BAHRAIN LEARNING FFP1 23-24 SD.pptx

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Building Blocks of Behaviour I - Learning Class FFP1, Medicine Year 1 Lecturer Dr Sally Doherty [email protected] September 23- 24 Enter subtitle here (24pt, Arial Regular) Enter date: 25.06.13 Learning Outcomes 1. Def...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Building Blocks of Behaviour I - Learning Class FFP1, Medicine Year 1 Lecturer Dr Sally Doherty [email protected] September 23- 24 Enter subtitle here (24pt, Arial Regular) Enter date: 25.06.13 Learning Outcomes 1. Define learning 2. Describe, giving medically relevant examples: 2. Classical conditioning 3. Operant conditioning 4. Observational learning 5. Outline therapeutic methods derived from Learning Theory 2 LEARNING OUTCOME 1: Define learning 3 https://www.youtube.com/watch?v=BZUQQmcR5-g 4 Physarum polycephalum (Slime mould) https://www.youtub e.com/watch?time_ continue=112&v=ll s27hu03yw Definition of learning: A relatively durable change in behaviour or knowledge that is due to experience 5 Learning • More than facts or knowledge – Behaviours – Skills e.g. social skills – Personal habits – Values – Emotional responses – Preferences • Lifelong, dynamic process • Enables adaptation Think-Share As medical students, why is it important for you to understand how we learn? Why is understanding how we learn important? • To better acquire the information and skills you need to become a HCP • To better understand your patients (e.g., health habits, emotional responses, adjustment to illness) • To better communicate and educate your patients and supervise and train junior colleagues • Own life applications (e.g., problem solving, changing habits, building relationships, managing emotions…) *** learning through direct experience Behaviourist Learning Theories LEARNING OUTCOME 2: Describe, giving medically relevant examples, classical conditioning 10 Classical (Pavlovian) Conditioning • An initially neutral stimulus acquires the capacity to evoke a response that was originally evoked by another stimulus. • Learning usually proceeds gradually but can occur rapidly • Learned response = involuntary, automatic reactions (e.g. reflexes, emotional responses) 11 Classical Conditioning (NS) (UCS) (UCR) (CS) (CR) 12 Classical Conditioning Summary: An originally neutral NS  CS: Sound of bell UCS: Food CR: UCR: Salivation stimulus comes to elicit a response that it did not previously elicit 13 Everyday examples of Classical Conditioning • Dogs get excited when you put on your coat or pick up their lead NS CS: Coat/Sound of lead UCS: Going for a walk • Cringing and/or feeling fearful when you hear the sound of a dentist’s drill – Development of phobias Apply your learning Can you think of any other examples of classical conditioning? NS  CS: Sound of drill UCS: Discomfort from drill NS  CS: ??? UCS: ??? CR: UCR: Excitement CR: UCR: Fear/Cringe CR: UCR: ??? Everyday examples of Classical Conditioning Advertising • Associate a medication with happy and improved lifestyles Celebrity endorsement of Xarelto to promote use over Warfarin (generic drug), to reduce risk of blood clots • Campaigns to change attitudes Associating smoking with death… 15 Health-related examples of Classical Conditioning • Form unconscious associations with healthcare experiences – e.g. • Dentist drill • White coat syndrome • Conditioned nausea • Implications – Can result in long-lasting attitudes, emotional responses and physiological responses Applications of Classical Conditioning • Prevent or change responses learned through classical conditioning e.g.… – Emotional responses • e.g. prevent anxiety during medical interventions • e.g. extinguish responses to phobias – Involuntary reactions • e.g. overshadowing to prevent anticipatory nausea Pavlovian conditioning of nausea and vomiting. Autonomic Neuroscience, 129(1-2), 50–57. doi:10.1016/j.autneu.2006.07.012 Applications of Classical Conditioning • To condition desirable responses, e.g…. – Positive attitudes/emotional responses – Physiological responses • e.g., conditioning an immune response by pairing an immunosuppressant with a distinctive flavour Learned immune response: www.sciencedirect.com/science/article/pii/S0889159109003948 18 LEARNING OUTCOME 3: Describe, giving medically relevant examples, operant conditioning 19 Operant Conditioning • A form of learning in which voluntary responses/behaviours become controlled by their consequences • (CC: stimuli that precede response impact that response) • (CC: elicits automatic or involuntary responses) Behaviour Consequence Response Rewarding