Practice certainly does make one better. Whether it be shot after shot from the free-throw line or repeated cramming with multiplication facts flashcards, the more energy and practice time an individual dedicates to skill, the more honed their abilities will become; this is, of course, assuming the individual is practicing correctly. Why does this happen? The answer can be found within the science of how we humans learn and retain information through memory consolidation.
Anyone familiar with Charlie and the Chocolate Factory may remember when Mike TV, unable to be swayed by the warnings of Willy Wonka, was teleported from one area of the room to another. He was broken down into a million tiny pieces and reassembled as a smaller version of himself. He was still Mike TV, just a bit different; not all of his mass made it through to the other side. The reassembling of Mike TV is an analogy for how consolidation works with memories in the brain.
Urcleay & Miller (2008) define memory consolidation as "a time-dependent process by which recent learned experiences are transformed into long-term memory, presumably by structural and chemical changes in the nervous system (e.g., the strengthening of synaptic connections between neurons)." A more simplistic way to describe consolidation is how information is processed as it transitions from the short-term working memory to long-term, retrievable knowledge.
How do the principles of memory consolidation apply to recovery? The answer to this is quite simple; one needs just to replace the examples of basketball and multiplication with relapse prevention skills (self-care, understanding thoughts and triggers, grounding techniques, managing stress, knowing who to turn to for support, playing the tape through, etc.). Suppose patients can access the knowledge and skills they learned in recovery with automaticity. In that case, they are more likely to follow through with their recovery plan outside of the facility's safe and structured environment.
As learners, in our case, the patients, are introduced to new material, the neural links are weak and disorganized. The hippocampus is still scrambling to index different pieces of information in the working memory and communicate them to the neocortex. Eventually, with enough time and practice, the hippocampus helps refine neural links and make connections simplistic and efficient; this will lead to the consolidation of information into long-term memory that the neocortex can access with automaticity, without the help of the hippocampus at all (Oakley et al., 2021, Roesler & McGaugh, 2010).
Fire It to Wire It
We need to get patients to practice more, but research has shown that certain types of practice are superior, yielding more substantial learning results with greater efficiency.
Retrieval Practice focuses on students accessing the information they already have in working memory; not yet cemented in long-term, but not lost either. Once the clinician delivers the target information or demonstrates the desired technique, the patient should be expected to recall or copy to the greatest extent with as little support as possible. Difficult tasks may require more scaffolding, and it's essential to differentiate the level of support according to patients' needs to provide the right amount of desirable difficulty and fall within their zone of proximal development, their sweet spot for learning. It should be challenging but doable.
Retrieval practice is a type of rehearsal where the brain accesses information with fierce repetition. The target knowledge or skill can be fresh in their working memory or combined under varied practice conditions with prior knowledge, even if it is recently rediscovered. This is why people can feel a little “rusty” after picking up a skill they haven’t used for a while, but it will all come back at a quicker pace than would learning the skill the first time.
Activities that promote retrieval practice and could be used in a session to encourage neural linking are numerous:
Quick Fire Recall - After the information has been presented, visual aids are removed, and the clinician asks patients to repeat the information or demonstrate the skill. What are some relapse prevention skills we could deploy if stricken with the urge to use? Your friend offers you your substance of choice; what do you do? As an extension, spontaneously ask this throughout the session as it should be rapid responses. An alternative or addition could see the patients writing down their answer(s) quickly and revealing them as the writing process has been shown to enhance neural activity and increase linking (Ose, 2020).
Elaborative Investigation - Have patients in pairs as they talk through what they recall or demonstrate what they remember, using one another as resources. As one patient takes the lead, the other will prompt deeper thinking and conscious thought through open-ended "how" and "why" questions.
Create a Narrative - Having patients turn the target knowledge into a narrative increases neural activity and creates new links through more intense recall and consolidation. This method is especially effective for declarative, factual information. Still, narratives can be applied to skills-based practice in certain situations, especially in the early stages of rehearsing a multi-stepped response, such as responding to a trigger to use.
