Helping Patients with Schoolwork

In my clinic, I mainly see university students.  I believe it is important, and therapeutic, to invite students to bring their schoolwork to their psychiatry appointments, so that we can sometimes look at it together and discuss it.

Last year, I mentioned this practice to a reviewer, and I suspect it was considered an inappropriate use of time in a medical appointment, and a waste of resources -- a psychiatrist "helping with homework."

I would like to make a case for why "helping with homework" is useful, and part of a good therapy relationship:

Understanding

In order to help with a mental health issue, it is good to understand what your client, patient, or friend is doing with their time.   University students often spend thousands of hours studying, writing, and thinking about academic subjects.  Sometimes this work is experienced as a joy of life, a passion, or as a source of meaning.  For others, the work can be experienced as a burden, a chore, or as meaningless "jumping through hoops."   In many cases, a student's academic work is a reflection of health status (both mental and physical),  For many students, academic performance affects self-esteem:  low grades can cause a person to feel like a failure.  Perfectionism in schoolwork can cause almost any grade to feel like a sign of failure or inadequacy.

In order to understand another person's emotional life, it is very important to learn about how he or she is spending time.   Is the schoolwork a meaningful life pleasure?  Is it only a chore, a burden, or a stress?

It deepens understanding of this issue to explore it in more than a superficial way.  I believe it is valuable for understanding and rapport to encourage patients to show their notebooks, textbooks, and assignments, to talk about them a little bit.  Often this leads to a much better understanding of a whole range of other issues, including mood, attention, motivation, anxiety symptoms, learning disabilities (often never previously recognized), relationship problems, and existential uncertainty about direction in life.

Shared Interest

Many students I have seen have been passionately engrossed in their studies for many years, including at a graduate level.  But sometimes, they have almost no social conversation about their studies, with a person who shows interest.  The academic study becomes an insular, lonely experience, rather than a source of potential social interest.  Sometimes this lack of social sharing is due to an entrenched habit...the therapy setting can be a place to change this.    Not only does such a conversation boost rapport, it is also a practice for the patient to be able to converse with other people about their work, for the benefit of their social life.

Also I believe it is psychologically beneficial for a patient or client to have an experience of sharing their own expertise, and learned scholarship, rather than only being on the "receiving end" of such expertise.  It is a humble and respectful position for the therapist to take, which can only improve a therapeutic alliance.

Diagnosis

All mental health issues affect cognitive functioning and academic performance.  A direct discussion about academic matters is relevant to the assessment of overall mental health.  Sometimes cognitive and academic function is good, but a person's feelings about this functioning is very negative.  In this case, looking together at academic work leads to a very direct focus on an active set of symptoms.

What do Notes Look Like? 

The manner in which a person might keep notes, or organize essays, or surf the internet doing research, gives us better understanding of psychological health.    Are notes tidy, meticulous, or disorganized?  Do the notes fluctuate a lot from one week to the next?  Are the notes clear for someone else to read and understand?  Are there gaps where notes are missed entirely?  Is writing fluent once started, but just difficult to start?  Is there evidence of tremor or other neurological symptoms manifest in handwriting?

Cognitive Testing

If cognitive testing is to be done, it is most useful to refer to subject matter that the person is actually interested in, and experienced with.  A mathematician or engineer might not show any decrement on a simple arithmetic test (such as "serial sevens") despite having significant cognitive problems.  It would be more appropriate to ask them to solve a complicated mathematical problem having to do with their current work.    A literature student might not show any decrement on a simple verbal test (such as memorizing words, or reading a sentence) but might have difficulty describing the themes or dynamics of a current novel on the curriculum.    Another benefit to "testing" this way is that it can highlight unusual strengths and talents, which can then be a subject of positive feedback and encouragement.

Practical Therapy

Cognitive therapy is a type of "academic" process:  it requires note-taking, reflection, analysis, and homework.  Many students might not have time for diligent cognitive therapy.  But they do have time for their schoolwork!   Cognitive therapy can take place while doing schoolwork!  It could be rewarding in a therapy session for a patient to have a successful experience of completing an academic task, while having a chance to reflect on the emotional changes or barriers happening at the same time.   A creatively constructed regime of cognitive therapy could involve combining it with academic study.

Behaviour Therapy for performance anxiety

Many students have anxiety about sharing their work, being called on by a professor, speaking out loud in class, presenting in front of others, etc.  The therapy session is a chance to directly practice these things, in a supported setting.  It is a simple CBT exercise!

Therapy for Procrastination

Procrastination is one of the most common problems faced by almost all students.  This is often much worse when there are other mental health issues going on.  The increased stress, and decreased grades, caused by procrastination, often cause further worsening of mental health symptoms.  Procrastination is sometimes even a critical part of a deteriorating cascade of events, leading to leaving school unsuccessfully.    The core necessity in treating procrastination is to do the procrastinated thing as soon as possible!  In a therapy session, if this subject comes up, I believe it is optimally therapeutic for the patient to have an opportunity to do the procrastinated activity right in the session, immediately!   It is an incredibly simple way for a therapy hour to be directly helpful.  Otherwise, sometimes visiting a therapist can be yet another way to procrastinate work, and feel even worse!   If a patient of mine does agree to do some procrastinated schoolwork during a session, it is my goal to help the patient enjoy the activity, feel supported and encouraged, and to have an experience of success.

Study Techniques

Many students work or study inefficiently, which is an underlying cause of worse academic stress, then leading to worse mental health.  Discussion and practice of better studying techniques is directly relevant to mental health therapy.  I like to discuss various memory and time-management techniques with patients, and try them out right in the session.  These ideas are applicable to other life activities, including CBT exercises.

Reading and Oration

It has been remarkably common to find students who have trouble reading.  Often they have other cognitive strengths, which have allowed them to manage with this reading difficulty all their lives, while still doing well in school.  But in advanced academics, a reading difficulty can greatly slow down the rate at which a student can study.  Reading textbooks becomes a gruelling chore.   Reading out loud, or giving presentations, can become a source of dread.

