Author’s Note: This article is based on the author’s forthcoming edited volume, Supervision from Competence to Expertise: Using Deliberate Practice for Career-Long Professional Development (co-edited by Tony Rousmaniere, Rodney Goodyear, Scott Miller, and Bruce Wampold; Wiley Press) and the forthcoming book, Deliberate Practice for Psychotherapists: A Guide to Improving Clinical Effectiveness (Routledge Press).
Domain Note: The Role of Deliberate Practice across the Professional Lifespan
The Society for the Advancement of Psychotherapy Education and Training Committee is excited to be providing a series of articles on the role of deliberate practice (DP) in the development of highly effective psychotherapists. The initial article (Love, Davis, & Callahan, 2016) focused on DP in training contexts. The article below, by Dr. Tony Rousmaniere (who has two forthcoming books on the role of deliberate practice), continues with the next stage of professional development and with a focus on DP for ECPs.
Stewart Cooper, PhD, ABPP
Chair, Education and Training Committee
In the previous issue of the Psychotherapy Bulletin, Love, Davis, and Callahan (2016) explored how the principles of deliberate practice can improve the effectiveness of clinical training in graduate school. This article aims to explore the next step: How deliberate practice can aid early career psychotherapists who want to continue improving their clinical skills after they have completed graduate training and obtained their license for independent practice.
First, a brief introduction to how I found deliberate practice myself. In 2008, I graduated from my clinical psychology program and started a private practice under the supervision of a senior psychologist. Anyone who has started a private practice knows that the first year or two is stressful. The practice grew slowly, with only one or two new clients each month. The thinness of my referral pipeline focused my attention on a specific clinical problem: dropouts.
Clinical dropouts (also called non-completers in the research literature, Swift & Greenberg, 2014) are the invisible plague of psychotherapy. Most of us have them, but few of us like to talk about it. I had recognized my dropout problem early in training at my practicum and internship at a community health center. At least one-third of my clients dropped out within a few sessions of therapy. I had hoped that the problem was due to the clinical population I was serving (which is a fancy way of saying that it was my clients’ fault, not mine). To my dismay, however, my clinical dropout problem followed me to my new private practice where I was serving a very different client population.
I looked for clinical training to help me prevent dropouts. In graduate school we have little choice about how to train; we simply do what our supervisors and professors tell us to do. After you graduate and get your license, things are different: Your training regime is entirely up to you. I quickly discovered that there is a bounty of clinical training options available, commonly called continuing education units (CEU), including weekend workshops, lectures, and webinars.
Unfortunately, most CEUs are taught in a passive learning format, where the audience sits and listens to a lecture or watches a video, with possibly some discussion. This format can be effective for learning cognitively (e.g., new laws, regulations, or clinical theory), but research has shown that it does not result in improved clinical skills or client outcomes (Taylor & Neimeyer, 2015). Most CEUs do not include key components of skill acquisition such as repetitive practice of specific skills, personalized performance feedback, and follow-up skill assessment and refinement (Tracey, Wampold, Lichtenberg, & Goodyear, 2014). Summarizing their review of the research in this area, Neimeyer and Taylor (2010) stated, “A central concern follows from the field’s failure to produce reliable evidence that CE translates into discernibly superior psychotherapy or outcomes, which serves as the cornerstone of the warrant underlying CE and its related commitment to the welfare of the consumer” (p. 668).
My experience echoed the research. I attended weekend workshops, conferences, and webinars. I got certifications in variety of evidence-based psychotherapy models. However, my clinical skills did not significantly improve and my dropout rate actually worsened (perhaps because I was jumping around from model to model.)
What was I missing? Deliberate practice.
Deliberate Practice: A Primer
Deliberate practice is a term introduced by K. Anders Ericsson and colleagues in the science of expertise (Ericsson, Krampe, & Tesch-Romer, 1993). Defined as “the individualized training activities specially designed by a coach or teacher to improve specific aspects of an individual’s performance through repetition and successive refinement” (Ericsson & Lehmann, 1996, pp. 278‒279), deliberate practice involves an intensive training process with repetitive skill-building exercises informed by expert feedback and performed throughout a professional career. Professionals from a wide range of fields, from music to sports to chess to medicine, rely on deliberate practice to achieve expert performance (Ericsson & Pool, 2016).
Scott Miller was the first psychologist to consider the potential benefit of deliberate practice for mental health training (Miller, Hubble, Chow, & Seidel, 2013; Miller, Hubble, & Duncan, 2007). More recently, other researchers have examined how deliberate practice can improve the effectiveness of psychotherapy supervision and training (e.g., Chow et al., 2015; Rousmaniere, Goodyear, Miller, & Wampold, in press; Tracey, Wampold, Lichtenberg, & Goodyear, 2014).
