What is
Deliberate Practice?

Dive deeper with this text from Vidar Husby

How do top performers in other fields become so good at what they do? How are they able to prevent stagnation, and keep developing towards increasingly better performance? these were the questions that K. Anders Ericsson and his international team of researchers set out to answer (for summary, see Ericsson, Hoffman & Kozbelt, 2018). They studied musicians, pilots, chess players, surgeons and athletes, and identified a common denominator in these performers´ training principles: Deliberate practice. These are a few key features:

o   A coach who provides expert feedback

o  Identify a personal challenge and set tailored and specific learning goals just outside their comfort zones

o   Engage in Behavioral rehearsal with intention, quality and quantity.

o   Monitor performance and measure results

Let´s have a closer look at these components:

Expert Feedback: Expert feedback infuses most aspects of deliberate practice. A supportive and instructive trainer provides feedback that informs the performer on what to work on and how to work on it. In psychotherapy, this “trainer” may be the supervisor, if they are familiar with deliberate practice. The IDPS has a deliberate practice coach certification program defining the key DP coach competencies needed for effective training. Other sources of feedback are our colleagues and patients. Within a group of professional peers one will often find the knowledge needed for improvement. Even unexperienced therapists can make important observations of what is going on in our blind-zone. This is true, though in a different sense, to our clients as well. If we are perceptive enough to receive it, they will often provide useful feedback for therapist growth.

Identify a Challenge: Practicing things we already know, or attempting tasks too big for our size, are a wonderful recipe for stagnation and frustration. For a violinist to master a complex composition, he must focus on those parts of the composition that he is still unable to perform. The first step to expertise is finding the right challenge to focus on. In psychotherapy, this would mean identifying a clinical challenge where you want to respond more effectively. Using outcome data, video, and observing work with a trained deliberate practice coach is the gold standard for finding your clinical challenge. Having said that, there´s a lot you can do to improve your performance even if you don´t have access to these resources. Using peers, role-play and generic exercises goes a long way in adding a valuable procedural component to your training activities.

set learning goals: The violinist needs to have specific learning goals that make concrete what he needs to be able to do in order to become able to play the piece. It might be training to use the right finger on a note in order to make the move to the next note possible, it might be regulating the force in the hand holding the bow to create a crescendo, or any other “violinist behavior” we want to improve. It has to be specific and also tailored to the violinist´s zone of proximal development. The same goes for the therapist: In our field, we tend to use (and sometimes need) broad and vague concepts, but these are not useful for skill-building. In Deliberate Practice, an important part of the work is making your target skill very concrete – we try to break it down to a tailored step-wise chain of verbal and non-verbal therapist behaviors.

Behavioral rehearsal with intention, quality and quantity: If you’ve ever played an instrument, engaged in sports or any craft, you know this: Rehearsal is crucial. We know that the decisive factor for the professional musician is the amount of time spent in solitary rehearsal focused on tailored learning goals. Not just talking about the violin and listening to music. Doing it, both in class and for hours solitarily. In Deliberate Practice supervision, we do behavior rehearsal in supervision and we facilitate solitary practice by assigning homework for the therapist to do between sessions. This key component markedly sets deliberate practice aside from our traditional learning activities by promoting PROCEDURAL LEARNING, as opposed to declarative learning. In our view this is exactly what the field is missing. Furthermore, the rehearsal needs to be repetitive, with moment-by-moment tailoring to the therapists´ zone of proximal development. If the exercise becomes too easy or too hard, the repetitions will be mindless or exhausting, but when properly tailored they will effectively promote Skill acquisition.

Measure results: A musician or an athlete have objective criteria to measure their performance up against. Whether it is lap-times, number of scores or number of errors in musical performance, they all lend themselves readily as criteria for assessing performance. In our field, measures are a bit trickier - but no less important: Research (e.g. Walfish et al., 2016) shows that clinicians are prone to “self-assessment bias” leaving us virtually blind when it comes to identifying which patients are not responding to treatment and why. To overcome this blindness we have reliable non-intrusive instruments that counter this bias and help us identify non-responders. These are the patients that we bring to supervision. It´s nothing to be ashamed of – you´re in very good company. Your supervisor´s statistics are probably comparable to your own. We all struggle with clinical challenges.

Learning this way accommodates for tailored procedural learning – exactly what our field has been missing. A recent upsurge of studies yields promising results for the application of DP in psychotherapy (Shukla et al. 2021; Westra et al., 2020; Anderson et al. 2020; Goldberg et al., 2016; Chow et al., 2015).

