“Do that scale again.” “Do that fingering transition again.” “Let me hear that again.” Even if the scale was correct, it had to be done…again. As a novice musician, the word, “again,” became synonymous with repetitive practice. Practice for the sake of practice, because practice makes perfect.
I (voice of 3rd author; true story) had to reconsider the purpose of repetitive practice some years later, as I neared completion of the novice level. The precipitant of my reconsideration was a flushed director screaming in the middle of a full ensemble rehearsal. He was kicking at music stands and threw his baton with total disregard for the projectile’s trajectory. As he grabbed his hair with both hands, his vocalizations gave way to actual language and we heard the following: “Can you AT LEAST make a NEW mistake?! I am SICK AND TIRED of hearing THE SAME mistake EVERY day!” After calming himself, the director had us play again, but this time he instructed us to perform a planned, effortful, and fully intentional error as loudly as possible.
His pedagogy was poor, but his point was cogent. Simple repetition can take on a mindless quality that facilitates rehearsing errors and really entrenching them without awareness. The remedy was to heighten awareness and have us fully engage the troublesome phrase with intentionality. He did not demand that we be perfect; rather, he demanded we be deliberate in our practice.
What Is Deliberate Practice?
A scholarly conceptualization of deliberate practice had not yet appeared in the literature when the above event transpired, but the formal conceptualization nevertheless traces back to the instruction of music students. In studying top music students at a world-renowned music conservatory, Ericsson, Krampe, and Tesch-Romer (1993) first described deliberate practice as involving the completion of a series of activities designed to maximize skill acquisition. However, deliberate practice is more than simply practicing musical pieces repeatedly, as uncorrected mistakes made by a novice will be repeated until the student receives corrective feedback (Ericsson, 2015). Instead, deliberate practice includes engaging students in the following activities: observing their own performance, getting expert feedback, setting incremental learning goals just beyond the performer’s ability, repetitive rehearsal of specific skills, and continuously assessing performance (Ericsson, 2006).
It is important to keep in mind that while similar, the process of deliberate practice is different from mastery based learning, where students are given varying levels of time to meet a predefined goal (Carroll, 1963). The key difference between the two teaching methods is that deliberate practice requires that each student receive expert feedback on individual growth edges, allowing for greater mastery of the skill.
Deliberate practice has subsequently been found to foster competency in a range of health care professions. For example, a number of studies have shown requiring surgical trainees to review their recorded surgeries with their supervisors significantly improves patient outcomes in later procedures (Bann, Khan, Datta, & Darzi, 2005). Similarly, radiology students who receive immediate feedback on diagnoses of digitally recorded mammograms later perform significantly better in diagnosing mammograms (Geller et al., 2014). Encouraging students to verbalize their decision-making process in vivo augments the effects of deliberate practice, likely because it allows instructors to immediately correct errors in situational appraisal and problem solving techniques (Ericsson, 2015). It also seems likely that asking students to reflect on their actions would simultaneously build competency in reflective practice. Consistent with this conceptualization, recent studies have found highly skilled surgeons, those with the best outcomes, thoughtfully revaluated their surgical approach during procedures (Craig et al., 2012; Cristancho, Vanstone, Lingard, LaBel, & Ott, 2013).
With respect to the training of professional psychologists, a conceptual map derived from a deliberate practice model appeared last year (Callahan, 2015). As shown in Figure 1, key to this map is the integration of sequential, cumulative, and increasingly complex training experiences with rapid and substantive feedback. However, the Callahan model expands the deliberate practice model by scaffolding psychology trainees’ competency development with interleaved practice.
What Is Interleaved Practice?
Most of us are familiar with block practicing approaches. In block practice, presentations of stimuli focus on one skill at a time (e.g., remember those multiplication drills in elementary school?). You learn a skill, practice the skill to mastery, and then move to a new skill. In contrast, interleaving practice requires trainees to work on multiple skills in concert with one another. Training trials focused on one skill are interspersed with training trials of another developing skill (Szpiro, Wright, Carrasco, 2014). Practice using an interleaving format has been found to be more effective than blocked practice for active learning (where participants have to discover category rules) (Carvalho, & Goldstone, 2015). In addition, recent studies have found that interleaving practice is conducive to multiple types of learning, including perceptual learning (Szpiro, et al., 2014) and inductive learning (Birnbaum, Kornell, & Bjork, 2013).