Stimulus Presented Tell Jokes Friends Laugh Effect on Behaviour Tendency to tell jokes increases 20 Operant Conditioning: Increasing Behaviour Reinforcement • Occurs when an event following a response/behaviour increases the likelihood of that response/behaviour occurring again • Used to promote desired behaviours http://www.youtube.com/watch?v=d3PrZeCmXd0&mode=related&search= 21 Operant Conditioning: Increasing behaviour Method Positive reinforce Positive ment reinforce ment Negative Negative reinforce reinforce ment ment Definition Example Likelihood of the • Studying to receive behaviour/respon praise Likelihood of the • Studying to receive • praise se is increased Doing chores to receive behaviour/respon because a rewards (e.g. to money) • Doing se is increased chores receive • consequence is Drinking(e.g. alcohol to feel because a rewards money) rewarding/ a buzz/increase • Drinking consequence is alcohol to feel positive confidence a buzz/increase presented confidence Likelihood of the • Studying to remove behaviour/respon feelings of guilt • Taking pain killers to se is increased aversive/ because an remove headache negative is • Putting on your seatbelt consequence removed to remove the annoying warning tone in car • Complaining of sickness to get the day off school 22 Operant Conditioning: Reinforcement Always involves INCREASING the response/behaviour! • Positive: Adding something rewarding • Negative: Removing something aversive (unpleasant) 23 Operant Conditioning: New/complex behaviours Shaping: • Reinforcement of successive approximations to the desired response/behaviour – Used when no existing behaviours can be reinforced – Step by step approach is taken in order to achieve a more complex target/desired behaviour • Everyday examples: – Learning complex skills e.g. training animals to do elaborate routines 24 Operant Conditioning: Decreasing behaviour Method Definition Example Nonreinforce ment Likelihood of the • Decreasing tantrums by behaviour/respon ignoring them se is decreased because reinforcemen t is not presented Punishme nt Likelihood of the • Decreasing behaviour/respon speeding/illegal parking se is decreased after receiving a because an fine/clamp aversive/ event is negative presented 25 Operant conditioning • • Negative reinforcement: Removing something aversive  increases response Punishment: Adding something aversive  decreases response 26 Applications of Operant Conditioning Quick and effective way to change behaviour! • Improving knowledge and skills – Computerised tutorials with quizzes and feedback – Teaching complex skills through shaping e.g. surgery • Changing behaviours – Increase adherence e.g. through positive reinforcement – Applied Behaviour Analysis (ABA) for Autism – Nursing homes & long-term care facilities – Change maladaptive pain behaviours – Drug addiction e.g. Contingency contracting • Rehabilitation – Improve physical functioning following surgery e.g. shaping increasingly complex behaviours – Increase mobility in patients with chronic pain Classical vs. Operant Conditioning: Key differences Classical Operant Basic idea Learning based on paired associations: • the stimuli that precede a response come to impact on that response Learning based on consequences: • consequences which come after a behaviour come to impact that behaviour Type of response/behavio ur Involuntary, automatic reactions (learner is passive) Voluntary actions (learner chooses to “operate” on environment) 28 Conditioning in Action: Substance abuse STEP 1 Heroin “Rush” “Buzz” Classical conditioning Needle, syringe, tourniquet (CS) STEP 2 Withdrawal symptoms Positive reinforcement Heroin Negative reinforcement 29 Classical vs. Operant Conditioning: Shared terms Definition Generalisati on Discriminati on Extinction Spontaneou s recovery Classical example • Little Albert’s Learning is applied to similar situations fear (CR) of rats (greater similarity  (CS) generalised increases generalisation) to similar stimuli (e.g., dog, fur coat) • Fear response Learning is only applied in the presence of a only occurs when specific discriminative rat is presented stimulus/context • Fear response Learned response/behaviour decreases after decreases after the repeated paired association (CC) exposure to rat or the reinforcement without loud (OC) stops noise • Fear response Extinguished response starts again suddenly spontaneously after a triggered after a rest period period of no fear of rat (and no Operant example • Rat presses lever whenever it hears any music • Rat presses lever only for classical music • Lever pressing decreases when reinforcement