.
9. With practice, conscious creation of concept imagery and verbalizing becomes automatic.
10. Automaticity is the end game. Automaticity requires much less energy and is quicker than consciously visualizing and verbalizing.

visualizing and verbalizing restores reading comprehension

The Procedure

The Goal: to read and process literature at the level of your potential.

Lindamood-Bell trains to your potential not what falls into the average range. This is significant. The goal of restoring reading comprehension should be about what you need for independence, functionality, and most importantly, your potential.

Lindamood-Bell — or specialists who use Lindamood-Bell’s visualizing and verbalizing program — uses the same procedure for all clients. If you have a lot of fatigue, they will modify the hours of instruction per day but not the total number of recommended hours.

Lindamood-Bell calls their trained staff who work directly with their clients, “clinicians. ” Clinicians have gone through the visualizing and verbalizing program themselves before they start instructing clients. If you require post-graduate level or specialized reading skills, you’ll be assigned specific clinicians who have the background and ability to restore reading to that level. This is important because clinicians need to be able to come up with higher-order thinking questions that stimulate thinking. They can’t do that if they don’t have the knowledge base. You will work with several clinicians over the course of treatment.

The Results Point To What To Treat

A good rehabilitation clinic will test the entirety of reading cognition. This page focuses on reading comprehension. The results will reveal the specific issues in comprehension impairment. Before starting treatment but after learning the results, you and the clinic’s director discuss what’s possible to restore and what you desire to achieve. Perhaps it’s reading a novel as quickly and with as much comprehension as before brain injury; or it could be reading a non-fiction book; or maybe studying textbooks for university courses. Alongside establishing the goal, results will point to how many total hours will be needed. Usually eighty to one hundred and twenty.

The Daily Routine

Monday to Friday, at the same time each day, for four hours daily, for four to six weeks, you will sit in a quiet room with the clinician or attend virtually through Lindamood-Bell’s videoconferencing. For 55 minutes, the clinician will instruct, guide, and train you on that hour’s skill mastery. Break time occurs at five minutes before the top of the hour. At the end of five minutes, you will reconvene with a new clinician to either continue with the same skill mastery or possibly an increased level of skill. Repeat for each hour.

Fatigue from brain injury and/or lack of social support may require hours to be cut down to two hours per day, five days a week, for eight to twelve weeks. You may require breaks, but the length and frequency of breaks will diminish as the brain begins learning the visualization process.

Progress Report and Re-Evaluation

The clinicians work as a team and keep the clinical director informed of your progress and any difficulties. The Director may sub in for an hour to instruct you while they assess if you need to advance to the next level earlier than anticipated or root out the cause of unexpected difficulty. At the end of each week, they will email you a written progress report; at the end of Friday’s instruction. they will go over the report, discuss any difficulties, and present the following week’s goals. This meeting can be either in person or virtually.

Instruction starts with the basics, but the amount of language (text) processing as well as its complexity will increase daily and weekly until the goal is reached. The rapidity of increase will surprise you, but it’s crucial to success.

Lindamood-Bell schedules re-evaluation within a week of finishing the total recommended hours and achieving the stated goal. The re-evaluation comprises exactly the same tests as the initial assessment. They’ll email you the results and review them in person or virtually. They may offer five extra hours spaced a couple of weeks or a month apart from each other. These hours ensure you have begun daily practice, have your newly acquired skills reinforced, and get help with any difficulties that have arisen. These hours are especially important if you have no social support to provide encouragement because daily practice requires habit, and habit is not something that stays in a person with brain injury.

At first, reading comprehension, although regained fully, does still take effort and consumes energy, which diminishes only after months of practice brings on full automaticity. (Or years if there are complicating factors that impair brain function or cause regression.)

The Treatment

Treatment looks like an ascending ladder of difficulty. Difficulty increases for the amount of language processed and for its complexity. For each piece of language, whether a word, sentence, or paragraph, you and the clinician will alternate reading it out loud as they instruct you. In this way, you will learn how to connect imagery with language that you both hear and see. Ascending grade levels is also part of the ladder.