Interleaving practice is represented in the Callahan model via the different colored bands within each training experience (Figure 1). The article in which the model first appeared applied the interleaving approach to training in technical assessment skills and found deliberate interleaving practice yielded better outcomes than comparable studies relying on simple repetitive practice methods. Further, trainees’ competency gains were evidenced in many fewer learning trials (Callahan, 2015). Constructive, thorough, and supportive feedback both within and between training experiences is integral to the model to foster critical thinking among trainees. A study examining interleaving practice with complex judgment found evidence to support that such critical thinking prompts increased effectiveness (Helsdingen, Van Gog, & Van Merriënboer, 2011). An added potential benefit is this model encourages active on-going reflective practice, another important functional competency necessary before emerging into one’s early career (Fouad et al., 2009).
However, interleaving practice may not always be the most popular learning option. One study found participants believed blocked learning was more effective than interleaving learning, even in situations when this was empirically untrue (Zulkiply, & Burt, 2013). This misconception may stem from observation that, for any given single skill, interleaving practice can take longer than block practice by virtue of spreading out practice of specific skills across the training schedule (Helsdingen et al., 2011). In other words, trainees may find deliberate interleaving practice pushes their learning comfort zone if it is not handled delicately. Supervisors must be diligent to remember growing pains may occur and provide reassurance such pains are normative, transient, and addressable—with controlled stretching that takes them gently just to the edge of their current limits for the purpose of increasing the reach of their competency over time.
Why Does Deliberate Interleaving Practice in Psychotherapy Matter?
It matters because, frankly, we are not very good at training novice psychotherapists.
Unfortunately, psychotherapy outcomes in psychology training clinics, using naturalistic designs, support this admittedly provocative contention. The majority of doctoral programs in clinical and counseling psychology have affiliated training clinics. A central mission of these clinics is to lay the foundation for trainees’ development of professional competencies, particularly with respect to beginning psychotherapy competencies. Yet, studies of individual training clinics (Callahan, Aubuchon-Endsley, Borja, & Swift, 2009; Swift, Callahan & Levine, 2009), as well as a relatively recent multi-site study, indicate 69 to 77% of psychotherapy clients seen in these settings do not improve (Callahan et al., 2014). We can, and should, do better.
What Does Deliberate Interleaving Practice in Psychotherapy Look Like?
After acquiring and demonstrating foundational competencies pertaining to psychotherapy, novice psychotherapy trainees should be assigned very few cases of no more than mild distress to develop their functional competencies (see Fouad et al., 2009; Kaslow et al., 2009; Rodolfa et al., 2005; Spruill, 2004 for nuanced elaboration regarding foundational versus functional competencies). Importantly, while training novice clinicians in psychotherapy is associated with improved client outcomes, the effect of training is moderated by client severity (Owen, Wampold, Kopta, Rousmaniere, & Miller, 2016). Given this, novice psychotherapy trainees should be assigned minimally distressed clients as their first cases to maximize the propensity for a positive trajectory during their early competency development as psychotherapists. The trainee’s caseload and client difficulty level may be increased over time (as shown in Figure 1), but those increases should be made incrementally, with careful monitoring of client outcomes and supervisor feedback supporting that neither client nor trainee development is being thwarted by such increases in difficulty.
Aside from managing client difficulty and caseload sizes, other structural elements of training are important. As novice psychotherapists, beginning clinicians must have a means for recording sessions (preferably both audio and visual). Trainees need protected time and space to independently view recorded sessions in preparation for supervision to foster the development of reflective practice. Supervisors must also be provided with protected time and space to review recorded sessions in preparation for conducting supervision with trainees. A supervisor who is not regularly reviewing recordings (or, alternatively, engaging in live supervision) cannot know whether the trainee is accurately identifying and bringing to supervision the key elements of the session requiring expert feedback. Further, a supervisor cannot logically infer a trainee is ready for less intensive and/or close supervision until the supervisor has consistently observed the trainee correctly identifying their needs for supervision across a range of client presentations. Finally, trainees and supervisors should view segments of recordings together. The supervisor should encourage critical thinking by having the trainee explain as they review the recording just what the trainee was actually thinking in session (reflective commentary). Goals pertaining to specific skills should be identified and monitored for development across supervision sessions.
Wait. Aren’t We Already Doing That?
Initially, some readers are likely to read these ideas and think they represent conventional wisdom that is surely already widespread and commonly implemented. However, we contend that is not the case. While these ideas seem straightforward, trainees, supervisors, and training clinics nationwide routinely take shortcuts that significantly undermine the psychotherapy training process.