The most effective therapies for reading difficulties are very similar to therapies for mental health issues:  it involves practice, in a safe setting, with tasks that are easy enough to be enjoyable and easily mastered, but challenging enough to foster growth.    Reading out loud is very literally an exercise to strengthen one's voice.  Such voice-strengthening is a metaphorical cornerstone of all progress in psychotherapy.  Practicing this literally, in a psychotherapy session, is simple, relevant, enjoyable, diagnostically informative, and therapeutically useful, often in a very immediate way.

Study as Mood Therapy

I believe that studying and other intellectual work can be intrinsically therapeutic for mood.  It can be a meditative and meaningful experience, and a healthy coping technique or psychological defense.  But some students have study practices which are far from meditative.  The therapy session can be a chance to help people regain a sense of meaning and meditative joy in study, to recapture "flow."

Oliver Sacks

I am reminded of the famous neurologist, Oliver Sacks.  He spent time really learning to know his patients well, and in doing so became not only a great therapist and physician, but also a wise and insightful scholar about the ways of the mind.   Part of his technique was to always engage deeply with his patient's work and study interests.   In doing so, often he would discover phenomena that would never have otherwise been noticed or attended to.   I would hope to be a clinician more like him.

Other Work (not just study)

I think it is important to discuss other areas of work, with patients, and to be willing to look together at the work very directly at times, if desired.  I like to see examples of some of the work my patients do, and I think this relates to health in a similar way.

Benefit for the therapist

If a therapist takes sincere interest in a patient's work, study,  and other activities, it is also beneficial for the therapist.  What a delight it is to vicariously be part of an educational journey!   The therapist's health will therefore also be better.  This, in turn, will improve care within the system as a whole.  And this goodness will "bounce back" to the clients or patients, and continue a cycle of interpersonal positivity.

"The Lazy Controller" -- reflections about Kahneman's book

This is the first of a series of posts I've been planning based on Daniel Kahneman's book Thinking, Fast and Slow. 

I found this book to be excellent, an account of how the brain is very biased in its mode of forming decisions and judgments, loaded with very abundant solid research over 40-50 years in the social and cognitive psychology literature.

My purpose of reflecting on this book in detail is hopefully to add ideas about understanding the brain's biases in the context of psychiatric symptoms, and then to propose therapeutic exercises which could counter or resolve the biases, and strengthen cognitive faculties which may intrinsically be weak.

----

The first few chapters of this book are introductions to the idea that the brain can be understood as having two main modes of processing and responding to information; the author calls these "system 1" and "system 2."

System 1 is rapid, automatic, reflexive, and often unconscious.  It is the dominant system in most cases.  It is the foundation of "intuition."  It is built upon deeply engrained memory for similar situations.  It is a foundation of all talent and mastery of skills, in that it permits one to perform a difficult task with ease, without even having to "think" about it (e.g. for a master musician, athlete, surgeon, or really any other occupation).  But system 1 is extremely prone to biases.  Its mode of processing data is based on what it has experienced repeatedly in the past -- so it is a kind of autopilot -- and it can be very easily fooled  (yet, on the other hand, its rich set of past associations may be a fertile ground for imagination, creativity, and inspired insight). 

System 2 is a highly conscious, intellectually analytical mode.  It permits us to systematically solve a multi-step difficult problem of any sort.  It permits us to cope with situations which differ from an overlearned template.  It would be like the true pilot landing a plane in difficult or rapidly changing conditions, instead of letting the autopilot trying to land it.

One of Kahneman's main theses is that system 2 can be easily fooled too!  While system 2 is the only cognitive mechanism which could prevent biased interpretation of information, Kahneman shows that system 2 is intrinsically "lazy."  Because engaging system 2 is effortful -- it demands energy -- we are strongly drawn to intellectual processes which minimize the energy expenditure.  If system 1 has an automatic, "intuitive" answer for us, then we would tend not to engage system 2 at all.  And if a rapid engagement of system 2 appears to be sufficient to get an answer, we will usually not spend extra time or energy.  Thus system 2 can easily lead us to a premature and inaccurate conclusion.

Another of Kahneman's main theses has to do with the nature of phenomena, cause-and-effect, and data in general.  Accurate conclusions about cause and effect often require a type of statistical analysis (even a simple one, employing quite straightforward rules of probability), but Kahneman shows that the brain (both system 1 and system 2) are not intrinsically designed to think in a statistical fashion.  Therefore we tend to greatly distort the likelihood of various types of events.

An area I would want to extend beyond Kahneman's main theses is that I suspect both system 1 and system 2 could be very specifically trained to reduce biases.  Kahneman seems somewhat resigned to conclude that the brain simply can't resist the types of biases he describes (citing, for example, profoundly biased thinking in his psychology student subjects--or even in himself-- whose biases were evidently not reduced by understanding and education).  But I do not see that very much work has been done to very specifically and intensively train the mind to reduce biases -- I think that simply learning about bias is not enough, it is something that must be practiced for hundreds of hours, just like any other skill. (this reminds me of something said in psychotherapy:  "insight alone is not enough to effect change -- it must be accompanied by action.")

I believe this is relevant to psychiatry, in that all mental illnesses (such as depression, anxiety disorders, personality disorders, psychosis, and attention/learning disorders) contain symptoms which affect cognition.  In  cognitive therapy theory, it is assumed that depressive cognitions cause and perpetuate the mood disorder.    Many such "cognitive distortions" could be looked at through the lens of "system 1" and "system 2" problems.    For example, in many chronic symptom situations, system 2 may have developed a very deeply ingrained reflexively negative expectation about a great many situations, with many of these reflexes being unconscious.  These reflexes could possibly have been developed based on childhood experience of parents (consistent with a sort of psychoanalytic model), but I think the most prominent source of such reflexes would simply be due to having had a particular symptom frequently for years or decades at a time, regardless of that symptom's original cause.    Under such conditions the brain would change its expectation about the outcome of many events, based on the repeated negative experiences of the past (which could have been due to poor external environmental conditions, but also simply to the past chronicity of symptoms).

