Over the past couple of months, I’ve been wading through some literature about how best my patients can learn. More recently, a patient and I had a robust discussion about the prior experiences he had as a young lad and how that influenced his current ability to learn movement patterns again.
In clinical practice, we see this all the time. The ability to learn something well depends on how well encoded the person’s brain is in interpreting your instructions and applying itself to the task, shaping and modifying it as we go along. If the patient has been poor at sports or is generally not very physical active in the past, the idea of how to step around obstacles or change directions is much harder to learn.
Now learning and memory, while different, are very much linked ideas. You don’t always to have learn something to remember it. For instance, remember ‘keys’. You didn’t learn anything about the word ‘keys’ but you can still remember it. However, you cannot learn something if you have no memory of it.
So our first topic today is to understand memory.
Walker and Stickgold (2006) talk about the 2 main types of memory and learning: declarative and nondeclarative.
Declarative memory is fact-based, it includes knowing what you had for lunch, or what the capital of Spain is.
Nondeclarative memory is procedural-based. It is the way we remember how to do things, like riding a bicycle or drawing a picture. It includes habitual, functional and subconscious activities. This type of memory is much more difficult to teach but is also more resistant to being lost or decayed.
The key to teaching your patients how to change their behaviours, which is the goal of most forms of therapy in trying to change the way people perceive, move, feel and interact with our surroundings in daily life, we need to understand the 4 main stages of memory building. Walker and Stickgold (2006) talk about the 4 stages:
is when the brain first gets exposed to the idea, and starts to make sense of this new piece of information that it can turn into memory. It takes into account what the information means, how relevant, how useful, and all the attributes of the idea that may help make it ‘stick’ in the brain. All the senses fire up, particularly vision and spatial awareness if it is movement based.
If a patient has no concept of this idea, now’s the time to sit next to them and explain the idea from several angles, using visual, diagrammatic and metaphorical tools so their brain can conceive it more fully. The stronger this acquisition phase is, the more of a chance the idea will be acquired. For instance, to give someone the concept of a new exercise, we need to demonstrate, draw and describe the idea, and then explain the reasons for it. There is a lot of this in the first session together.
is where the memory is still raw and needs to be laid down. There are two subphases in this category, whereby the memory needs to go through stabilisation and enhancement.
This is the time for practise during the session, so they can be guided towards performing the desired movement or learnt the desired concept. This is the time to include key phases in time with their activity, which they can repeat mentally. Alternatively, to enable them to imagine the movement and get them to describe out loud what they are imagining. This will help stabilise the memory in consciousness. (I will discuss memory and learning enhancement and sleep in another post.)
The brain will take this memory and store it in its deep recesses. If this is a concept, it will take in all the explanatory (logic), visual (spatial) and emotional information and connect it to the memory to make it a storable ‘chunk’.
Proper storage requires that we as therapists do not overbombard the patient with too many messages, and that we focus on the single or two ideas we want to person to acquire through memory, and allow the passage of time to do its thing and the patient can be allowed to store it away. Sometimes we may ask our patients to go sit quietly after the session to process what was said, and to either repeat it back to you or have them write down what they feel they have now started to remember. The less interference we can make, the better the memory can be ‘chunked’ for storage.
The act of taking the memory out of storage and using it in the appropriate situation.
In the second or subsequent sessions to come, if the patient can recall what you have asked them to do (declarative memory) then you have successfully taught them something that they can now remember for the timebeing. However, if the patient can replicate how you have taught them to move (nondeclarative memory), then congratulations, you have successfully helped the patient lay down, stabilise and recall new habitual and planned memories that are more resistant to being lost.
The act of taking the memory out of storage and using it in the appropriate situation. To conclude, understanding how your patient can lay down new memories and where your patient is at any stage can help you become a better therapist, if we truly want to make a lasting and helpful change.