Deliberate Practice for Psychotherapists

A Guide to Improving Clinical Effectiveness

Tony Rousmaniere

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781315472232
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

This text explores how psychotherapists can use deliberate practice to improve their clinical effectiveness. By sourcing through decades of research on how experts in diverse fields achieve skill mastery, the author proposes it is possible for any therapist to dramatically improve their effectiveness. However, achieving expertise isn't easy. To improve, therapists must focus on clinical challenges and reconsider century-old methods of clinical training from the ground up. This volume presents a step-by-step program to engage readers in deliberate practice to improve clinical effectiveness across the therapists' entire career span, from beginning training for graduate students to continuing education for licensed and advanced clinicians.

Part I

The Path to Deliberate Practice

CHAPTER 1

THE PATH TO COMPETENCE

My entry into the field of psychotherapy was typical. Like many therapists, I was drawn to the field because I was a “people person.” I had a knack for talking with people about their inner life, I enjoyed introspective work, and I felt like I could be good at it. Furthermore, I was quite confident of the potential benefits of psychotherapy. Although I had never read any psychotherapy research, my gut told me that many individual and social life challenges were caused by psychological blocks, and psychotherapy offered the keys to healing, growth, and empowerment. (Turns out my gut was right: decades of research have shown psychotherapy to be, on average, very effective for helping people with a wide range of problems; Lambert, 2013.)

Like many aspiring therapists, no small part of my inspiration to enter the field came from my personal experiences in psychotherapy (Farber, Manevich, Metzger, & Saypol, 2005). In my late teens I had become deeply depressed; a psychologist’s evaluation recommended that I be removed from school due to risk of suicide. A mentor at my school connected me with a kind and compassionate psychologist. Using a patient, non-confrontational Rogerian style, the psychologist melted my angry and rebellious persona. My first few years of therapy with him were instrumental in helping me pull myself together, graduate high school, and enter college. I became an evangelist for psychotherapy and the power of introspection to transform lives. Now an adult, I wanted to provide that life-saving help for others.

When I started graduate school, I found myself among peers who also were enthusiastic and optimistic about the opportunity to help people change their lives through psychotherapy. In fact, I can’t recall a trainee from my graduate program—or any of the supervisees I’ve had since—who wasn’t clearly driven by the inherent motivation to help others. The research in this area mirrors my personal experience: 90% of trainees in a recent study reported a desire “to help others” as a main motivation to become a therapist (Hill et al., 2013). We are truly fortunate to work in a field where so many choose this work for such positive reasons.

Like many trainees, I entered the field with strong feelings about psychotherapy models. Specifically, I was convinced that psychodynamic therapy was the best model. Even more specifically, I felt sure that long-term psychodynamic therapy was the best. I say that I felt this because I had not yet bothered to actually read any psychotherapy-outcome research. Unburdened by the facts, I found peers who agreed with me, and together we enjoyed the clarity of confidence that only comes from a lack of contact with real data, which is invariably messier.

One year into my training I started working with actual clients. One of my first practicums was at a high school near Palo Alto, where I helped students with a wide range of problems, from academic concerns to depression to eating disorders. Although the school was in a wealthy suburb, my client population was very diverse. About half of my clients were children of undocumented immigrants. Many were in gangs. I initially felt a strong, heady rush of exuberance as I sat down with this diverse group of young people to help them change their lives.

A GOOD START

My first few months working as a therapist trainee were very positive. I connected quickly with my clients. I still had something of a rebellious streak left over from my teenage years, and this probably helped me bond with my teenage clients, many of whom were in trouble at school, with their parents, or law enforcement.

Quickly bonding with clients gave me great hope. The therapeutic relationship is the basis for psychodynamic work. Additionally, we were taught in graduate school that the therapeutic relationship is the variable most associated with successful psychotherapy, across all models of treatment (Norcross, 2011).

I was lucky to have a practicum where clients were not mandated to be in therapy: they came of their own free will and were largely very eager to get help. My clients were enthusiastic and resilient despite having a wide range of multisystemic stressors at home, including poverty, domestic violence, peer pressure, and prejudice because of their skin color, culture, nation of origin, and sexual orientation.

My clients’ initial successes in therapy occurred very quickly. Roughly 25% of my clients were like rocket ships blasting off from a launch pad: all it took was a bit of empathy and advice to achieve ignition and send them tearing off into the sky. These clients worked hard in therapy and implemented our work in their daily lives. I didn’t know it at the time, but psychotherapy research has identified that a large number of clients have a dramatic positive response to therapy, called “sudden gains” or “rapid response” (Lambert, 2013).