A proposed treatment for this phenomenon could very much be along the lines of cognitive therapy.  But I might suggest extending a specific focus on depressive "cognitive distortions" etc. to work on understanding and countering bias in systems 1 and 2 in general.  I propose that intellectual exercises to minimize biased interpretation of perceptions -- even if these exercises have little directly to do with psychiatric symptoms or depressive cognitions, etc. -- could be useful as a therapy for psychiatric disorders.

As outrageous as it seems, educating oneself about statistics, and practicing statistics problems repeatedly -- may be therapeutic for psychiatric illness!  

I'll try to continue this discussion with more specific examples in later posts.

Alternative conceptions of "IQ"

Standard IQ tests measure a particular set of intellectual skills.  But this leads to a big question about what exactly is being measured.  The notion of "IQ" implies that the test is measuring an innate, relatively fixed intellectual capacity.

But consider the following analogies:

-Suppose reading skill in English was being tested.  Obviously, we could see that those who score very well in a test of rapid reading and comprehension would most likely be classified as more "intelligent."  Yet, the test would have massive potential sources of bias or inaccuracy.  Many people with excellent language skills would do poorly on an English reading test simply because of their lack of knowledge or experience with English.  Others with excellent minds might not have had much reading education or experience of any sort, therefore they would not have acquired the skill to read or comprehend written language quickly.

-If "athleticism" was being measured, suppose the test involved having subjects shoot free throws on a basketball court.  People who would score very highly on this test would most likely fit reasonably into a "high athleticism" category.  But many very athletic people would score poorly on this test, simply because they had very little experience shooting basketballs. If a  skill that was brand-new to all subjects was being tested one time (e.g. archery target practice), those who performed very well might well be more "athletic" but perhaps they had more experience in a similar type of skill in the past, or they just happen to be more calm with novel activities. 

Acquisition of skills is a process that grows over a period of hundreds or thousands of hours of experience.  If a test is measuring a skill, it may simply be measuring how many hours of experience that person has with a similar activity.    Of course, an intrinsic strength in something is more likely to lead to a person spending more time developing the strength -- talent leads to passionate commitment; it facilitates and makes enjoyable the thousands of hours of work

So, an IQ test may be measuring--to a significant degree--the number of hours of experience the subjects have with similar types of activities (e.g. memory tasks, logic puzzles, arithmetic, etc.).

On a related note,  recent findings have suggested that doing cognitive exercises such as brain-training video games does not really improve intellectual function significantly.  But--the manner in which this conclusion was reached was testing subjects before and after using tests that did not directly relate to the cognitive games which were being played.  Therefore, I believe the findings are spurious. 

Here is my thesis on this issue:

"Intelligence" could be understood not as an absolute quantity of a skill (since this quantity would depend mainly on how many hours of practice or experience the person has had, which arguably should be viewed independently from the concept of "intelligence" as an innate trait).  Rather, "intelligence" could be viewed as the RATE at which brand-new skills improve with a given period of practice.  For example, the amount of improvement after 10 hours of practice of a brand-new activity would be a much better measure of "athleticism" than simply measuring the absolute performance one time.   Even this type of measure would be influenced by a person's past experience:  for example, a person with thousands of hours of experience learning different languages would probably be able to learn a completely new language more quickly with 10 hours of practice, compared to someone with very little past experience of this sort.   The proviso that this be a "brand new" activity is important, because if a person has a very high level of expertise in a particular skill, then their rate of further improvement will be very low (since there is not much further improvement humanly possible).

So, for example, with athletic tests, it would seem a reasonable measure of "innate athleticism" to introduce a completely new sport or fitness activity, and to measure how quickly subjects could improve or master it with limited practice time.

Another complicating angle on this theme is that intellectual experience and focus in ANY area is likely to improve "innate intelligence."  If you have practiced music for 10 000 hours, you will probably have strengthened a variety of other "innate" intellectual capacities.  But this strengthening effect would not be obvious if measured conventionally.

Similarly, I suspect that "brain training" video games could have a significant effect of strengthening various intellectual capacities.  But this positive effect would not be captured well by simply repeating single "before" and "after" skills tests.  A much better measure would be the following:
1) "pre" test:  subjects would have to put in 10 hours of practice learning a game having to do with verbal memory.  The absolute scores, and the rate of improvement over the 10 hours, would be recorded.

2) Subjects would put in 100 hours of practice doing either a battery of memory-focused brain training games, or a "placebo" set of games not focusing on memory.

3) "post" test:  subjects would put in 10 hours of practice learning a completely new game having to do with verbal memory.  Once again, the absolute scores, and the rate of improvement, would be noted.

Here is my hypothesis about the findings of such an experiment:

1) The absolute scores at the beginning of  the "pre" and "post" tests would be quite similar.  This would be like testing the basketball skills of a group of volleyball players before and after volleyball training season.  You would not expect any difference.  This is the conventional type of assessment, which is bound to lead to the conclusion that there is no beneficial training effect.

2) What I would expect to be different is that the subjects who had done 100 hours of memory games would be able to much more rapidly IMPROVE their scores in the "post" test.  In the athletic analogy, a group of people who have spent the summer in volleyball training would be able to much more rapidly learn soccer skills, compared to a group who spent the summer watching TV, even though both groups might have very similar soccer skills at the beginning of a 10-hour training period.  


I believe my hypothesis is supported by observations of individuals acquiring expert skills, such as playing chess.  While the absolute number of hours practicing chess correlates directly with performance, there are some individuals who advance more rapidly with the same number of hours of practice.
(see the following reference: http://www.ncbi.nlm.nih.gov/pubmed/17201516)
I believe it is this "rate of change" that is the most reasonable measure of "innate" cognitive ability.  Even this "innateness" could be more malleable than the term implies, since I suspect that there could be a type of "meta-training" which could improve one's rate of skill learning or acquisition.  This would involve practicing ways to use time more efficiently, and, most importantly, practicing ways to bring devotion, joy, and energetic attention to one's learning experiences.

"Outlier": The causes of high achievement

Outlier by Malcolm Gladwell, is a brilliant book about the causes of success, outstanding achievement, and personal greatness.

Gladwell describes a variety of interesting life stories, of people with outstanding ability or outstanding achievement, then looks carefully at the factors leading to these successes.

