Professionals : are your patients forgetful? Here are some tips

Strategies to help clients better remember the content of your sessions.

Let’s think about ways to help our clients benefit from our interventions! Below are strategies to help our clients remember and keep track of content of your sessions.

Encompassing all of the strategies, four main approaches might be most useful to help clients better remember the content of your sessions:

A. Provide a consistent structure
B. Alleviate pressure on memory
C. Target fewer points of discussion
D. Repeat the information over time

A. Provide a consistent structure

1. Same time, same place. If you can, have the sessions on the same days of the week, at the same time and location. For some clients, some difficulty with a change in day/time should be expected. Reminder phone calls could help diminish the chances of missed appointments.

2. Set up an agenda at the beginning of each session. At the beginning of each session, tell your clients the agenda for the session. This makes the session predictable and could help lower anxiety for some.
• Briefly enunciate the main point(s) that will be discussed.
• Ask your client if there is anything he/she wants to talk about and put it on the agenda.
• After setting up the agenda, review what will be discussed during the session.

3. Review homework from the previous week, if there is any.
• Example: Welcome the client, introduce yourself, and set agenda for this session: “Today we will 1) review homework from last week; 2) discuss the reason for consultation; 3) set goals and determine a number of sessions; 4) set homework for next week.”

4. You can also remind the person about the duration of your session. Have a clock on the wall or a timer with big numbers on the table next to them. This can help the person stay oriented with time and can sometimes help decrease anxiety (because they will know how much time is left, etc.).

B. Alleviate the pressure on memory

5. Encourage the client to take notes during your meetings. Provide a pen and a paper for them to use. You can also encourage them to use a notebook to write down the things discussed in the sessions. They can also use it to record their thoughts or the work they are doing between sessions.
• Example of a session: 1) review content from last session (CLIENT CAN READ HIS NOTES FROM LAST SESSION); 2) review homework; 3) set agenda for this session with the client (etc.)
• Taking notes during session might not be appropriate for every client. Some need a pause from your discussion to write down some notes. Others will function better with an outline of the session, which you can prepare on a piece of paper and give to them before the session.
• You can also prepare pictures or pictograms and provide them with a paper copy to refer to during the session. This is most appropriate for children or for those with limited language proficiency.
• Finally, some have reported that it is useful to work with a smart pen. Others have found that recording the session on a tape recorder is useful.

6. Encourage them to use a calendar to remember appointments. You can also support your client into finding him/her an agenda and give them prompts to use it. Alternatively, ask them where they can find a day planner, what type to buy, etc. Some need a little push to get started so get the process started for them if you feel it’s necessary!
• Example of a session targeting the implementation of a day planner: 1) review content from last session; 2) review homework; 3) set agenda for this session with the client; 4) REVIEW USE OF AGENDA; 5) PROBLEM SOLVE AROUND USE OF THE DAY PLANNER; 6) assign homework. Use this session structure for each and every session, if needed.
 Encourage them to write down the date and time of your next meeting or suggest they write down appointments and tasks in the day planner whenever they get a chance.

7. Provide strategies to help with medication adherence: you can discuss different strategies with your client and assist him/her in picking the one that best suits him/her.
• Take medication at same time every day. Take medication with another activity you do every day (e.g. with breakfast). Make it part of a routine.
• Use visual reminders. Make sure you see it – place it next to the coffee pot, if you make coffee in the morning, or next to your toothbrush.
• Buy an alarm clock from the dollar store; set the alarm(s) and place it next to the pill box.
• Ask the pharmacist to organize the medication in blister packs.
• Use a calendar. Put it on the fridge or on your wardrobe door.
• Get another person to remind you.

8. If you are worried about forgotten medication, put it on the agenda.
Example of a session agenda for session #3: 1) review what was discussed during last session; 2) review homework; 3) set agenda for this session with the client; 4) REVIEW MEDICATION ADHERENCE; 5) PROBLEM SOLVE AROUND MEDICATION ADHERENCE; 6) assign homework.
Use this session structure for each and every session, if needed.

C. Target fewer points to discuss

9. Select a maximum number of topics to discuss with your client. Not every topic can be covered at once. Talking about a reduced number of challenges might be more efficient and less confusing. If you feel a client is more tired, more symptomatic or less motivated, adjust the number of topics discussed during your session. Leave time for problem solving.

10. Adjust to lower distractibility in sessions. Not every topic can be covered at once. Too many topics can distract the patient.

11. Adjust to lessen fatigue in sessions. Take a break and encourage the client to stand up and go get a sip of water. Make sessions shorter.

D. Repeat the information over time

12. At the end of the session, summarize and repeat, in simple words and short sentences, the main topics discussed.
 By summarizing the whole session in a few main topics, you are helping the person remember the information in the future.
 Organizing the information in main points – let’s say one or two main ideas – makes it easier to remember than the whole conversation. These one or two main ideas can serve as cues to remember other aspects of the conversation. But first, these cues have to be memorized. Then, more info could be added onto these points. It works like scaffolding.

13. Errorless learning: At the beginning of your therapy process, start sessions by restating what was discussed in the last session. This refers to the principle of “errorless learning”. In errorless learning, you want to prevent a person from “mis-learning” the information.
 Errorless learning (Baddeley and Wilson, 1994): a category of techniques where errors are minimized during the learning phase by providing the correct response before the client attempts to state it. In this approach, guessing is discouraged and we want to ensure clients don’t memorize the wrong thing.
Have you ever taken a wrong turn to go to a new place and then noticed you have a tendency to make the same wrong turn again? This is because you have memorized your mistake.
In errorless implicit learning, we want to avoid making mistakes to reduce the possibility of errors “sticking” in our memory. That is why, in the first few sessions, if you feel the information was not well understood, take time to re-explain what was discussed last session, and what the “take home message” was.

