{"id":6191,"date":"2024-10-18T02:27:00","date_gmt":"2024-10-17T18:27:00","guid":{"rendered":"https:\/\/darylchow.com\/frontiers\/?p=6191"},"modified":"2024-12-27T02:32:40","modified_gmt":"2024-12-26T18:32:40","slug":"can-deliberate-practice-make-things-worse","status":"publish","type":"post","link":"https:\/\/darylchow.com\/frontiers\/can-deliberate-practice-make-things-worse\/","title":{"rendered":"Can “Deliberate Practice” Make Things Worse?"},"content":{"rendered":"\n

Note: This article was originally published in Substack on 18 Oct. 202<\/em>4<\/p>\n\n\n\n

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There has been a proliferation of deliberate practice studies in the field of psychotherapy. It\u2019s hard to keep up.<\/p>\n\n\n\n

A recent Swedish study caught my attention.<\/p>\n\n\n\n

Does Practice Make Perfect? The Effects of an Eight-Week Manualized Deliberate Practice Course With Peer Feedback on Patient-Rated Working Alliance in Adults: A Pilot Randomized Controlled Trial<\/a><\/strong><\/em><\/p>\n\n\n\n

H\u00e4kan Lagerberg and colleagues looked at the effects of an eight-week manualised deliberate practice course, aimed at boosting therapists ability at alliance formation in their naturalistic clinical setting.<\/p>\n\n\n\n

This pilot study randomised 37 therapists in Sweden comparing a DP group vs. a control group i.e., waitlist. As a primary measure, they used the Session Alliance Inventory (SAI), which is a shortened version of the Working Alliance Inventory (WAI). Therapists saw patients in their naturalistic work setting; the SAI was employed as a pre-post measure of the working alliance.<\/p>\n\n\n

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So what did they do in the two month DP Intervention Group?<\/p>\n\n\n\n

In each of the 75 mins weekly online group sessions, a prescribed targeted skill was introduced, followed by 55 mins of role-plays and ended with reflection.<\/p>\n\n\n\n

Here\u2019s more about the role-plays:<\/p>\n\n\n\n

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During the role-plays, the participants were divided into groups of two or three in separate breakout rooms. They took turns playing the roles of client, therapist, and observer. The client role-played the vignettes, and the therapists attempted to give an authentic response in line with the skill criteria being practiced.<\/p>\n<\/blockquote>\n\n\n\n

Within the peer-group,<\/p>\n\n\n\n

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the observer and the client gave feedback to the therapist based on the skill criteria and their own observations. After receiving the feedback, the process was repeated, maximising repetition and feedback exposure for the therapist.<\/p>\n<\/blockquote>\n\n\n\n

Here\u2019s an example of the two of the targeted skills:<\/p>\n\n\n

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Results<\/h2>\n\n\n\n

Here\u2019s what they found:<\/p>\n\n\n\n

Therapists in the DP group experienced a <\/strong>decrease <\/strong><\/em>in patient-rated alliance scores, and therapists in the control group showed <\/strong>improvement.<\/strong><\/em><\/p>\n\n\n\n

What!?<\/em><\/p>\n\n\n

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Let\u2019s pause for a moment, and think this through\u2026<\/p>\n\n\n\n

Why is this the case? How could a DP training have a negative impact on client engagement, when the training was aimed at improving engagement?<\/p>\n\n\n\n

First, I applaud Lagerberg and team for publishing this study. Too often, negative findings<\/a> get shelved and we don\u2019t see the light of day of its results. Null or negative findings teach us things we might take for granted, that normally don\u2019t reveal itself in usual circumstances.<\/p>\n\n\n\n

Here one of the things this important study reveals:<\/p>\n\n\n\n

Peer feedback without a coach to guide is likely to limit, confuse or even impede learning.<\/strong><\/p>\n\n\n\n

Based on the data from this study, it seems like peer inputs messed up their ability to engage normally as they would.<\/p>\n\n\n\n

Deliberate Practice Defined<\/h2>\n\n\n\n

Let\u2019s zoom out for a second and reexamine our proposed working definition of deliberate practice1<\/a>.<\/p>\n\n\n\n

In a nutshell, DP has four critical elements:<\/p>\n\n\n

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The Four Pillars of Deliberate Practice<\/strong><\/figcaption><\/figure><\/div>\n\n\n

Here\u2019s what the late K Anders Ericsson said,<\/p>\n\n\n

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Seen from another angle, any DP efforts must help each learner improve at each of their own zone of proximal development.2<\/a> We must help each therapist move from their comfort zone and into their learning zone, while being mindful of not tipping them into their panic zone.<\/p>\n\n\n

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For more about the Circle of Development (COD), see this post<\/a>.<\/strong><\/figcaption><\/figure><\/div>\n\n\n

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Okay. Now that we have these concepts loaded into our minds, let me zoom in and focus on two issues at hand:<\/p>\n\n\n\n

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  1. Types of Feedback<\/strong><\/li>\n\n\n\n
  2. Top-Down vs. Bottom-Up Learning<\/strong><\/li>\n<\/ol>\n\n\n\n
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    1. Types of Feedback<\/h2>\n\n\n\n