He does not claim that "inborn traits" or hereditary factors are unimportant.  But he shows quite convincingly that inborn talents correlate with achievement only to a certain point.  Individuals with extreme talents tend not to achieve more than those with merely "sufficient" talents. A recurring theme in this book, shown through one example after the next, is that the simple stories many people might have, to account for a person's great achievements, are often appealing and believable, but are in fact often inaccurate or at the very least incomplete.

He shows that various situational biases can have a profound, snowballing effect on the course of successfulness in a person's life.  A trite detail such as birthdate can lead to a cascade of advantages or disadvantages for athletes, which then accumulate over many years (his example is of successful hockey players being much more likely to have an early birthday--if you're born in December, this is an instant disadvantage, as you will be a little bit smaller and weaker on average compared to your teammates, therefore the older players will tend to outperform you, leading to a smaller chance of  you being noticed or advanced to a more challenging team, or to be deemed "gifted" and given more ice time, etc.)  

He emphasizes the role of thousands of hours of intensive practice being required to master a skill.  Those who have 10 000 hours of practice under their belt early on in their lives--particularly if some serendipitous quirk of fortune allowed them to be one of the only individuals, or one of the first, to gain this experience-- have a strong chance of succeeding spectacularly in their fields.  He gives examples such as Bill Gates, or the Beatles, or some of the most successful New York lawyers doing a particular type of law. 

One of the psychologists cited in this book,  who has studied the area of "exceptional achievement" is AK Ericsson, who generally argues that "extended, intense practice"  is the primary determinant of elite performance, as opposed to inborn talent.  The ability to do this type of practice, of course, requires or is greatly facilitated by, motivational resources as well as environmental opportunity, parental support, a culture which favours such as endeavour, etc.) Here are some references to articles of his:
http://www.ncbi.nlm.nih.gov/pubmed/17905932
http://www.ncbi.nlm.nih.gov/pubmed/17642130
I suspect that heredity is quite relevant, but may manifest itself in many ways aside from what many people might assume.  Factors that could be considered at first glance to be a disadvantage, either hereditarily or environmentally, may, in the world of successfulness, end up being compelling advantages.

Guillermo Campitelli is another excellent researcher in this field; here's a reference to one of his recent papers: http://www.ncbi.nlm.nih.gov/pubmed/17201516.  The evidence here, looking specifically at chess players as a model of acquiring expertise, affirms the extreme importance of thousands of hours of  practice, but also recognizes that some players improve much more than others with the same amount of practice.  This is probably the influence of inherited talent.  Maybe there could be other hidden variables, including family or cultural factors.   He suggests that the age at which the practice begins is another important variable.  

It should be noted that, in this literature, "deliberate practice" refers to a type of activity which is specifically directed towards performance improvement, is adequately difficult, has feedback about performance, and which has opportunity to correct errors.  This differs from "ordinary" work experience, which may be quite a bit less intense and much less geared towards improving skills.  I suspect that the quality of "deliberate practice" may vary quite a bit, depending on the degree of immersion, concentration, energy, engagement, and meaningfulness there is in the action.  I wonder if enjoyment of the practice is a major variable too, I would be interested to see if some of these researchers would look at this.  If someone finds their 100 hours of practice meaningful and enjoyable, I have to wonder if they might advance much more than someone whose 100 hours were a drudgery.    

Another excellent angle of discussion in Gladwell's book has to do with understanding a person's cultural background and childhood developmental history, as extremely important determinants of success.   This leads to discussions about opportunity, pedagogical technique and policy, etc.  Sometimes cultural or developmental factors cause individuals to lack a certain skill necessary to succeed, or put individuals at risk of recurrent severe problems or frustrations.  Good examples are given, including the story of a profoundly gifted intellect who was never able to share his talents; and of highly trained pilots who were too quietly respectful of authority to be able to proactively use strong assertive social skills to prevent an aviation disaster.

I'll add to this post later on, to expand some thoughts about achievement and success.  In the meantime, I think Outlier is a worthwhile and entertaining read.

Writing about worries can ease exam anxiety

Here's another simple research finding, published recently in Science by Sian Beilock:  students who spent ten minutes--immediately before a test--writing down their thoughts about what was causing them fear, performed substantially better on the test.


http://www.ncbi.nlm.nih.gov/pubmed/21233387


I'll have to review this paper in more detail to comment further, but I think it is another simple anxiety-management tactic for exam or performance preparation.  A frantic review or a frantic bout of anxious rumination right before an exam is unlikely to help -- an anxiety-management exercise such as expressive writing is very much more likely to help, and a study like this is strong evidence of this.

The article shows that the effective action was specifically to write about negative thoughts and feelings during the ten minutes before the beginning of a stressful exam.  A control activity--of writing about anything that comes to mind--was not effective.   So the effectiveness of this technique was not simply due to distraction. 

I would be interested to see the authors' opinions and/or research about whether specific journaling techniques could work particularly well, or less well, in various anxiety scenarios.  Sometimes, purely "negative" journaling can end up being a somewhat ruminative activity which entrenches negative emotional states and attitudes (e.g. one can get worked up in a cynical, pessimistic rant, which could increase or magnify one's following cynicism or pessimism, or increase one's filtered attention to negative events in the day).
See the following references:
http://www.ncbi.nlm.nih.gov/pubmed/12173682 
http://www.ncbi.nlm.nih.gov/pubmed/17120515
   A "balanced" journaling style, which includes room for free discussion of thoughts and feelings, but also room for positively-focused or constructive discussion may prevent this risk of snowballing rumination or negativity from a journaling activity.   One simple aspect of this experiment was that the journaling was immediately before a performance, and was very time-limited (10 minutes); these factors may reduce the potential for the journaling to be a negative or ruminative behaviour, and may increase the chance of the activity serving to process anxious emotion effectively.