 Traditional methods for learning in the field of psychotherapy

Psychotherapists agree that supervision, reading literature, attending continued education and gaining experience are important factors in therapist development. These are valuable learning activities common in our field. Learning theory supports the clinicians´ decision making and organizes their thinking. Attending workshops cultivates collegiality. Supervision has an important supportive and quality-controlling function. A very important thing that these activities have in common, is that they improve declarative knowledge. The question we want to ask is - do they also improve therapist performance?

Supervision: Researchers are less convinced than therapists that these learning activities are helpful for therapists´ skills development and client outcome. Let us review a few selected examples, that represent the ample available evidence:

Experience: One example is this extensive meta-analysis of available research on psychotherapy supervision research (Watkins, 2014), which concludes as follows:

“We do not seem any more able to say now (as opposed to 30 years ago) that psychotherapy supervision contributes to patient outcome” (p. 235)

Passive learning: Another example is findings from the research on passive learning formats: A comprehensive review of instructional learning research (55 studies) finds that instructional learning does not reliably lead to improved clinical skills (Herschell et al., 2010). line with this, other studies find that traditional passive learning activities are ineffective in changing therapist behavior (Beidas og Kendall, 2010; Farmer et al., 2008).

A clear implication of the research on therapists´ development is that we need to re-think some of our assumptions about how we train clinical skills.  Therapists need better tools to promote their development, and to get more in return for all their learning-efforts. What therapists have been lacking is reliable methods for developing procedural knowledge.

Improving therapist training is essential for the future of psychotherapy

Psychotherapy is not about record-setting. Our goal is not a competitive one, our goal is being optimally helpful. Psychotherapy research shows that many of our patients don´t profit on our efforts to help them (Lambert, 2013).

That is the result that we are aiming to improve. Our field has a lot to learn from other fields that can help us towards this goal. A growing community of therapists around the world feels the same way. Together, we try to develop and disseminate methods and culture for the procedural learning of key psychotherapy skills. This is to improve and supplement our traditional learning methods – not to replace them.  Distinguished psychotherapy researchers agree that deliberate practice is a very important step forward in the training of psychotherapists (Anderson & Perlman, 2020; Miller, Hubble & Chow, 2020; Norcross & Karpiak, 2017; Rousmaniere et al., 2017; Wampold et al., 2019; Wampold, 2021).

We hope you enjoyed this very brief introduction to deliberate practice. Feel free to make contact if you have any questions about deliberate practice, want to get involved with our work, or have questions regarding our certification programs.

References

Anderson, T. & Perlman, M. R. (2020). Therapeutic interpersonal skills for facilitating the working alliance. I J. N. Fuertes (red.), Working alliance skills for mental health professionals. Oxford.

Ericsson, K. A., Hoffman, R. R., & Kozbelt, A. (Eds.). (2018). The Cambridge handbook of expertise and expert performance. Cambridge University Press.

Ericsson, A. & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt.

Lambert, M. J. (Ed.). (2013). Bergin and Garfield's handbook of psychotherapy and behavior change. New York, NY: John Wiley & Sons

Miller, S. D., Hubble, M. A. & Chow, D. (2020). Better results: Using deliberate practice to improve therapeutic effectiveness. American Psychological Association.

Norcross, J. C. & Karpiak, C. P. (2017). Our best selves: Defining and actualizing expertise in psychotherapy. The Counseling Psychologist, 45(1), 66–75.

Rousmaniere, T., Goodyear, R. K., Miller, S. D. & Wampold, B. E. (red.). (2017). The cycle of excellence: Using deliberate practice to improve supervision and training. John Wiley & Sons.

Wampold, B. E., Lichtenberg, J. W., Goodyear, R. K. & Tracey, T. J. (2019). Clinical Expertise. I S. Dimidjian (red.), Evidence-Based Practice in Action: Bridging Clinical Science and Intervention (s. 152–166). Guilford Publications.

Wampold, B.E. (2021, November 3). What distinguishes good therapists? [Keynote-presentation at the Nordic Conference of Mental Health, Stavanger, Norge]

Header Photo: A behavior rehearsals session at a deliberate practice workshop with Alexandre Vaz and Vidar Husby at the Nordic Conference for Mental Health (2021). The participants are practicing Alliance Rupture repair as their clinical challenge. Photo Credit: Alexandre Vaz.