Summarizing - Having patients illustrate the key points of a concept selectively encourages retrieval practice while also outlining the patients' preference(s). There are numerous relapse prevention skills a patient could employ, and summarizing which might best support their recovery demonstrates cognitive selection. Again, modifying this activity to include writing will help reinforce memory recall.
Interleaving is another learning technique that aids in retrieval through mixed rehearsal practice. Rather than repeating the same information in a route style or under identical conditions, the learning is blended into different topics or situations. Specific relapse prevention skills may be more effective on a situational basis, and how a patient should respond may change depending if they are alone, at work, or at a family get-together when they feel the urge to use. Using role-plays or dialogues to work through responses under different conditions will help patients solidify their skills-practice (Brunmair & Richter, 2019).
To advance learning results, therapists should do more than relay the information one time; they must repeat the target knowledge and, more importantly, have patients repeat it, over and over, intermittently within and across sessions if necessary. Of course, patients need to be actively retrieving it. Just having the patients passively listen to the therapist or others in the room repeat information or skills isn't enough. Engagement and repetition by the patient under a variety of conditions are essential.
To first build and reinforce neural links within the neocortex, the brain needs demanding mental processes such as conscious attention, information retrieval, and practice. However, the "fast-learning" hippocampus offloads the indexed information to the "slower-learning" neocortex during periods of mental rest, which creates a sort of paradox. Which is more critical to learning and knowledge retention, intense mental workouts or providing the brain time to rest and consolidate information? The answer is both.
Cooling Down
Intensive mental workouts have been shown to produce numerous positive effects across the brain, such as improved processing speed (focus, conscious attention, information recall), executive function (abstract reasoning, selective attention), and working memory (accessing, processing, and storing information) (Nouchi et al., 2013). Even though the brain is not a muscle, it sure does act like one in this instance. Muscle fibers are disrupted during strength training or intensive exercises, causing satellite cells to fuse to repair the disruption, resulting in growth (Kwon & Kravitz, 2004), but this happens after the workout when the muscle is at rest. The brain needs its own opportunity for a cooldown.
According to cognitive neuroscientist Erin Wamsley, "Consolidation occurs during the many briefer moments of reset interspersed between and within the activities of our day. Indeed, even seconds-long rest breaks during a learning experience have been shown to trigger memory-related activity that predicts later test performance. Thus, far from being a waste of time, 'rest' during wakefulness may end up being a crucial and widely underappreciated contributor to long-term memory formation in everyday life (2019).” The major takeaway is that scheduled breaks are vital to the learning process of patients, but perhaps a greater contributor to the consolidation process than a short break following a focused mental exercise is the biological process of sleep.
The role sleep plays in memory consolidation cannot be overstated. During sleep, parts of the brain are 30% more active than when we are awake, especially during REM (rapid eye movement) sleep, which typically occurs in 90-minute intervals once an individual falls asleep. Disruption to this cycle results in various impairments in working memory, attention, and sensory-motor performance the following morning (Rasch & Born, 2013, Walker, 2021).
In early recovery, many patients report poor sleep quality, likely resulting from their sleep patterns during use. Because sedative drugs, such as marijuana and alcohol, are often used to silence the mind and sedate the body, they are easily confused with a sleep aid. However, these substances do not facilitate sleep as much as they do unconsciousness. Falling asleep is a biological process, and sedative substances interfere with this natural procedure, producing a fragmented sleep that prolongs the time necessary for the mind to begin REM cycles and reduces the total time spent in REM each night (Walker, 2021).
How can understanding this information be beneficial to patients in group therapy?