Of particular importance for psychotherapists, deliberate practice requires five processes that are not present in traditional CEU formats: observing your own work, getting expert feedback, setting incremental learning goals just beyond your ability, repetitive behavioral rehearsal of specific skills, and continuously assessing performance (Ericsson, 2006).
How can early career psychotherapists use this research to improve their clinical skills? Following is a list of nine practical take-away lessons from the expertise literature that can help therapists maximize their training time and dollars (Rousmaniere, in press).
#1: Focus on stalled or deteriorating cases
Choose clinical training formats that help you focus on your clinical weaknesses, skill deficits, and blind spots. “Only when people face failures of their entrenched procedures do they actively engage in learning and modification of their skills” (Johnson, Tenenbaum, & Edmonds, 2006, p. 118). Research suggests that psychotherapists commonly have a particularly strong blind spot regarding their own cases that are at risk of deterioration (Hannan et al., 2005; Hatfield, McCullough, Frantz, & Krieger, 2010). Focusing on our weaknesses has an added benefit of guarding against over-confidence, termed “defensive pessimism” (Norem & Cantor, 1986) and “professional self-doubt” (Nissen-Lie, Monsen, & Rønnestad, 2010).
#2: Use active learning methods
Look for training opportunities that emphasize active learning methods such as repetitively practicing skills through role-play or simulations (in contrast to passively listening to a lecture or watching a video). Simulation-based behavioral rehearsal facilitates state-dependent learning and helps move skills into procedural memory (McGaghie & Kristopaitis, 2015). The best learning formats are simulations (role-plays) that try to closely match the conditions in which you will be actually using the skills (i.e., psychotherapy). According to Ericsson and Pool (2016), “The most effective forms of practice are doing more than helping you learn to play a musical instrument; they are actually increasing your ability to play” (p. 43).
#3: Work at a threshold of strain
Deliberate practice works through intentionally seeking disequilibrium. This is a challenging process of strain and repair through which old habits are broken so they can be replaced with new skills. “Lengthy engagement in some training activity has minimal effect unless it overloads the physiological system sufficiently to lead to associated gene expression and subsequent changes (improvements) of mediating systems” (Ericsson, 2003, p. 73). Learning about a skill can feel comfortable or easy, but actual skill acquisition is difficult.
#4: Train in long-term relationships
Clinical trainers can help you best when they know your personal weaknesses, blind spots, and growth edges. This often requires a long-term relationship, and cannot be accomplished through occasional weekend workshops. A long-term relationship also lets your trainer customize your growth specifically for your style of learning and give you performance feedback over time.
#5: Emphasize homework
To get the most from your training dollars, pick trainers who assign homework for you to practice on your own. In most other fields the majority of learning occurs in solitary deliberate practice (Ericsson, 2006). For example, it would be inconceivable to train to be a professional musician, athlete, chess player, dancer, singer, or pilot without dedicating many hours to solitary practice. In their first study in this area, Ericsson and colleagues (1993) found that solitary deliberate practice was the only variable that predicted the skill of violinists: “There is complete correspondence between the skill level of the groups and their average accumulation of practice time alone with the violin” (p. 379). Solitary deliberate practice also has the important benefit of being free.
#6: Use video recordings
Asking for consultation on a clinical case via notes or memory is like getting an art review by verbally describing your art instead of letting someone see it. If you want help identifying your blind spots, which we all have, then you have you show your work. Video recording is now widely acknowledged as invaluable for enhancing the effectiveness of clinical training (e.g., Bernard & Goodyear, 2014; Ellis, 2010; Friedlander et al., 2012). Notably, this includes psychodynamic practitioners, who previously were among the most cautious regarding video (e.g., Abbass, 2004; Briggie, Hilsenroth, Conway, Muran, & Jackson, 2016; Eubanks-Carter, Muran, & Safran, 2015; Haggerty & Hilsenroth, 2011; McCullough, Bhatia, Ulvenes, Berggraf, & Osborn, 2011).
#7: Use performance feedback loops
Skill acquisition works through performance feedback loops: You learn a skill, practice in simulation (role-play), use it with real clients, and then review the results via video with a trainer who provides feedback, which in turn informs the next skill to learn. This stands in contrast to most CEU programs that are single-shot events, or perhaps a short series of workshops, without opportunity for follow-up performance feedback. Ericsson (2015) noted that “workshops or even a four-day training will be insufficient for attaining substantial improvement in everyday performance” (pp. 12‒13).
