Deliberate Practice

When we practice, we rehearse a behavior or action repeatedly in order to master it. As we say in the music field: “Practice makes perfect.” Whether it’s a sport, an art, or a craft, everyone has to practice certain skills to develop expertise.

So, the question becomes: how do we need to practice in order to become expert? We need to practice frequently. In music, that means about three hours a day, every day. We need to get expert feedback on our performance. In music, each week your music teacher listens to you play exercises you agreed to work on to develop at your current skill level. In sports, your coach observes your moves in every practice and reviews your movies on a video after every game. In therapy, ideally you find a good supervisor who observes videotapes of your work with a patient every week over the course of years.

But if you rely only on your opinion or a book, your practice will be ineffective or even harmful: you will learn and reinforce bad habits. If we don’t practice enough, we won’t master the exercises, and we will forget what we learned. That’s why mastery requires us to practice often to make sure we gain the skills and mastery we want. Musicians practice a minimum of three hours a day and often much more. Basketball players, think Michael Jordan, practice for up to six hours a day, varying the skills they are working on. As a therapist, how often are you setting time aside to develop your skills, analyze your video transcript, watch your videotaped sessions, or going to supervision? Did you know that the vast majority of therapists stop getting expert feedback from a supervisor once they are licensed? Could this be a reason that therapy effectiveness has not changed substantially over the past fifty years.

K. Anders Ericsson proposes “that the differences between expert performers and normal adults reflect a life-long period of deliberate effort to improve performance in a specific domain. It’s not just how much we practice a particular skill, but how we practice it. Experts in any field break down complex skills into small chunks. Then they practice those small skills daily, often reviewed by a coach, teacher, or instructor. We see this with scales in music, serves in tennis, and shots in basketball. In all these fields, deliberate practice involves continual repetition of ever more complex skills at more challenging levels to achieve mastery.

Some, like Malcolm Gladwell, have asserted that practice is not enough; talent is essential, along with deliberate practice and a good support system. My own experience as a musician makes that clear. To become a professional musician, you must have a certain degree of talent. Without it, a professional level of mastery will be impossible. Yet every music school has students with massive talent who failed to develop it up to their potential due to their failure to engage in deliberate practice systematically. Every music teacher could point to this pattern.

What is deliberate practice in psychotherapy?

  1. We need to analyze our session videotapes and transcripts to assess which skills we possess, which skills we need to improve, and which skills we need to develop.
  2. We need feedback from an expert who can help us see what we need to work on, who can work on those skills with us, and who can help us develop a plan to work on those skills until the next feedback meeting.
  3. We need to repeatedly practice cognitive skills at our level of development (e.g., ability to create a case formulation, ability to understand the roles played out in therapy, ability to understand how your feelings [countertransference] relate to those roles).
  4. We need to repeatedly practice intervention skills at our level of development (e.g., helping the patient declare an internal emotional problem, mobilizing the patient’s will to work in therapy, getting consensus on the therapeutic task, regulating anxiety, helping patients see strategies that cause their symptoms and presenting problems, helping patients let go of those strategies, helping patients face what they usually avoid).

 

Just as in other arts and crafts, repetitious practice of basic skills is most helpful in the earlier phases of learning. As we progress, we must practice increasingly complex and difficult skills. Once the therapist has mastered the skills, then supervision and training shifts away from skill development over to countertransference analysis. Why? At first, we don’t know what to do. Once we know what to do, if we aren’t doing it, it’s because our own emotional conflicts are getting in the way. Thus, later phases of supervision and training in psychotherapy focus primarily on internal obstacles in the therapist that are preventing her from helping the patient.

Thus, the supervision and teaching literature of psychotherapy shows that the focus of our training must shift as our mastery increases. At first the student needs the teacher to learn how to assess the work. Eventually, the student learns how to engage in systematic self-assessment. But at all phases of our work, we need to engage in deliberate practice if we want to improve. Thus, later phases of supervision and training in psychotherapy focus primarily on internal obstacles in the therapist that are preventing us from helping the patient.

The relationship of Deliberate Practice to the ISTDP Institute

In intensive short-term dynamic psychotherapy (ISTDP), we teach therapists specific skills for specific groups of patients. And research is showing the effectiveness of this model of psychotherapy. However, many of the skills we teach are not peculiar to ISTDP. All therapists of all orientations must help patients declare an internal problem to work on in therapy. All therapists must be able to regulate anxiety. All therapists must be able to help patients see and let go of behaviors that will increase their symptoms and presenting problems. In other words, the vast majority of skills we teach are trans-theoretical, i.e., they apply to all therapists regardless of their theoretical orientation.

On this website, we offer a series of skill-building exercise programs designed to help therapists of all orientations. In fact, we are beginning some research projects now to assess the impact of skill-building exercises on patient outcome not only in ISTDP but in therapists across modalities.

This past year, a pilot project with drug counselors who were doing skill building exercises found an interesting result. Only 17% of patients from the control group were still sober at six months. But 48% of the patients from the skill-building therapist group were still sober. And when we looked at the therapists in our unit, the therapist who missed the most skill building sessions had the lowest effectiveness rate.

It stands to reason that deliberate practice of specific skills for specific populations should lead to improved outcome. Our hope is that we can give you the specific studies you need to develop your skills no matter what theoretical perspective you use. After all, psychotherapy research has found that the most effective therapists tend to look very much alike in their work. That suggests that certain trans-theoretical skills lead to improved outcome. We hope to help you build those skills.