Through strategic design and thoughtful inclusion of activities that help break up a lesson, improve the pace of a session, and allow for practice under various conditions, the therapist can intentionally schedule the brain breaks necessary for consolidation to occur within group time as patients transition from one activity to another. Within a 60 minute session, for example, the scheduling of five or more activities will include five or more transitions, analogous to brain breaks, for the patient. Strategically throughout home practice assignments, spread over a couple of days rather than one long focused assignment will benefit patients because they promote intervalled retrieval practice with breaks built in. Furthermore, the therapist can schedule or hold impromptu brain breaks (physical movement, mindfulness/breathing/reflection, or sensory activities) when they notice fatigue in their patients.
A lack of REM sleep can lead to emotional instability as it is during REM cycles that individuals will process emotions and consolidate and cement memories. If patients are struggling with sleep, recommend they avoid napping during the day, cut out caffeine at least eight hours before they plan to sleep, disengage with technology to promote winding down before sleep, and keep sleeping times consistent throughout the week.
Understanding how the brain attains and retains information is consequential if we want to give patients the best possible outcomes. Repetition and practice are of critical importance for procedural understanding, and being intentional about the activities selected is paramount to facilitate engagement, retention, and growth. Intentionally build in breaks, encourage sleep, and also, ideally, structure content so that it repeats elements every couple of days in order to encourage consolidation over time after a few good night's sleep. Designing group therapy sessions with various mentally challenging practice activities, transitions, and brain breaks is the best way to promote memory consolidation and help your patients get the recovery capital skills they learn in your group to stick.
References:
Brunmair, M., & Richter, T. (2019). Similarity Matters: A Meta-analysis of Interleaved Learning and its Moderators. Psychological Bulletin, 145(11), 1029–1052. https://doi.org/10.1037/bul0000209
Kwon, Y., & Kravitz, L., (2004). How Do Muscles Grow? https://www.unm.edu/~lkravitz/Article%20folder/musclesgrowLK.html
Nouchi, R., Taki, Y., Takeuchi, H., Hashizume, H., Nozawa, T., Sekiguchi, A., Miyauchi, C., Kotozaki, Y., Kawashima, R., (2013). Brain Training Games Boosts Executive Functions, Working Memory, and Processing Speed in Young Adults: A Randomized Controlled Trail. https://journals.plos.org/plosone/articleid=10.1371/journal.pone.0055518 https://doi.org/10.1371/journal.pone.0055518
Oakley, B., Rogowsky, B., Sejnowski T., (2021). Uncommon Sense Teaching: Practical Insights in Brain Science to Help Students Learn. Penguin Publishing. 0593329740, 9780593329740
Ose Askvik E, van der Weel FR and van der Meer ALH (2020) The Importance of Cursive Handwriting Over Typewriting for Learning in the Classroom: A High-Density EEG Study of 12-Year-Old Children and Young Adults. Front. Psychol. 11:1810. doi: 10.3389/fpsyg.2020.01810
Roesler, R. McGaugh, J., (2010). Memory Consolidation - Encyclopedia of Behavioral Neuroscience, Academic Press. Pages 206-214, ISBN 9780080453965, https://doi.org/10.1016/B978-0-08-045396-5.00147-0.
Rasch B., Born, J., (2013). About Sleep’s Role in Memory. Physiol Rev. 2013 Apr;93(2):681-766. doi: 10.1152/physrev.00032.2012. PMID: 23589831; PMCID: PMC3768102.
Urcelay, G.P., Miller, R., (2008). Learning and Memory: A Comprehensive Reference, Academic Press, Pages 53-73, ISBN 9780123705099,https://doi.org/10.1016/B978-012370509-9.00075-9
Walker, M., (2021). The Science & Practice of Perfecting Your Sleep. Huberman Lab Podcast #31. https://www.youtube.com/watch?v=gbQFSMayJxk
Wamsley, E.J., (2019). Memory Consolidation During Wakeful Rest. Trends in Cognitive Science 23, No 3.
Image: CC BY-SA 3.0, https://en.wikipedia.org/w/index.php?curid=14562440