My case study of teaching someone to remember a cane using spaced retrieval with errorless learning generated many comments and questions about how to teach someone who has a moderate to severe memory loss.
I’ll explain why I recommend adding errorless learning (EL) to spaced retrieval (SR) and share seven tips to maximize EL for people who have a moderate to severe memory loss. I’ve also written a tutorial on SR with EL.
Free DIRECT download: Errorless learning for moderate to severe memory loss (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Free DIRECT download: free cheat sheet with instructions for errorless learning.
(Email subscribers get free access to all the resources in the Free Subscription Library.)Outline of this article:
- Our default teaching method is trial-and-error.
- Spaced retrieval (SR) is helpful for normal memory or mild deficits.
- You have learned many things using SR + trial-and-error learning.
- Errorless learning (EL) is helpful for moderate to severe memory impairment.
- SR with EL doesn’t work with all learners.
- What you can do if SR with EL isn’t working.
- 7 tips for working with someone who has a more severe memory impairment.
- How is SR and/or EL working for you?
Our default teaching method is trial-and-error
If you’re a clinician, then you know that a major part of our job is to teach people information and skills. Best practice is to teach and practice the information or skill in one session, and then assess how well that person remembers in the following session.
Because the learner is allowed to make mistakes, this trial-and-error learning.
In my experience, most people with intact cognition or a mild impairment usually learn well using trial-and-error learning.
Spaced retrieval (SR) is helpful for normal memory or mild deficits
Spaced retrieval is a more structured teaching method. From the learner’s perspective, they’re taught some information or skill and asked to repeat or demonstrate until correct. Then they’re asked to recall that information or skill in the following session.
If they get it right, then great! The session moves on. If not, then they’re taught again.
The trial-and-error method works well for people who have:
- Good attention, memory, and executive function skills.
- Good ability to monitor own performance.
- Good ability to recognize and remember mistakes.
A person with good memory is able to learn from their mistakes, and likely can learn the information or skill we teach in just a few sessions.
You have learned many things using SR + trial-and-error learning.
SR is simply practicing learning information or skills across more than one training session. It’s used by people of all ages and abilities, for example:
- Preschool: Learning numbers, colors, the alphabet, and favorite stories.
- Older children: Learning to ride a bike, facts from history and science, and writing skills.
- Adults: Learning a new hobby for fun or a new software program for work.
And SR is used by many people to learn a wide variety of skills and knowledge. Here are just a few examples:
- Knowledge: Learning a poem or a speech, current world leaders, or co-worker’s names at a new job.
- Skills: Learning to golf, play the piano, speak another language, cook, self-defense, or change a flat tire.
It’s a rare person who can learn these types of information or skills after just one exposure!
Errorless learning (EL) is helpful for moderate to severe memory impairment
People who have a moderate or severe memory loss are less likely to have a strong enough ability to monitor their own performance or recognize and remember mistakes. Trial-and-error learning often causes confusion and variability in recall.
Instead, consider combining SR with errorless learning (EL).
The demands on the learner are much less. They simply need to:
- Pay attention during the training.
- Imitate the trainer.
The trainer is essentially training a habit using classical conditioning. We can train many things, including:
- Remembering names of family and staff members.
- Remembering his or her own birthday, current age, and address.
- Using a chin tuck when drinking.
- Using a cane or walker correctly and consistently.
Video
Watch this video to get a good overview of spaced retrieval with errorless learning from the authors of Spaced Retrieval Step by Step: An Evidence-Based Memory Intervention*.
*The link to the book is an Amazon affiliate link. As an Amazon associate, I may earn a small commission on qualifying purchases. There is no extra charge to you, and it will help keep Eat, Speak, & Think sustainable.
Although the video barely touches on the errorless aspect, the book goes into much more detail. The basic idea is that the trainer’s prompt question and the learner’s verbal response (and physical response, if there is one) must be the same every time.
As soon as it becomes clear that the learner is going to make a mistake, even if it’s just hesitation, the trainer interrupts with the correct response and immediately asks the question again. This is the errorless aspect of the training, which conditions the correct response and minimizes confusion.
The trainer repeats this process until the learner is able to provide the correct response immediately. Then the trainer waits five seconds and asks again. If the learner is correct again, the trainer waits for 10 seconds and then asks again.
The basic waiting periods between trials are:
- 5 seconds, 10 seconds, 20 seconds, 30 seconds, 1 minute, 2 minutes, 4 minutes, 8 minutes, 16 minutes
If at any point the learner hesitates or starts to make an incorrect response, the trainer interrupts with the correct response and asks the question again. Then if the learner is correct, the trainer drops down one level on the waiting period chart. For instance, if the learner made a mistake at the 2 minute mark and answers correctly immediately following the model, then the next wait period will be 1 minute.