1. Noun. Master creating an image of a single word.
2. Sentence. Master creating an image of a single sentence.
3. Sentence by Sentence. Master creating an image of each sentence when read two sentences in a row, building them into a single concept image.
4. Picture Summary. Learn how to verbalize a summary of the picture (describe the picture).
5. Multiple sentences. Read out loud or listen to multiple sentences and create an image that represents the whole of them together.
6. Word Summary. Instead of describing the image as in the picture summary, summarize what was read, drawing on the mental concept imagery.
7. Whole Paragraph. Read out loud or listen to an entire paragraph and create an image that represents that paragraph.
8. Higher Order Thinking. Answer higher-order thinking questions (HOTs) that the clinician asks. Eventually, the clinician will ask you to come up with your own HOTs and then answer them.
9. Page. Read a page in one go, creating mental movies. At the end of visualizing the page, verbalize with word summary and HOTs. Eventually, replace word summary with the main idea, that is, three key concepts.
10. Chapter/article. Read a chapter in one go, creating concept imagery and mental movies. At the end of visualizing the chapter or article, verbalize the main idea and HOTs.

As with using sentence by sentence to progress from one sentence to multiple sentences, the same method is used to progress from multiple sentences to a whole paragraph, a whole paragraph to a page, and from one page to a chapter. So, for example, between one whole paragraph and a page, you will work on paragraph by paragraph then multiple paragraphs, and so on.

Connecting Words to Images

The first one or two days are fairly simple. The aim is to familiarize you with the process of connecting words to images.

The clinician shows you a picture (via their document camera if done virtually) so that you can learn about creating images in your head. They ask you to describe the picture out loud. Then they turn it over and describe the picture back to you. After that, the clinician asks questions about it; turns it back over so that you can see it; and they will discuss it some more. This process is difficult. Lindamood-Bell uses structure words to aid in learning how to create a concept image. Although “image” makes it sound like it’s all visual, in fact a concept image also includes sound, smell, emotion, and movement

Structure Words

Structure words to describe an image are:

Once you understand how to create an image, the clinician will move on to having you image one word, for example, snowman. At the same time, the clinician will introduce a second concept: independence.

Independence

Independence is being able to image and describe the concept image using the structure words, or as many of them as are applicable. Once you achieve independence, the clinician will move on to Sentence and Sentence by Sentence..

Lindamood-Bell’s vision for instruction includes increasing the volume of information processed while at the same time decreasing fatigue. They achieve this by systematically and consistently reinforcing independence with visualization for increasing lengths of language. Just like any foundational skill such as learning a new language, practice and continuous exercising of the skill, makes it more automatic. Instruction stimulates and strengthens the process, but practice outside of sessions and beyond instruction, is key. However, with brain injury, they may not recommend practice outside of sessions until instruction is completed because of the debilitating effects of instruction on additional fatigue.

Associating Colours with Sentences and Their Images

At this point, the clinician will introduce a third concept. Before the clinician reads a sentence from the first one-paragraph story, they’ll place a coloured square of felt underneath the document camera. Each coloured square represents a different sentence. You are to associate the picture you create in your head with the coloured square the clinician places down when they read out one sentence. The process is:

Main Idea

The main idea is tough. It’s one sentence, but not a long, verbose, wordy sentence with lots and lots of conjunctions and subjunctive phrases. It must be short. Think of three main points, in sequence; create one short sentence with those three points. And think of the main idea as the first sentence of an essay that summarizes what is to come. 

Higher-Order Thinking Questions (HOTs)

Concept imagery underlies comprehension. Comprehension, not based on having an adequate vocabulary nor ability to hear phonemes. Nanci Bell: “What they struggle with is the concept or the whole. And if you don’t have the whole, you can’t do higher order thinking skills such as main idea.” They call it in the U.K. aphantasia, the inability to visualize. Higher order thinking: From what you pictured— not what you think — what comes next in this story?

Higher-order thinking questions (HOTs) are designed to increase reading comprehension. Once you connect imagery to language, you expand your thinking to include meaning. It isn’t enough to equate an image of a cat with the word “cat,” you must also understand the concept of cat from the mental picture. What does a cat look like is the question that leads to a picture summary. What is the cat thinking is the question that leads to comprehension. To know what the cat is thinking, you need to know how the cat is looking, sounding, moving and, as well, infer mood from your mental picture and connect past knowledge about animals to your picture of the cat.

HOTs can start simple like what do you conclude and ramp up to Socratic questions such as “What is the nature of the cat?” “Why do you assume the cat is angry?” “How does that fit with what we learned before?” Abstract concepts are harder to image and thus ask questions about. Remember to hold on to the image of the whole concept as you go through HOTs. Prediction questions may be the hardest for a person with brain injury.