Testing improves learning

Here's another recent bit of research, published in Science, demonstrating the value of doing a test ("retrieval practice"), immediately after learning something.  Those who did the tests, instead of other study techniques, had much better retention 1 week after learning something.

http://www.sciencemag.org/content/early/2011/01/19/science.1199327.abstract
This finding is consistent with my believe that a lot of study time is inefficient, because it encourages the studier to push forward to "get more reading done", before the reading which was just done has been consolidated well or reviewed.  Even though "pushing forward" may seemingly cover more pages of text, it accomplishes less long-term learning.  A much more efficient use of time is to pause, review, and do a test on the material at just the right interval.  If the interval is too short, the tests will be too easy, and the review will also be an inefficient use of time.  If the interval is too long, too much will have been forgotten already, the tests will be too hard, and it will make you have to go over the same material again, another inefficiency.

I don't believe findings such as this one necessarily contradict ideas about  flexible or "constructivist" approaches to education.  Nor do I believe it has anything to do with the controversial area of standardized tests for children or professional schools, etc.  Standardized tests are not a mechanism for education, they are assessment tools (how good they are as assessment tools would be a subject for a good debate).

There are some instances in which pausing frequently to review could disrupt a larger thematic appreciation of a subject or experience--it would be like pausing a movie every ten minutes to answer questions about the plot or characters--so, of course, sometimes this technique would have to be set aside.

I think that flexible, personalized educational approaches are extremely important--but this evidence about the merits of retrieval practice testing can be applied to any such style.  Its immediate value is in helping people use their time more efficiently for many study tasks.

A previous post also deals with the subject of study efficiency, and actually cites a more densely technical analysis showing more or less the same result, though it adds information about the frequency with which one should optimally pause to test oneself: http://garthkroeker.blogspot.com/2010/04/optimal-learning-training-schedules.html

Reading Exercises

A common problem I find among university students is difficulty reading quickly or efficiently.  Reading problems can also occur in conjunction with depression.

The best thing to do to improve reading skills is, of course, to read more.  But a phenomenon which often happens when reading any text, but especially longer texts, such as novels, is that you can lose track of what you have just been reading.  Whole sections of the text may end up being skimmed superficially, as part of your attention lapses or wanders, while still maintaining a basic pace of absent-minded reading.  This leads to a lack of enjoyment or feeling of mastery with reading, dampened morale, sapped motivation, contributing further to any depression which had been present, and deterring further reading efforts. 

An approach to this type of problem requires you to stop to reflect or answer questions frequently about what you have just read.  Whenever you test yourself regularly, your learning and retention are greatly increased.  Most good introductory university textbooks are set up this way.  But not very much in the line of non-textbook reading.  

So, I have been trying to find resources to help with reading skill, for adults.  Elementary-school language textbooks or readers seemed like a reasonable thing to check.   I certainly recommend that adults at least periodically read books which have been written for children or adolescents.  The best things I've found online are from ESL (English as a second language) programs.  Even if you are an advanced reader, or have spoken English all your life, I think that ESL exercises could be good for improving reading skill. 

Cognitive-skills training websites tend not to offer very much in terms of language learning or improving reading fluency or retention.  I wish that the cognitive skills website people could develop more along these lines: reading-oriented games don't seem very difficult to imagine or design, compared to other types of games.

Here's a list of a few sites I've found, where you can practice English reading skills:

http://web2.uvcs.uvic.ca/courses/elc/studyzone/
This is an excellent free resource from the University of Victoria (in BC).  For the reading exercises, choose an "English language level"  (beginner to advanced), then follow the links about reading. 

Houghton Mifflin College
This site also offers timed readings with questions afterwards. 


Quizzes Based On VOA Programs (ESL/EFL)

This link goes to a site where you have to read a text a sentence at a time, and fill in the blanks from a list of options, according to what makes sense or is grammatically correct.  While some might find this type of exercise too easy, I think it is a nice way to remain more interactive with the text.  If you do find it easy, you can just try to do it faster, and make it into a game. 

Another useful thing to look for is an online book club which has discussion questions about the book you're reading.  Some sites have questions for each chapter, which is the type of thing I'm recommending, so that you can pause frequently to review what you have just been reading.   I haven't found a single site which has chapter-by-chapter questions for a wide variety of books, but here's an example of a specific site, giving questions about Great Expectations by Charles Dickens (a great book, by the way):
http://www.victorianweb.org/authors/dickens/ge/pva107.html

Tetris or sleep deprivation to treat or prevent PTSD?

Here's a reference to an interesting 2009 study showing that playing tetris for 30 minutes can interfere with memory consolidation of upsetting visual imagery:
http://www.ncbi.nlm.nih.gov/pubmed/19127289

This is an example of evolving evidence that an important period for consolidation of  memories occurs in the first 24 hours after an experience.  A consolidated implicit association between the factual components of memory and strong negative emotions may also form most strongly during this initial post-exposure period.

The same group published a 2010 study showing that a game like tetris was more effective than a quiz-type game activity for reducing visual flashbacks following exposure to upsetting imagery:
http://www.ncbi.nlm.nih.gov/pubmed/21085661

I think the message here is not that tetris in particular has some kind of unique medicinal properties, but that a non-passive activity which requires continuous, intense visual attention is most effective at reducing consolidation of intrusive visual memory.  A distracting activity lacking strong visual involvement may be less likely to interfere with this consolidation mechanism. 

Other research has suggested that propranolol, a beta-blocking drug, can reduce post-traumatic memory consolidation, particularly the troubling implicit or emotional component responsible for psychological symptoms of PTSD.  (see my other post, http://garthkroeker.blogspot.com/2009/02/beta-blockers.html)

Some of the standard psychological treatments in the immediate post-trauma period may be harmful, such as critical incident stress debriefing.  If individuals are compelled to revisit details of their trauma in a group setting,  during the sensitive 24-hour post-incident window,  this may increase rather than decrease memory consolidation.  I think this tactic is especially problematic if there is social pressure or overt prescriptive advice from professionals to do this, when the individual may not wish to talk about the trauma.   This type of pressure may feel coercive rather than freely consensual, a dynamic which could be re-traumatizing. 

In another recent study (http://www.ncbi.nlm.nih.gov/pubmed/20889142 ),  sleep deprivation following exposure to upsetting visual stimuli was shown to reduce aspects of implicit memory consolidation.  This is consistent with other evidence showing that sleeping facilitates learning, by helping to consolidate recently acquired memories.