SR with EL doesn’t work with all learners
If the potential learner can’t pay attention or can’t imitate what you want to teach, then they’re not a candidate.
In addition, if the potential learner can’t recall a new piece of information after a 30-second delay with you using spaced retrieval with errorless learning teaching methods, then they probably aren’t a good candidate.
What to do if SR with EL isn’t working
If the potential learner fails the screening task
If the potential learner isn’t able to recall a new piece of information after a 30-second delay with you following the SR with EL teaching methods, consider trying again at another time. Perhaps the potential learner wasn’t feeling well, was tired, or was distracted at the time of your initial screening.
Also, be sure that you set the stage for success:
- Turn off the TV or other source of noise.
- Work in a quiet setting with good lighting.
- Make sure the learner is wearing glasses and hearing aids if needed.
- Sit face to face.
If you’ve tried the screening task on two or three occasions and the person can’t recall a new piece of information, then they aren’t a good candidate for SR with EL. In this case, you would proceed with environmental modifications and caregiver training.
If the learner isn’t making progress
If the learner passed the screen, but isn’t making progress towards learning the correct response using SR with EL, consider the following:
- Are you using familiar language in the prompt question and response?
- Is the response meaningful to the learner?
- Does the response include too much information or too many steps?
You can change your prompt question, the verbal response, and/or the physical response.
7 tips for working with people who have a more severe memory impairment
- Set the stage for success.
- Carefully choose the prompt question and response.
- Use the learner’s own language.
- Make sure the learner isn’t struggling to perform the response.
- Do not allow hesitation or the slightest mistake.
- Ask the prompt question as soon as the waiting period is up.
- No talking until you pass the 2-minute waiting period.
- Be patient.
Set the stage for success
Always set the stage for success: TV off, sensory aids on, and work face-to-face in good lighting.
Carefully choose the prompt question and response
In my experience, the more impaired a person is, the more important it is to find the right wording that makes sense to the learner.
I’ve found it’s very helpful to demonstrate what I want my patient to do and then ask them to tell me what I just did. Then I can use that wording for my prompt question and verbal response.
It’s also important to break information or skills down into manageable chunks. If the learner is struggling to imitate you, then they’re less likely to succeed.
Do not allow hesitation or the slightest mistake
One critical tip I learned the hard way is to be very strict. In the beginning as I was gaining confidence with this teaching method, I sometimes allowed hesitation or a slight mistake to pass.
Every time this happened with someone who had a moderate or severe memory impairment, they made slower progress. I quickly learned to be vigilant and to immediately step in with the correct response whenever there is hesitation or the slightest error.
Ask the prompt question as soon as the waiting period is up
Another mistake I made in the beginning was to delay asking the prompt question if someone was talking when the waiting period ended. I didn’t want to be rude by interrupting. But my patients frequently forget the response when I delayed asking the prompt question, especially if their memory was more severely impaired.
SR with EL is building momentum towards someone learning the correct response as a conditioned response. If I miss a training step, then the momentum may slow or stop altogether.
We don’t know exactly how many seconds or minutes can pass before our patient forgets. But the longer we delay in asking the prompt question after the waiting period is up, the more likely it is they will forget.
Unless there are extenuating circumstances, I always interrupt the speaker by saying, “I’m sorry to interrupt but I have to ask a question… ” and then I ask the prompt question.
No talking until you pass the 2-minute wait period
Another critical tip I discovered the hard way is that talking during the rest periods in the beginning often means the learner won’t remember the response. I explain to my patient at the start of each session that sitting quietly between the questions helps his or her memory.
Some of my patients remember to sit quietly during the short breaks, but many don’t or can’t sit quietly.
If my patient talks during the wait periods, I simply nod my head to acknowledge but I don’t respond. Instead, I continue doing documentation until my timer goes off. I’ve never had a patient who complained.
Once we pass the two-minute mark, then I engage with my patient in some way. I start off with unrelated and easy topics, but as they make more progress towards learning the response, then I work on other goals during the wait periods.
Be patient
It can take several sessions for someone with a more severe memory impairment to get past the two-minute wait period. Often, the rate of improvement dramatically increases once the learner successfully makes it past the four-minute mark.
How is SR and/or EL working for you?
If you’re already using spaced retrieval, consider adding errorless learning to your practice. If you’re having success with SR with EL, please share your tips!
If you’re not using SR with EL, check out the free cheat sheet download which walks you through using errorless learning. I’ve also written a tutorial on SR with EL, with access to a free data collection sheet and a completed example.
Download a free cheat sheet with instructions for errorless learning.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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