Push Steps

Push steps are added to the core program of Sentence by Sentence and Multiple Sentences. A push step is exactly that — to push your brain. The expectation is that maybe you’ll achieve 40 percent, but the next week, 70 percent correct or so. The push step will be to introduce reading and imaging an entire paragraph at once. The person in charge of your instruction will decide whether to increase the grade level difficulty first or the concept imagery level. They may choose to increase you from grade 9 reading level to grade 10 for Sentence by Sentence and Multiple Sentences before moving on to Whole Paragraph Imaging with Higher Order Thinking. Or they may choose to move you to Whole Paragraph first and then up the grade level.

Acquiring New Vocabulary

After introducing the push step of Whole Paragraph imaging, they’ll start instructing you on acquiring new vocabulary and more abstract language. New words aren’t memorized; instead, you’ll learn to create your own image for a new word and to recall, know how to use the word, and what it means from that image. I found it was important to write down a picture summary so that I wouldn’t forget the image I’d create for my new vocabulary. Index cards work well for this work. On one side is the word. On the other side is a drawing of your image along with the definition. You then place these cards in a box, sorted into stable and not stable folders. Just as with reading, practicing new vocabulary daily (or weekly) is important. Once you’ve stabilized a word and can recall your image and its meaning from hearing or seeing the word, you can move it to the stable folder. Occasionally, you’ll dip into the stable folder to ensure you still can recall the imagery.

Discussion

“For eighteen years, to sit down to read was to schedule and strategize, not to work on regaining comprehension and automaticity. Like writing and walking were for many years, reading was a conscious act from start to finish. Anything that must be done with the conscious mind always consumes more energy than an automatized skill.

Although some who remain in the standard medical model understand automaticity is necessary for success, the methods they use aren’t geared to regaining automaticity.”

Shireen Jeejeebhoy. Changing Perspective in Quest to Restore Cognition. Psychology Today. 27 May 2019.

By restoring reading comprehension through visualizing ad verbalizing, you’ll find that you can also remember what you’ve read long after you’ve read it. You’ll be able to talk about books and articles like other people do. You will also be able to add to your knowledge bank and laterally connect concepts and information. Books and learning experiences will become richer. Over time, you will no longer need to nap after reading. That’s because you’ll have gained more and more automaticity.

Reading is meant to be enjoyable not a chore. It’s meant to take you into a different place so that for a little while you can escape this world. That’s what visualizing and verbalizing restores.

[After 81 hours of visualizing and verbalizing instruction] I needed nothing else. No highlighters, no pens, no notebooks, no iPad to look up definitions, no timer.

The burden of strategies was gone.

Reading was no longer like studying for an exam and immediately forgetting most of what I’d studied.

Shireen Jeejeebhoy. What Makes Reading Enjoyable? Psychology Today. 4 November 2018.

Lindamood-Bell provides professional development courses online. Since Lindamood-Bell primarily instructs children and teens, the courses are aimed at teachers. However, any cognitive rehabilitation specialist can take courses and workshops and learn to diagnose and treat reading difficulties effectively in people with brain injury. Leaving people without the ability to read and comprehend books is egregious. No longer are strategies acceptable in lieu of restoring reading comprehension.

Individuals can also learn these methods if no reading rehabilitation is offered at a clinic near their loved one with brain injury.

reading loss is a profoundly serious issue that specialists must heal

Depending on injury location, you may find it harder to read the story as opposed to having it read to you. In addition, processing speed may be slower for hearing rather than for seeing, and so the clinician may have to adjust reading speed, depending on who is reading. Eventually, the clinician will read at a normal rate in order to push the injured brain to process at the edge of its speed ability. Having a qEEG will forewarn you and the clinician which area is slower.

Visualizing and verbalizing not only restores reading comprehension, it also restores the ability to follow, comprehend, and remember videos, webinars, movies.

The moment the first clinician begins asking to create a mental image, you will feel your brain work. You will feel the effort even though your mind may think this is dead simple to do, even if you show good independence. 

If you’re not exhausted, they’re not stimulating the brain enough to heal it.

During breaks, nutritious snacks with immediately available sugars such as dried fruit in small amounts will provide the brain with the energy it needs to learn and rewire.

Beyond treatment, you will work on increasing the amount of language processed and complexity by reading chapter by chapter then multiple chapters and increasing the difficulty of material. In addition, any new stressor, such as a pandemic, can cause regression, just like with any other skill after brain injury. Taking a couple more hours to refresh the skill is important to maintenance over the long term.

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Sketches courtesy of Dana Kernik-Theisen, Center Director, Lindamood-Bell Learning Processes, Edina, Minnesota, who generously gave of her time to explain my results, recommendations, and reading theories.