In conclusion, I think it is useful to know some simple techniques which could reduce the harm which traumatic experience can immediately impose upon the brain's memory systems.  Immediate distraction with an absorbing visual activity, such as tetris, could be helpful.  Sleeping right away may not be helpful, and may actually increase consolidation of traumatic memory.

For consolidated symptoms of PTSD, and for longstanding troubling thoughts, memories, images, and emotions, etc.  it is clear that therapeutic dialog can be very helpful, provided the setting is safe, non-pressured, comfortable, with a strong sense of trust.    Such gentle dialog could begin the process of weakening the strong negative emotional grip that the traumatic experiences may have in daily life.  The evidence mentioned above has to do with reducing the incidence of PTSD in the first place, through specific tactics to be undertaken immediately after the trauma. 

We could infer, conversely,  that engaging in distracting activities, such as video games, after doing an activity that you would want to remember vividly (such as studying, or some other pleasurable or meaningful event), could lessen retention of these positive experiences  (so, you shouldn't distract yourself with an absorbing visual activity right after studying).  Also, having a good sleep after a pleasurable event, or after studying, would be expected to make these experiences more permanent in your factual and emotional memory. So, it's important to be conscious of what you do, during, but also after, events of significance.

"Brain Training" ineffective?

Adrian Owen et al. published a letter in Nature this week, summarizing the results of a study examining the effects of playing "brain training" computer games.  Here is the link:
http://www.ncbi.nlm.nih.gov/pubmed/20407435


The format of the study is interesting, involving the BBC website, inviting mass public participation in ongoing on-line research projects (here's a link to that site, which has a variety of other entertaining surveys you can do: http://www.bbc.co.uk/science/humanbody/mind/index_surveys.shtml).

In this case, over 11 000 subjects did various types of computer games on-line, aimed at developing various cognitive skills.  The subjects had to practice for at least 10 minutes per day, at least 3 days per week, for 6 weeks.  Some subjects practiced much more than others. 

The results are not very surprising to me:  basically, they showed that the skills developed while practicing a computer game do not "transfer" : they do not lead to generalized improvement in cognitive ability.   Even the subjects who practiced much more than the minimum requirement did not end up improving in a set of generalized cognitive tests afterwords.

Subjects improved significantly only in the specific tasks which were practiced.  This is intuitively obvious.   If you practice Tetris, you will become much better at Tetris, but are not likely to improve your mastery of French vocabulary!  Practicing volleyball will not help your guitar skills very much -- in some cases, such practice may in fact interfere with other skills acquisition, because one is procrastinating or redirecting energy away from one skill while practicing another.    Certainly it is true that computer games can be quite addictive:  if someone is spending many hours per week playing computer chess, or some other game, instead of reading, then overall educational performance is likely to decline rather than improve.

For participants in this study, it may be true that benefits occurred in "process" which were not adequately measured by the benchmark tests administered before and after the 6-week trial.  For example, playing a game which improves reflexes or visual memory might not immediately or directly "transfer" or  lead to improved performance in another reflex-based or memory-based benchmark test--but it might cause improvement in the rate at which another reflex-based or memory-based test, task, or game would be learned or mastered.  Analogously, if you have played a lot of volleyball, you might not immediately perform well in soccer--but you might learn to play and master soccer more quickly.  Or, if you have learned French and Spanish, you might not immediately perform well in a German vocabulary test, but you might be able to learn German much more quickly.  These types of benefits would not be picked up by the testing administered in this study. 

Here are some further ideas:

1) Is it possible that some particular cognitive games are more useful or generalizable than others?

-I think this is very possible.  I think that one should consider what type of gain is desired from the exercise you are doing.

A game which helps you practice learning and remembering faces and names could be quite helpful if such memory issues are problematic in your daily life.  Such a game would be inherently generalizable, since the daily behaviour and experience outside of the game would be similar to the game challenges. Lumosity.com has examples of such games.

A game which helps you pay attention to reading texts closely, while monitoring and testing your speed, accuracy, memory, and comprehension of the text, could be very useful if you are having trouble reading or studying.

Games which teach and test general knowledge subjects could be obviously useful to gain general knowledge -- e.g. learning vocabulary, facts about nature, etc.

So, I think one should choose games carefully, with the knowledge that the game will train you to improve in a particular skill.  Is that particular skill likely to be useful or generalizable in your daily life?

2) Is it possible that some of the specific games used in this study could be generally useful to some particular individuals, even though they were not helpful to the group as a whole?

-I think this is very possible as well.  There are three main issues that leap to my mind about this:

First, the study looks at a large general population of volunteer subjects.  A great many of these subjects were probably already in pretty good shape cognitively, and were motivated and enthusiastic to participate in such a research project.  This would be like asking a bunch of fitness enthusiasts to do 10 minutes of calisthenics 3 times per week, and then checking to see if their overall fitness improved 6 weeks later.  It would not be surprising to see an absence of any effect.  However, if the participants were chosen because of having cognitive weaknesses, due to learning disabilities, dementia, other illnesses, or environmental deprivation, then perhaps there could have been a much more substantial and relevant improvement with such a regime.  People with a lower fitness level would be expected to benefit much more substantially from a simple calisthenic routine than those already in good shape.  Many people with depression might have low motivation or engagement with intellectual tasks -- in this case, games of this type might help people get their minds more active again, as a prelude to other types of learning or intellectual engagement. 

Second, I am reminded of some other requirements for change in the brain: an immersive or highly intensive environment can be required for the brain's plasticity to be harnessed.  This might require many hours per day, over many months.  These hundreds of hours of training would contrast with the total of 3 hours' minimum training which this study evaluated.   

Third, some of these game types could be useful, diagnostically, for evaluation or identification of particular cognitive or perceptual strengths and weaknesses.  If these problems are identified, then a specific recipe for improvement could be mapped out.