14. Repetition: Repeating an idea using different forms will help the person really grasp the meaning of the message you are trying to convey. Give examples and reformulate your point as often as you feel necessary.
15. Always review homework from last session. As mentioned above, learning that is spread out over time (spaced rehearsal) is more durable than learning that is concentrated within a short period (massed trials).

However, simple repetition is not enough..
As Nickerson & Adams have shown in in their famous ‘Penny study’ (1979): Simple repetition is not sufficient for learning
 Especially if the information is complex
 Especially if the information is not perceived as “immediately useful”

The Penny Study: Researchers asked students from the prestigious Brown University to identify the real penny..
Students were only able to identify the correct penny 50% of the time, despite the fact that they are exposed to pennies repeatedly. Was there a benefit to these multiple exposures? Not really. Because it was passive encoding. Recall does not improve with rote rehearsal and recognition only benefits slightly. Strong explicit recall really depends on elaborative processing. Take home message: there is more to learning than simple repetition!

16. Effortful learning: As you might have guessed by now, learning is greatly facilitated when the learner is actively engaged AND able to connect target content to existing information. This will increase the likelihood that this memory will be durable. This next section is in line with this idea:

17. The generation effect (Jacoby, 1978): Having to come up with an answer, rather than having it provided, leads to greater retention! (Eureka!)
 Guide your client to spontaneously verbalize the solutions to the problems you are trying to solve. Guide your client to spontaneously verbalize their understanding of a situation if you want them to remember it better. Engage them in the process so they can come up with answers, which could lead to better remembering of this information.
In line with this, read more about Motivational interviewing. In this approach, your role is a directive one – i.e. to elicit self-motivational statements and behavioral change from the client to enhance motivation for positive change. Motivational interviewing builds on Carl Rogers’ optimistic and humanistic theories about people’s capabilities for exercising free choice and changing through a process of self-actualization. Very interesting read!

 How ‘motivational interviewing’ does relate to the ‘generation effect’ (Jacoby, 1978)?

Putting it all together…

Errorless learning (Baddeley and Wilson, 1994): providing the correct response before the client attempts to produce it. Clients should avoid guessing to avoid memorizing the wrong thing. The generation effect (Jacoby, 1978): Having to come up with an answer, rather than having it provided, leads to greater retention.

1-Asks questions, engage clients. (Asking clients for their understanding. Asking them to come up with the answers themselves. Asking them to share what they have understood of the session). Then:
2- Tell them the answer if they cannot spontaneously verbalize it yet. If there are indications that the client might not be able to spontaneously come up with the information, tell them the answer. Method can be applied to memorizing simple information or a new behavior or coping skill.

Zone of Proximal development is a concept in psychology that was initially suggested by Vygotsky. Studying intelligence in children, he suggested that skills and understanding contained within a child’s zone of proximal development are the ones that have not yet emerged but could emerge if the child engaged in interactions with knowledgeable others (peers and adults) or in other supportive contexts (such as make-believe play for preschool children). Now, if you work with adults, take a moment to think about ways this principle could guide your work.

18. Vanishing cues method (Glisky et al., 1986). This is actually a form of errorless learning or “error-controlled training” Here, we teach something to the clients while providing them full support to learn the new information or skill. Then, the support is progressively reduced and only cues are given to prompt the client to remember the learned information, or use the learned skill. Learning occurs with full support and then the help is reduced over time.
 Study by Haslam, Moss and Hodder (2010): More recent versions of vanishing cues methods typically involve presenting the information in full to the patient (e.g., a new skill), then reducing the cues progressively, rather than adding more cues or encouraging guessing.
 The Memory-Link program from the Baycrest Institute in Toronto used this technique when they were teaching patients with mild memory problems to use Smart Phone/Smart day planner: They initially gave a lot of support to their participants and then slowly took it away.
 Think about how you might want to use this with clients, younger or older.

19. Spaced retrieval: Occasionally question the client about content from past sessions. Practice “spaced retrieval”. Gradually spread out the repetitions over longer and longer intervals. Spaced rehearsal will promote effective memory consolidation and retention.
Long retention for material is better when memory for the material is tested during the time of learning.
Read study by Roediger and Karpicke (2006) to learn more about this graph.
 Spaced retrieval is a form of successful recall of information over longer and longer time intervals (McKittrick, Camp and Black, 1992).
 In spaced retrieval, the client is provided with the full correct response initially and then asked to recall the information at progressively longer intervals without any cues.

20. Retrieval as re-encoding: Every time we look into our memory to consciously remember something, we make this memory stronger. In other words, every time someone consciously remembers an idea, it makes this idea more solid in his/her memory. Yes, every time you ask your client to tell you what was discussed last week, you are not only verifying if this person understood the information, but you are also making their memory of your discussion stronger!

Try it!
 Read this document a second time while thinking about clients you can use these strategies with.
 Select 1 or 2 strategies and start using them with 1 or 2 clients.
 See how you feel about them. See if they work and how you can make them work for you and your clients.

Track change/evolution
21. If you want to implement a change on X, put this topic on the agenda for each session. Come back to it every session. Assess progress and problem solve around difficulties.
22. Find a way to keep track of progress. For instance, use the same questionnaire every week: “How many times have you done X?”

Dre. Genevieve Gagnon, Ph.D., C. Psych.

Give me feedback on how this worked for your patients/clients and you! Knowing is growing! Send me an email and tell us what you think so we can improve our work!