Why aren’t you doing Deliberate Practice?

Therapists, here is the bad news:

1. You are not as good as you think you are. On average, therapists think they help 65% more clients than they actually do, and the least effective are the most overconfident.
2. You are not getting better with experience. Therapist performance improves for a few months post-qualification and then flatlines or declines slightly thereafter.
3. Your qualifications don't mean much, either.
4. Nor your therapeutic orientation.
5. Supervision doesn't generally help to improve outcomes, nor do your usual CPD activities.
6. Our field isn't progressing. Outcomes are the same now as they were when first measured, 50 years ago.

This could all be rather depressing. But there is good news: there might be a way out of this mess, and it's called Deliberate Practice.

To see how it works, imagine you wanted to get better at tennis (or any other sport). Which of these two strategies would work better?

1. You play point after point, without keeping score. Every couple of weeks, you meet with your coach and tell them how you think you are doing. Your coach listens carefully and gives you some suggestions of things to try in the future. You also read some books and go to some talks about how to play tennis.
    
2. Your coach watches and video-records you playing. Together, you identify exactly which aspects of your game can be adjusted to give the biggest improvements. You engage in exercises designed to train those specific skills. You record the scores in the matches you play, to see whether your training is working and to help identify the weak points in your game.

So, which strategy is more likely to work? Which one, if followed by all competitive tennis players, is likely to push the whole sport forward?

That's right: the second one.

And which one do most therapists use?

We do endless therapy sessions, alone with our clients, unobserved and usually without tracking our outcomes. Even if we do collect outcome data, we don't aggregate or analyse it. We attend supervision, read books, and attend CPD events, but we never (after qualification, at least) engage in the kind of rigorous, systematic training that is required in competitive sports. And so, perhaps it's not a surprise that our field as a whole doesn't move forward, while others do. The fastest time in the 1896 Olympic marathon was just 1 minute faster than the time required for entry to today's Boston Marathon.

It is not just athletes that train systematically, according to K Anders Ericsson, a Swedish psychologist who spent 20 years studying elite performance in a wide range of fields. He found the same pattern everywhere he looked: the best performers practice around twice as much as the rest, but also in a different way. They attend to feedback on their performance, using it to identify learning goals that are currently just out of reach, and then train in a way that targets those goals, and attend to feedback on the result. He called this Deliberate Practice.

So, can therapists do Deliberate Practice?

The answer is "Yes", according to a small but promising body of research, together with the first-hand experience of therapists who have tried it and seen their outcomes improve.

As for how exactly to do it, the answer is evolving.

Deliberate Practice was introduced to the world of therapy by Scott Miller, a US Clinical Psychologist who was seeking to explain a recurrent but mysterious finding in psychotherapy research: that some therapists get better outcomes than others.

The pattern in the data was elusive: performance was not predicted by experience, qualifications, therapeutic orientation, or any demographic characteristic of the therapists. When Miller, by chance, read an article on Ericsson and his theory of Deliberate Practice, he realised that this might be the answer: the best therapists worked harder than their peers, and they worked smarter. They practised deliberately.

Since then, Miller has founded the International Centre for Clinical Excellence as a means of promoting and developing Deliberate Practice for therapists. It has been joined by the International Deliberate Practice Society, based in Europe, and Sentio, in the US, which have built on Miller's work in an effort to make Deliberate Practice more engaging and accessible to therapists.

Because Deliberate Practice (whisper it quietly) is hard. And no one will pay you to do it.

The starting point, according to Miller, is to measure outcomes with all your clients, using brief self-report questionnaires at each session, because you need to know your baseline. You cannot hope to improve if you don't know where you started from.

You also need to see yourself in action. So, you need to video your sessions.

After that, you need to rigorously analyse your data, to identify which groups of clients you are least successful with. Perhaps you get worse outcomes with women than with men, or with old rather than young people, or with clients you see in the morning rather than the afternoon.

After that, you need to figure out what exactly is going wrong with these clients. You need to review your notes, watch videos, and listen closely to client feedback, which you should be soliciting in every session.