I do wish the authors of this study, given their interest in computer-based learning & cognitive testing, would invent some games which could help people develop ability in reading, comprehension, general knowledge, etc.  Also, there are game-like computerized exercises which can help people develop skills in recognizing emotions, empathizing, etc.  (examples can be found at the BBC site).   These exercises could be useful for dealing with social anxiety, relationship problems, Asperger's Syndrome, etc.

Optimal Learning & Training Schedules

An interesting question I have often considered has to do with the most efficient way to use time, in order to prepare for something, or to learn.  This is relevant in psychotherapy, in terms of helping therapeutic change progress at the most optimal pace.

To formalize the question, consider the following:

1) If you had 100 hours to learn something (e.g. to memorize a text; to learn a foreign language; to learn a musical instrument; to understand a set of complex ideas; to learn a new sports skill; or overcome a psychological symptom), how would you distribute these hours, so as to optimize the therapeutic change?  Would it be 10 hours per day, for 10 days in a row?  Or 1 hour per day, 100 days in a row?  Or 1 hour twice per day, for 50 days?  Or 1 hour per week, for 2 years (!?) 

2) Another set of constraints on this problem would be this -- if you had 10 weeks to learn something, a maximum of 10 hours per week to learn it, and a maximum of 10 hours on a single day to spend, what would be the best way to work?  Would it be 10 hours every Monday, for 10 weeks?  Or 2 hours every weekday? Or 1 hour twice a day on weekdays? 

It interests me to note that answers to this type of question come from different fields of research, from cognitive psychology to education to athletic training.

The most sophisticated piece of research I found regarding this issue is described in the following article:

Pavlik et al., "Using a model to compute the optimal schedule of practice," Journal of Experimental Psychology: Applied, v14 n2 p101-117 Jun 2008

The research shows that, in general, "spacing" is far superior to "blocking" in terms of time management or study scheduling.  That is, if you have 10 hours to learn something, it is better to split the time up into short blocks, with rest periods in-between, rather than spending all 10 hours at once.

Pavlik's article includes a much more sophisticated analysis:  for a memory task, items which were more difficult to remember were reviewed with a shorter interval, whereas easier or more well-learned items were reviewed with longer intervals.  As each item became more well-learned, the spacing increased gradually.  To review something too soon would not be using time well:  not only could that moment be used more efficiently to review something more difficult, it also does not develop the longer-term memory of the item as well.  It is most optimal to review something just as its memory is starting to decay.  These memory decays take place over a longer and longer time, the more you have learned something.    To review something with too long an interval between study trials would also be inefficient, as too much forgetting will have taken place, and an inefficient investment of time will need to be spent re-learning the same material.

Common practices in studying or practicing  include the following:
1) familiar or easy material is revisited too much:  it is often inefficient to review something you already know well, unless this causes you to  develop some new insight about it.
2) unfamiliar material is reviewed in large blocks of time (cramming) -- this is profoundly inefficient, and does not allow for long-term learning.

Pavlik's experiment also confirms that high levels of accuracy should be sought, right from the beginning, so as to maximize efficiency.

In summary, Pavlik's work shows that one should space learning efforts.  When just starting out, the spacing interval should be brief, with enough frequent review to master what you have just learned.  With the material mastered on a short-term time scale, the spacing interval can be extended, just enough to make the review slightly challenging.  This process continues, with gradual expansion of spacing intervals, until the material is permanently learned.   Once the spacing interval extends for days, weeks, or months, the learning will probably be permanent. 

The research is very incomplete on this matter, for a number of reasons:

1) the complexity of each individual learning task needs to be taken into account.  For example, if one is trying to solve a complex physics problem, or to comprehend a difficult concept in philosophy, it may be necessary to invest many solid, continuous hours of effort in a "block."  In this sense, each individual "trial" of learning takes place over many hours, rather than over seconds (as in memorizing a foreign-language word).  So, for more complex tasks, fragmenting one's study time could decrease efficiency.  But in a general sense, it will be extremely inefficient to try to "cram" in order to learn how to do complex physics problems.  The "spacing" needs to take place generously, but with each space over a period of days--allowing you to complete individual problems--rather than hours.

2) It remains true that action is required in order to learn.  If accuracy is valued so highly as a priority that action does not take place, than learning cannot occur.  So, for example, in order to learn a new language, one must practice speaking it, or using it.  If one is excessively meticulous about accuracy of vocabulary or grammar right from the beginning, and therefore one is silently contemplative in a conversational language class,  then the action cannot proceed, and instead a stifling self-critical process will inhibit learning and engagement. 

3) The existing research does not account for the powerful effects of "constraint-induced" neurologic change.  Immersive processes may permit the brain to develop new pathways much more efficiently -- anything less than immersion allows a continuing neural pathway of least resistance.  The Taubian ideas about stroke rehabilitation exemplify this phenomenon:  neurological recovery may be much more complete if the brain is not allowed to by-pass or compensate for the disabled body part:  in this way the brain's energy and capacity  and plasticity may be directed towards regaining lost function.  So, in this sense, a continuous "immersion" in a study process may be more effective than any sort of "spacing" regime.  The immersive experience would be a "block" lasting months at a time, continuously.  Of course, there could be smaller spacing effects within this.  Addiction recovery requires similar "immersion" in an abstinence process.  The neurological recovery from the addictive process could then proceed over months or years (typically a year being a significant milestone).   

4) Sometimes, large blocks of time can be useful.  Even though it is not the optimal schedule for using time, in terms of memory formation, it may be optimal on other levels, such as with developing the ability to maintain longer periods of attention in the subject matter, with developing deeper insights about patterns within the subject, or with developing a richer sense of community or identity around the activity.  Thus, a "weekend retreat" experience of something can be educationally powerful, even if the same number of hours spread over several weeks might be a more optimal use of time, if simple memory is the only consideration. 