    In our Difficult Conversations in Therapy (DCT) Project <\/em>(more on this in the near future), we employed the four pillars of DP, aimed at helping therapist dealing with challenging scenarios that typically occur in clinical practice. We learned the following:<\/p>\n\n\n\n

    The quality of the feedback determines the quality of learning.<\/strong><\/p>\n\n\n\n

    Not all feedback is created equal.<\/p>\n\n\n\n

    Plus, I make a distinction between performing feedback and learning feedback3<\/a>:<\/p>\n\n\n\n

    Performing feedback is evaluative, i.e., how well you did. Learning feedback, on the other hand, is descriptive and specific, delivered in manageable chunks in order to assist the practitioner to reach just beyond their current ability, i.e., learning zone.<\/p>\n\n\n\n

    We can infer that likely, the feedback delivered by peers in Lagerberg et al.\u2019s (2024) study didn\u2019t exactly help in their learning process. (It would be interesting if there were self-reports from therapists during the process. In our DCT project, self-ratings from therapists in the feedback group experienced more difficulties and an even a perceived decrease in performance, compared to the control group\u2014even though they were improving in their abilities!)<\/p>\n\n\n\n

    Feedback from Supervisors<\/h3>\n\n\n\n

    But even if feedback is not delivered by people in the same boat as you (i.e., your peers), an \u201cexpert\u201d or your clinical supervisor, needs to deliver specific feedback that helps you at your growth edge. And in order to do so, they have to know your work. Said in another way, your supervisor has to build upon your existing <\/em>ability, instead of superimposing what you \u201cshould\u201d be learning.<\/p>\n\n\n\n

    This is hard. Because it means that your clinical supervisor has to know how you do what you do in the therapy room, develop an individualised learning direction to take, and help you take successive steps towards this learning goal.<\/p>\n\n\n\n

    Case in point: Notice how much evaluative<\/em> feedback we tend to give and receive (e.g., that\u2019s good. Keep it up. Good on ya!\u201d<\/p>\n\n\n\n

    What does a good coach do instead?<\/p>\n\n\n\n

    In a study examining what the legendary UCLA basketball coach John Wooden does in his teaching practices, the researchers said,<\/p>\n\n\n\n

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    We conclude that exquisite and diligent planning lay behind the heavy information load, economy of talk, and practice organisation.4<\/a><\/p>\n<\/blockquote>\n\n\n\n

    How exactly does this look like on the ground?<\/p>\n\n\n

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    Wooden spent so little time dispensing praises or reproofs, and the majority of the training with his players giving specific instructions, what to do and how to do.<\/p>\n\n\n\n

    This is relevant to the topic of feedback. We can only provide this level of nuanced feedback if we can assess where someone is at, and where they need to grow.<\/p>\n\n\n\n

    2. Top-Down vs. Bottom-Up Learning<\/h2>\n\n\n\n

    This is where a debate might be lurking.<\/p>\n\n\n\n

    In Lagerberg et al.\u2019s study, a list of set skills are pre-defined. This is similar to most existing pedagogical approaches to traditional teaching. You provide a list of common-core objectives and you strive for the learners to meet the mark.<\/p>\n\n\n\n

    This top-down approach resembles more like what Ericsson might call Purposeful Practice.
    <\/strong>There is a place for purposeful practice. But I\u2019m not sure if this should be conflated with deliberate practice, which is much more individualised, and learning objectives are determined based on the learner\u2019s baseline ability, i.e., bottom-up approach to learning.<\/p>\n\n\n\n

    In a sense, purposeful practice is like building LEGO with fixed instructions and specific design to build. Deliberate Practice, on the other hand, is like the original LEGO\u2014it\u2019s up to you on what you choose to build<\/a>. The former is much easier, but the latter is ultimately more fulfilling.<\/p>\n\n\n

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    Get back from LEGO into psychotherapy, I see it this way: purposeful practice <\/strong>aims for competency<\/strong>, whereas deliberate practice<\/strong> aims for excellence<\/strong>.<\/p>\n\n\n\n

    Rod Goodyear, Bruce Wampold and colleagues argued that the most meaningful definition of expertise should not be based on expertise in therapist performance, but it must be anchored in improvement in performance in client outcomes.5<\/a> In the learning sciences, this is often called \u201ctransfer of learning<\/a>.\u201d<\/p>\n\n\n\n

    Conclusion<\/h2>\n\n\n\n

    As the field conducts more empirical studies into DP and its effects on performance in psychotherapy, I hope that we use the four pillars of DP as a working definition that can be built upon (and tear down) when needed.<\/p>\n\n\n\n

    History does not have to repeat itself.<\/p>\n\n\n\n

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    If you would like to learn more topics that can help your professional development, subscribe to the Frontiers of Psychotherapist Development (FPD). On Frontiers Friday (FPD), we serve you directly to your Inbox highly curated recommendations each week.<\/em><\/strong><\/p>\n\n\n\n