And that is all before you come up with a way to address this particular problem, systematically implement it, and then return to your outcome data and client feedback to see if your efforts have paid off.

The process is lengthy, arduous, and often demoralising. Few of us enjoy collecting and analysing outcome data, especially when it reveals that we are worse therapists than we thought. Collecting client feedback can be even more painful: it's hard to look someone in the eye while they tell you exactly why you're a worse therapist than you thought. And, while a surprising number of clients are willing to be filmed, many of us will baulk at reviewing the recordings in order catch our very worst moments and then show them to a Deliberate Practice coach (you should always work with a coach).

And even if you do all this, any improvement will be small, slow – on the order of months and years – and uncertain. Your efforts might not pay off at all.

Finally, should you succeed in shifting your outcomes northwards a little, there will be no material rewards. Because therapists are not hired or remunerated on the basis of outcomes. If you want to boost your career, you would be better to get more letters after your name, more managerial experience, or better photos for your website. The quality of your work behind the doors of the therapy room is, currently, invisible to prospective clients and employers.

Our only hope?

And so, as Miller gloomily notes, Deliberate Practice is "unrewarding in almost every way". Perhaps especially so for therapists. The best athletes can expect fame and fortune, whereas the best therapists remain unknown. And for this reason, most therapists who try Deliberate Practice give up fairly quickly.

But if we want to do our best work, it's currently our only hope. So, it seems like a matter of urgency to make Deliberate Practice easier and more fun.

This challenge has been taken up by the International Deliberate Practice Society and Sentio, which operates a counselling clinic and training centre. The idea is to simplify the procedure and build in more peer support. Using their methods, the therapist can dispense with the torturous process of data analysis, and simply zero in on a case that is not going well (according to a quick glance at outcome data) or feels challenging.

Using case notes, video, and outcome data, the therapist then reviews their work with that client and identifies a particular therapeutic skill to work on. Then, in collaboration with their supervisor, they hone that skill through behavioural rehearsal: pause the video of your therapy session and say what you think you should have said in that moment. Now, listen to your supervisor's feedback, and try it again. And again, and again, until saying the right words feels natural and automatic.

To support the therapist, this stripped-down method is held within a framework of peer consultation, group work, regular training events, and a pathway for accreditation as a Deliberate Practice Therapist and, with further training, a Deliberate Practice Supervisor.

Time and research will reveal whether IDPS and Sentio's methods can equal the effectiveness of Miller's, and whether either can ever catch on enough to make a real impact on the therapeutic landscape. But not everyone has the same aspirations for Deliberate Practice, as evidenced by a recent (collegial) exchange of blogposts by Daryl Chow, who is one of Miller's collaborators, and Jordan Harris, a Deliberate Practice Advisor for Sentio.

On Harris's view, the aim should be to spread Deliberate Practice far and wide, for which purpose he recommends 'gamifying' it by tying it to professional certifications which are themselves tied to other useful resources that therapists desire.

Chow, meanwhile, replies that Deliberate Practice will always be a niche pursuit for the few who are intrinsically motivated to do it. If you tie it to external rewards, he says, you undermine the possibility of 'deep learning' of the kind that produces true excellence. Instead of incentivising Deliberate Practice, we should aim to reduce the pressure on therapists so that they can breathe, think, and perhaps discover their intrinsic motivation for Deliberate Practice.

So, it seems that Deliberate Practice faces the same dilemma as many great new ideas: aim for breadth or aim for depth. Maintain the most exacting standards or reach the most people.

Maybe we don't have to choose: the two approaches can co-exist. Practitioners might start with one and move to the other; or move fluidly between the two according to how much time and energy they have to spare. Best of all, as true Deliberate Practitioners, we might try each method and see for ourselves which works better for us, as reflected in our outcome data.

So, whichever path you choose, knowing what you now know, how can you not try Deliberate Practice?

- Dr Michael Eisen is an HCPC registered Clinical Psychologist. He is co-host of a one-day IDPS event on deliberate practice on 18 March 2024.