What Does Deliberate Practice Look Like? Look at What’s Onstage, ...

“What does deliberate practice look like?” Thanks to Ivan for a great question!

“Lots of people want to be the noun,” says artist and writer, Austin Kleon,  “without doing the verb.” First, I want to make sure that we are not using deliberate practice (DP) as a noun, but as a verb to describe a set of activities that are aimed at overcoming automaticity and at improving our performance in a focused and effortful manner. [1] Let’s resist the temptation to turn DP into a special set of technique.

Photo by Danielle MacInnes

I’d use an analogy to exemplify what deliberate practice is and isn’t, and then I’d take us to the top and examine the four pillars that constitute deliberate practice in psychotherapy.

Onstage vs. Backstage vs Offstage

Onstage

“Onstage” is when we are in clinical practice. This is where we deliver the work, co-creating a new reality of change in conversation with our clients.

Clinical practice is not deliberate practice. What we do onstage is the output component of our efforts.

Backstage

“Backstage” is the immediate prep that we do before a session. This may consist of reading the case notes to prime our immediate recall, and rituals and routines that we engage in the get us in the right frame of mind in therapy[2].

If you met a performer at the backstage before they get onstage, you’d notice that they are in almost an altered state of consciousness. They are not quite present, but yet highly focused on something that’s about the happen onstage.

Therapists can afford to design better prep routines for themselves, instead of checking their inboxes before a client comes in. This may include a minute of the following:

1. Contemplative routines (e.g., breathing exercises, mindfulness, intentional non-doing)
2. Prayer
3. Mantra (e.g., “May I devote this next hour to the person that I’m about to meet”)
4. Listen to a particular piece of music
5. Reviewing key notes from previous sessions and progress of outcomes

Offstage

“Offstage” is when we are probably not in the therapy office. Offstage activities include

1. Self-care activities (exercise, hobbies)
2. Reading
3. Reflecting
4. Note-creation (I’m not referring to case notes here)
5. Reviewing your learning notes (see previous post).

Naturally, having a life outside of therapy is important, but the stuff that I’m referring to in “offstage” activities are not about our day-to-day activities. I don’t think most of us can function very well without the support of our families and friends. Offstage activities are clearly distinct from onstage and backstage activities.

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Given the three distinctions above, deliberate practice tend to recite more in the “backstage” and “offstage” domain.

The Four Pillars of Deliberate Practice

1. A Coach

The role of devoted teachers and coaches is evident in top performers’ development[2]. Not only can our coach help us pick up our blindspots and inoculate us from a self-assessment bias, a good coach is central in helping us design a good individualised learning objective, provide us specific feedback, and tighten up the learning process through successive refinement.

It may seem odd to be using the term coach in psychotherapy as opposed to the traditionally defined role of a clinical supervisor, which has been the signature pedagogy in psychotherapy[3]. A coach is focused on helping you not only to grow, but also to obtain the results.

(Join our next enrollment for the Online In-depth course, Reigniting Clinical Supervision. Our first enrollment was fully subscribed by an elect group of 40 practitioners and supervisors worldwide. Drop me an email to be on the waitlist. The next batch starts on the 9th of April, 2018).

2. Individualised Learning Objectives

Here’s what I said in a chapter from The Feedback Informed Treatment (FIT) in Clinical Practice edited book: “This may be one of the most vital and sorely lacking element in a practitioner’s professional development. Too often, we engage in clinical supervision on a case-by-case basis, with no coherent thread explicitly weaving in the therapist’s learning needs and clinical case concerns. It is vital to help therapists go beyond their zone of proximal development[4], but to do so, one’s current realm of ability and limitations needs to be well defined.”[5]

Especially when you first start to make the effort to define your learning objectives, it’s crucial that you take the time to figure out “what” is the one thing you need to work on. Two suggestions:
1. Make sure what you pre-determine to focus on to improve has leverage on actually improving on client outcomes. Making the time to introspect or reflect may feel good to the learner, but it rarely pays dividends into the actual improvement of engaging.

2. If you have a supervisor/coach who is helping you to define your current learning objectives, make sure he/she knows your work i.e., has listened/viewed at least 3-4 of your therapy recordings. Without knowing your work, you and your supervisor are likely not only miss the mark, but would easily skew towards our pet solutions/methods/approaches.

3. Feedback

There are two types of feedback you want to make sure you get in your deliberate practice efforts. Performance Feedback and Learning Feedback.

Performance Feedback
When we use the word “feedback,” most of us are really thinking of “performance feedback.”