Here are some references to other  research which addresses this question:

http://www.ncbi.nlm.nih.gov/pubmed/19122053
Extinction more effective if spaced rather than in a block of time.


http://www.ncbi.nlm.nih.gov/pubmed/19831094
Variable practice (involving several versions of a skill) has advantage over constant practice


http://www.ncbi.nlm.nih.gov/pubmed/17326522
Random training in basketball has better retention after 1 year


http://www.ncbi.nlm.nih.gov/pubmed/12831284
Contextual interference improves learning skill

http://www.ncbi.nlm.nih.gov/pubmed/19093603
Blocked practice better for immediate acquisition, random practice better for retention (long-term).

http://www.ncbi.nlm.nih.gov/pubmed/17037668
blocked practice better for acquisition, random practice better for retention (long-term) --pistol shooting

http://www.ncbi.nlm.nih.gov/pubmed/16383091
variable practice better in tennis


http://www.ncbi.nlm.nih.gov/pubmed/1989009
knowledge of results (KR) -- more is not necessarily better.  less KR improves results after a delay, especially if tested without KR


http://web.ebscohost.com/ehost/detail?vid=7&hid=3&sid=04efbc76-6010-4987-ab5f-353b00504841%40sessionmgr13&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh&AN=26941729
 shuffled practice of math problems vastly superior to standard blocked practice, when measured 1 wk later

http://web.ebscohost.com/ehost/detail?vid=7&hid=3&sid=3588cd73-af26-475d-81e9-6186d4241292%40sessionmgr10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh&AN=47668545
spacing better, in general; but if the learner prefers a block strategy, then spacing less advantageous



http://web.ebscohost.com/ehost/pdf?vid=3&hid=3&sid=902d9a70-de9b-4441-835b-2fddc6ff0698%40sessionmgr14
1988 psychology article reviewing spacing as optimal memory strategy



http://web.ebscohost.com/ehost/detail?vid=8&hid=3&sid=3588cd73-af26-475d-81e9-6186d4241292%40sessionmgr10&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=ehh&AN=37193344
1 day per week courses -- much inferior to 3 days per week


http://en.wikipedia.org/wiki/Spacing_effect

Sleep & Napping Improve Memory & Learning

Sleeping after learning improves consolidation of memory. Slow-wave sleep, which tends to occur in the first few hours after you fall asleep, is particularly important for memory consolidation. In one clever 2007 study published in the presitigious journal Science, subjects were exposed to an odor when learning a task. If they were exposed to that same odor during subsequent slow-wave sleep, their retention of the learning task was significantly improved. Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/17347444

This suggests a simple aromatherapy technique to enhance your studying: infuse your study environment with a distinct, pleasant fragrance (for example, try an aromatherapy oil) -- then infuse your pillow with the same fragrance afterwards. During an exam or test, try infusing the same fragrance on your skin or clothes (just don't overdo it, or you might irritate the people writing their exams next to you!)

Furthermore, there is evidence that brief naps (60-90 minutes) in the middle of the day can help with memory consolidation, motor learning, and can also prevent the deterioration of mental and physical performance which tends to happen in a long day. Here is one reference about this:
http://www.ncbi.nlm.nih.gov/pubmed/12819785

There's a lot more research on sleep & learning. All of it supports the practice of healthy sleep habits in the life of a successful student. Many students have a very unhealthy, disrupted, perhaps heavily-caffeinated sleep schedule, particularly while "cramming" during the week of exams or other tests. This is hard on the body, physically and emotionally; it also leads to inefficient learning.

So, consider good sleep to be a component of your studying. And a nap after a bout of hard academic work can help you learn better.

Studying & Practicing Techniques

The field of optimizing study or practice time is quite interesting. There are elements of wisdom from diverse points of view, such as from athletic trainers & coaches, elementary and high school teachers, musicians, and educational psychologists.

Here are a few ideas:

1) make a commitment to spend regular, frequent periods of time in study or practice

2) make your study or practice time interesting or fun

3) if your attention is failing, try to compete with yourself gently (e.g. put a mark on your page if you catch your attention wandering off); but also allow yourself brief breaks. In order to control this process (and to prevent your brief break from becoming a 6-hour break), you could use a timer. During breaks, you could rest quietly or go for a walk, perhaps reviewing in your mind some of what you have just learned. During periods of decreased attention, you may need to allow for more frequent breaks.

4) frequent review helps with memory consolidation. If you have just learned something, go back right away to remind yourself of it--maybe ask yourself, and answer to yourself, a few questions about it, rather than immediately plowing ahead with the next chapter.

5) Sleeping after learning improves consolidation of memory. Slow-wave sleep, which tends to occur in the first few hours after you fall asleep, is particularly important for memory consolidation. In one clever 2007 study published in the presitigious journal Science, subjects were exposed to an odor when learning a task. If they were exposed to that same odor during subsequent slow-wave sleep, their retention of the learning task was significantly improved. Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/17347444
This suggests a simple aromatherapy technique to enhance your studying: infuse your study environment with a distinct, pleasant fragrance (for example, try an aromatherapy oil) -- then infuse your pillow with the same fragrance afterwards. During an exam or test, try infusing the same fragrance on your skin or clothes (just don't overdo it, or you might irritate the people writing their exams next to you!)

Furthermore, there is evidence that brief naps (60-90 minutes) in the middle of the day can help with memory consolidation, motor learning, and can also prevent the deterioration of mental and physical performance which tends to happen in a long day. Here is one reference about this:
http://www.ncbi.nlm.nih.gov/pubmed/12819785

6) choose a study or practice environment which is psychologically pleasing. This could include multi-sensory environmental manipulation, including access to healthy foods, smells, comfortable seating, quietness, soothing background noise, etc.

7) if part of the learning task requires repetition, make special effort to infuse the repetition with something imaginative.

8) if part of the practice is for exam preparation, etc. then you could try to mimic the exam environment repeatedly--e.g. by doing mock exams at the same time of day as the scheduled exam, or by doing these practices in the same physical location as the actual exam, if possible.

9) if the practice is for a performance, it can help to record yourself periodically; when you hear or look at your recording you may need to be critical but you should also consciously affirm the aspects of your performance that went well. Self-criticisms should never be in the form of a personal attack (e.g. "I'm stupid!") but should be gentle observations of areas to work on or change.

10) a tutor could be quite helpful, not merely to "teach you" but as a motivational figure to help you practice or study more efficiently or with greater enjoyment (along the lines of a personal trainer for fitness). A friend or study partner could have this type of role, provided the friend does not become a distraction from your work.