#8: Assess effectiveness through client outcome
In deliberate practice, client outcome is the bottom-line criteria for assessing therapist effectiveness. This can be disorienting for therapists who were trained with a focus on adherence and fidelity. However, research has shown little connection between adherence to a model and client outcome (Branson, Shafran, & Myles, 2015; Webb, DeRubeis, & Barber, 2010), and inflexible adherence to a model can harm clients (Hatcher, 2015). Describing this problem for the broader psychotherapy community, the psychodynamic supervisor Jon Frederickson says, “We’ve come to prize ritualism over results” (personal communication, January 3, 2016). Learning psychotherapy models and techniques requires a balance between following the model and retaining sufficient freedom and flexibility to attune with each unique client (termed appropriate responsiveness; Hatcher, 2015).
Assessing client outcome can be tricky. Research shows that therapists’ judgment in this area is not reliable (Walfish, McAlister, O'Donnell, & Lambert, 2012). Furthermore, clients are reluctant to acknowledge when therapy is not helpful; in a recent anonymous survey of 547 clients, 93% reported having lied to their therapist, with common subjects being “pretending to find therapy effective” and “not admitting to wanting to end therapy” (Blanchard & Farber, 2016).
To aim for a more reliable assessment, therapists should use multiple data sources for evaluating client outcome. The most common are (1) client report, (2) therapist judgment, (3) routine outcome monitoring (ROM) data, (4) qualitative data from the client, and (5) collateral information from other people who know the client (e.g., partner, employer, teacher).
#9: Don’t rely on clinical experience alone to improve your effectiveness
Ericsson (2008) described the limits of work experience as, “Once a professional reaches an acceptable skill level, more experience does not, by itself, lead to improvements” (p. 992). Research in psychotherapy has shown the same: Accumulating thousands of hours of face-to-face time with clients does not reliably lead to improved clinical effectiveness beyond competency (for a review, see Tracey, Wampold, Goodyear, & Lichtenberg, 2015). In a notable example, a recent study examining the outcomes of 170 therapists at a large university counseling center found that the average therapist actually had a small but statistically significant decrease in effectiveness over time (Goldberg et al., 2016). Improving effectiveness requires observing your own work, getting expert feedback, and continuously assessing performance (Ericsson, 2006).
Challenges to Deliberate Practice
The greatest challenges to deliberate practice are that it is hard and resource-intensive, requiring time from a busy schedule and money for expert feedback. Unfortunately, our field does not currently recognize, reward, or incentivize meaningful and sustained efforts towards skill development. Thus, engaging in deliberate practice requires substantial inherent motivation to get better. Most therapists enter the field out of a desire “to help others” (Hill et al., 2013); keeping this goal in mind can help provide motivation for sustained deliberate practice.
My personal motivation for deliberate practice was to halt my alarming dropout problem. I accomplished this through two methods. First, I attended a monthly consultation group with Victor Yalom, PhD, a senior psychologist in San Francisco. In the group I showed videos of my cases that were stalled or at risk of deterioration. Victor taught me specific skills to aid each case and used role-play simulations to help me practice the skills. Second, I had biweekly individual consultation with two psychodynamic supervisors, Jon Frederickson, MSW, and Allan Abbass, MD. Those consultations included videotape case review, role-plays to aid skill development, and also live one-way-mirror supervision (Rousmaniere & Frederickson, 2015). I monitored my cases with routine outcome management (ROM) data, and got regular client feedback with the Session Rating Scale (Miller et al., 2007).
The consultants helped me prevent dropouts by identifying a range of clinical errors I was making (Rousmaniere, in press). For example, Victor Yalom noticed that I used an inauthentic “therapist” voice with clients when I became anxious, and helped me practice speaking more authentically. Allan Abbass pointed out that I was confronting clients too quickly, and helped me find a better balance of challenge versus encouragement. Jon Frederickson observed that I was talking over some of my clients, and taught me how to better control my pacing and energy to foster stronger attunement. Notably, most of the problems the consultants noticed in my work were revealed only because I showed videos of my sessions; these mistakes would have been invisible to us in my session notes and memory.
Over time, my dropout rate gradually improved. I knew that I was advancing when one of my clients remarked to me, “You finally understand what I've been trying to tell you for months!” Two years later my full-time private practice was full.
When a therapist transitions from graduate training to independent practice there is a sudden and dramatic increase in autonomy. This can be exciting, but also confusing or disorienting. Therapists can use the principles of deliberate practice (Ericsson, 2006) as a rudder to guide their clinical development through the sometimes turbulent seas of early career and beyond.
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