For trainees, a common misimpression is more client contact hours are better with respect to applying for internship (Boggs & Douce, 2000). Addressing their eagerness to accrue hours, novice clinicians may be assigned transfer cases from more advanced students who are departing the training clinic as a way to quickly establish their caseload. Almost by definition, such cases do not reflect low difficulty presentations. Quickly taking on too many cases (hours tallied on internship applications), but not watching session recordings or otherwise preparing for supervision (hours that do not contribute to the hours tally) is the most efficient way to accumulate clinical hours prior to applying for internship. Perhaps not surprisingly, an empirical study of national data revealed large discrepancies between time spent performing direct services activities and trainees self-reported accrual of hours (Rodolfa, Owen, & Clark, 2007). As noted earlier, the idea that accruing more hours results in a trainee being more competitive for internship is errant and a vast over-simplification of what it takes to ready oneself for internship (Callahan, Collins & Klonoff, 2010). Close supervision significantly interacts with the accumulation of client contact hours (Callahan, Hogan, Klonoff, & Collins, 2014). In short, close supervision on a small number of cases yields more gains in preparing for internship than does carrying a large client caseload with light supervision.
For supervisors, every hour spent preparing for, or engaging in, supervision risks wasting an hour on the tenure/promotion clock. A review of my own supervision notes indicates that at times I have been required to supervise the care of as many as 30 clients a week, with some trainees arriving on my supervision team already carrying as many as 12 psychotherapy clients (for context in understanding the time constraints, being on call for a half day per week and supervising an additional 10 integrated assessment reports per semester is also required of supervisors in our training clinic). In looking at the content of my notes specifically associated with trainees in their first psychotherapy practicum, client concerns pertaining to active psychosis and/or self-harm are peppered throughout. Supervision, as described herein, should entail previewing all 30 hours of session recordings and meeting individually for an hour with each of the 6 to 8 students on my supervision team. Add in a 2-hour group supervision meeting each week, which is customary in many training clinics, and the clock is up. Hiring of adjunct faculty to serve as supervisors is unlikely to solve this problem. The typical pay structure for adjunct faculty is not sufficient to support the time required for review of every session of every trainee before meeting with them for supervision. Under the conditions revealed by my own supervision notes, it is clear this would require hiring a full-time adjunct position for supervision of a single practicum team. The course fees generated by those few students enrolled on that practicum team would not come close to covering the cost of hiring the adjunct supervisor. The solution, unfortunately, is starkly obvious. Supervisors, regardless of whether they are tenure-track or not, are strongly disincentivized from engaging in high quality supervision. Personal communication suggests that high quality supervisors tend to describe it as intrinsically rewarding; however, exploiting such supervisors in that regard is not acceptable. Much more needs to be done to remove barriers to providing high quality supervision.
Finally, training clinics also take short-cuts that undermine psychotherapy training. Some are pressured to cover their operating expenses via client fees, which creates a pressure to increase the volume of clients served and/or accept into treatment clients whose difficulty level exceeds the readiness of novice trainees. It also increases the likelihood the clinic will prioritize service delivery in scheduling their space allocations, thus limiting trainees or supervisors access to viewing recordings. To deal with accusations of inequity by eager trainees wanting more cases and/or overburdened supervisors wanting fewer cases, assignment of cases may be centralized. Such a practice increases the likelihood neither client outcome data nor supervisor feedback will be incorporated routinely prior to every new case assignment (see Swift et al., 2015 for suggestions on how to incorporate client outcome monitoring as a tool in training and supervision).
Is There Any Hope?
Much like the novice musicians in the ensemble rehearsal, psychotherapy trainees risk repeating the same mistakes over and over without realizing it. They may even inadvertently rehearse and entrench therapeutic errors, thereby compromising their competency development as well as client outcomes. In this article, we provide a model illustrating how incorporating deliberate interleaving practice into the training of novice psychotherapists can provide a mechanism for heightening awareness and fully engaging trainees with an efficient number of cases to advance their competencies and, we hope, improve client outcomes in training clinics. As mentioned earlier, there are supervisors who find training psychotherapists to be intrinsically rewarding, and we made an appeal that they not be exploited. We contend they should be celebrated because they give us all hope. They provide hope we will right our ship as a profession and enact what we know we need to do to be effective in training psychotherapists. So, with that in mind, we will close this article by acknowledging and dedicating this piece to Vincent J. Adesso, PhD, ABPP. Dr. Adesso found a way to do all of the things described for a young psychotherapist in training—one who remains forever grateful.