stops • Lever pressed again when music is heard even though this 30 was no longer Limitations of Behaviourist Learning Theory 1. Teacher-centred model 2. Reductionist: Ignore what goes on inside the individual 3. Focus on extrinsic rewards and incentives 4. A lot of the evidence is based on animal models 5. People’s changed behaviour can deteriorate over time LEARNING OUTCOME 4: Describe, giving medically relevant examples, observational learning 32 Observational Learning • Response is influenced by the observation of others (called models) • Alfred Bandura – Importance of the social context and the learner (“human agency”) – Role models for how to think, feel and act • No direct experience necessary – Vicarious reinforcement: Indirect conditioning (seeing what happens to others…) – Imitation can also occur in the absence of rewards 33 Applications of Observational Learning • Influencing behaviour in healthcare setting/in response to illness – Modelling patient behaviour • Children, use of patient videos – HCPs as role models • Reactions to symptoms – Promote psychological adaptation/coping • Support groups (model behaviour; learn from others) • Buddy programmes for cancer or addiction • Teaching doctors and other HCPs – Medical Teaching: “See one, do one, teach one” vs. Simulation and deliberate practice – Mentorship programmes 34 – LEARNING OUTCOME 5: Outline therapeutic methods derived from Learning Theory 35 Therapies derived from Learning Theory: Behaviour Therapy: Flooding Sustained exposure to feared stimulus; fear eventually subsides: “Feel the fear & do it anyway” 36 Therapies derived from Learning Theory: Behaviour Therapy: Systematic desensitisation Anxiety Spiders Relaxation Step 1: Progressive muscle relaxation Step 2: Hierarchy of fears Step 3: Imagined exposure + relaxation Step 4: Gradual exposure + relaxation Examples: • Reducing fear of withdrawal and preparing addicts to handle difficult situations during rehabilitation • Teaching children with ADHD and Autism to swallow pills Drug addiction: www.tandfonline.com/doi/pdf/10.1080/02791072.2000.10400455 Swallowing pills: http://journals.sagepub.com/doi/pdf/10.1177/000992280504400608 37 Other therapeutic applications of Behavioural principles • Social skills training • Behaviour modification – e.g., changing maladaptive chronic pain behaviours • Biofeedback • Cognitive-behaviour therapy 38 Practical considerations of learning theories • The context in which you deliver care is important! • Recognise the role of patients’ previous learning experiences in shaping their attitudes and behaviours – Habits, culture, familiar patterns, feelings about themselves, what they value and what they perceive to be successful or rewarded in society – Relate new information to patients’ past experiences • Ideal learning approach can differ between individuals – Behavioural (passive) vs. cognitive (active) approaches; effectiveness of reinforcement; and types of reinforcers that are effective varies between individuals 39 Test your understanding Based on your learning from this lecture… 1. Try to explain classical conditioning, operant conditioning, and observational learning to a friend. 2. Think of a healthcare-related example or a practical application of each that was not covered in the lecture. 40 Reading • Relevant reading: – an Teijlingen E, Humphris GM. (2019) Psychology and Sociology Applied to Medicine: An Illustrated Colour Text. 4th edition. Elsevier Health Sciences, p 20 – 21. • Older editon: Alder, Beth; Teijlingen, Edwin van; Porter, Michael (2011) Psychology and Sociology Applied to Medicine, 3rd edition pages 22-23; • Useful resources: – Khan academy videos and knowledge check questions: • https://www.khanacademy.org/test-prep/mcat/behavior/learning-slug/e/learning-questions • https://www.khanacademy.org/test-prep/mcat/social-sciences-practice/social-science-practice-tut/e/explorin g-clinical-applications-of-classical-conditioning ? – Example of systematic desensitisation (feather phobia): www.youtube.com/watch?v=lMZ5o2uruXY • Recommended, if interested in reading more: – Baumgart, M. & Baumgart, R. Applying Learning Theory to Healthcare Practice. Chapter 3. Health Professional as Educator: Principles of Teaching and Learning. Bastable, S. B, Gramet, P. Jacobs, K. & Sopczyk, D. L. (Eds.) 2011; Mississauga, Ontario: Jones & Bartlett Learning www.jblearning.com/samples/0763751375/chapter2.pdf – Grantcharov TP, Reznick RK. Teaching procedural skills: “see one, do one” is not the best way. BMJ 2008; 336: 1129-1131. Available from: www.bmj.com.proxy.library.rcsi.ie/content/336/7653/1129 41