Once again, from The Feedback Informed Treatment (FIT) in Clinical Practice edited book:
“When chess players engage in solitary examination of past chess games by masters, they are able to compare their own moves with those of the masters, thus receiving immediate and specific feedback on the quality of their moves. Athletes get virtually immediate feedback by the observable outcome itself, feedback from coaches, as well as delayed viewing of video recordings of their games. Such feedback looping provides rich and contextual information about the performance, which in turn helps to develop actionable steps toward improvement. To this effect, it is vital for psychotherapists not only to receive ongoing client feedback but also to have the audio/video means to record their sessions, so that supervisors can provide specific feedback about their performance.”

In other words, if you are using outcomes and alliance measures in your practice, they are your performance feedback tools.

Learning Feedback
Learning feedback focuses on the learning goals at hand. Sometimes, focusing on the outcomes alone cripples the learner from experiencing deep learning. Robert Bjork points out a critical distinction between Performance vs Learning. Focusing entirely on performance does not necessarily mean that we are learning.[6]

Emphasising on short-term performance may not necessarily translate to an increase in long- term learning. Likewise, a focus on learning may not necessarily improve performance in the short term. However, promoting learning may improve performance in the long term. Using current performance as a measure of learning is susceptible to mis-assessing whether learning has or has not occurred.[6]

4. Successive Refinement

Repetition should not be confused with experience. It is well-established that clinical experience is not a significant predictor of client outcomes. [7] One of the simplest ways to enable the iterative process of gradual refinement is to tighten the loop of what you’ve learned (see Individualised Learning Objective) and the impact on your overall effectiveness at a pre-defined time point.
The other micro approach that you can use in clinical supervision is to make sure that you close the loop between what you’ve discussed in consultation about a case, and what you’ve applied from the advice of the supervisor/coach, and crucially, if what was applied has a measurable impact on improving the client’s wellbeing. Too often, we do not close the loop. We end up fighting fire, discussing case after case in a haphazard fashion.

So, what does deliberate practice look like? Don’t look at what’s onstage. Peek behind the curtains; see what’s going on backstage and offstage.

“A master in the art of living draws no sharp distinction between his work and his play; his labor and his leisure; his mind and his body; his education and his recreation. He hardly knows which is which. He simply pursues his vision of excellence through whatever he is doing, and leaves others to determine whether he is working or playing. To himself, he always appears to be doing both.”

~ L.P. Jack, 1932. Education Through Recreation

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YOUR TURN: Do you have a question that you’d like to ask about our development as psychotherapists? Please email me or list them down in the comments below, and I’d do my best to respond to them.

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Footnotes:
[1] Ericsson, K. A., & Lehmann, A. C. (1996). Expert and exceptional performance: Evidence of Maximal Adaptation to Task Constraints. Annual Review of Psychology, 47(1), 273-305. doi:10.1146/annurev.psych.47.1.273

[2] see McGinn, D. (2017). Psyched up: How the science of mental preparation can help you succeed. New York: Penguin Random House.
[2] Hunt, E. (2006). Expertise, talent, and social encouragement. In K. A. Ericsson, N. Charness, P. J. Feltovich, & R. R. Hoffman (Eds.), The cambridge handbook of expertise and expert performance (pp. 31-38). Cambridge: Cambridge University Press.

[3] Watkins, C. E. (2011). Does Psychotherapy Supervision Contribute to Patient Outcomes? Considering Thirty Years of Research. The Clinical Supervisor, 30(2), 235-256. doi:10.1080/07325223.2011.619417
[4] Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press.
[5] Chow, D. (2017). The practice and the practical: Pushing your clinical performance to the next level. Prescott, David S [Ed]; Maeschalck, Cynthia L [Ed]; Miller, Scott D [Ed] (2017) Feedback-informed treatment in clinical practice: Reaching for excellence (pp 323-355) x, 368 pp Washington, DC, US: American Psychological Association; US, 323-355.
[6] Bjork, E. L., & Bjork, R. A. (2011). Making things hard on yourself, but in a good way: Creating desirable difficulties to enhance learning Psychology and the real world: Essays illustrating fundamental contributions to society (pp. 56-64). New York, NY: Worth Publishers; US.
[7] Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., H., T., Noble, S., & al., e. (2004). Therapist Variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 227-306). New York: Wiley.

Chow, D., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337-345. doi:http://dx.doi.org/10.1037/pst0000015. 

Wampold, B. E., & Brown, G. S. (2005). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting & Clinical Psychology, 73(5), 914-923. doi:10.1002/jclp.20110 

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