Another 25% of my clients took a bit longer to respond positively to therapy. Like a rocket ship struggling to gain altitude, they sputtered at first, showing no initial improvement. Sometimes their symptoms even worsened for the first few sessions. However, after three to six sessions they righted themselves, started to recover, and settled into a pattern of gradual improvement. This pattern of initial symptom deterioration followed by gradual improvement has been recently identified in large research studies (e.g., Owen et al., 2015). Like the fast responders, these clients worked hard in therapy and actively tried to implement what they learned in their daily lives.

A QUICK HONEYMOON

Then came the disappointment. After a few months at my practicum, I started to notice that a sizable percentage of my clients were not improving. By sizable percentage, I mean half. While the fast responders were rocket ships that blasted off towards the stars, 50% of the clients couldn’t even find the ignition switch. They engaged in therapy; we talked about their challenges, their goals, their relationships, their history, their everything. But these clients simply didn’t improve.

Like the 25% of my clients who were slow responders, some of these 50% experienced worsening of initial symptoms during their first few sessions. However, unlike the slow responders, they didn’t then get better. Instead, about 10% of my clients continued to get worse. In clinical terms, this is called deterioration. Some deteriorated so much that they dropped out of school or ended up in a hospital psychiatric ward. Rather than taking off, these clients were like rocket ships that blow up on the launch pad.

I felt frustrated and guilty about my clients who showed no improvement. Curiously, these cases were not correlated with the clients’ socio-economic status or other variables that could cause stress at home and thus impede progress. Caucasian clients from wealthy families were just as likely not to respond as children of undocumented immigrants living in poverty and surrounded by gangs.

Then came the dropouts.

I responded to my first few dropouts with outright denial. I assumed they couldn’t come back to therapy because of some external reason: maybe their schedule had changed, or possibly their friends convinced them to stop. However, as more and more of my clients stopped coming back, I had to acknowledge that maybe it was because therapy wasn’t actually helping them.

In summary, about 50% of my caseload was not benefiting from therapy. The psychotherapy research literature has a term for these cases—clients who don’t show improvement, who deteriorate, or who drop out: “nonresponders” (a less gentle term is “treatment failures”). I know now that my therapy batting average was actually pretty typical. Research suggests somewhere between 40% and 60% or more of clients do not benefit from therapy (Lampropoulos, 2011).

CLINICAL SUPERVISION TO THE RESCUE?

I was quite embarrassed about my therapy nonresponder and dropout problem. But I knew the solution: clinical supervision. Called the “signature pedagogy of the mental health professions” (Bernard & Goodyear, 2014, p. 2), clinical supervision is the primary method of clinical instruction. In a field characterized by intense antagonism among treatment models, one constant point of agreement is clinical supervision. Every major model of psychotherapy relies on supervision for clinical training.

The primary goals of clinical supervision fall into two broad domains. The first is aiding supervisee professional development. For example, supervision serves a critical role in helping supervisees improve their sense of self-efficacy, develop a professional role identity, reduce performance anxiety, and increase professional autonomy (Bernard & Goodyear, 2014).

The second goal of supervision is to improve and protect client welfare. Unsurprisingly, there is wide consensus among scholars that this second goal is primary. Supervision scholars Carol Falender and Edward Shafranske (2004) succinctly summarized this point when they wrote, “The most important task of the supervisor is to monitor the supervisee’s conduct to ensure … the best possible clinical outcome for the client” (p. 4). Michael Ellis and Nicholas Ladany, two prominent supervision researchers, famously called client outcome the “acid test” of good supervision (Ellis & Ladany, 1997, p. 485).

Although I had not yet read the work of these supervision scholars, I shared their view. Specifically, what I wanted most from supervision was help with the “other 50%”—the clients who stalled, deteriorated, or dropped out. I had great confidence in supervision to help me navigate through my clinical impasses towards better clinical effectiveness. If it worked for Sigmund Freud, it would work for me.

My faith in clinical supervision was not unique. Data from a survey I conducted some years later with colleagues at the University of Alaska Fairbanks suggest widespread confidence in supervision’s ability to improve clinical outcomes. From a national pool of 185 supervisees and 189 supervisors, almost all participants affirmed that supervision should have a positive impact on client outcome (92% of supervisees and 89% of supervisors), and large majorities reported that supervision does have a positive impact (70% of supervisees and 79% of supervisors). When given an opportunity to voice concerns, only six supervisors and seven supervisees (out of 374 participants) expressed hesitation or doubts about supervision’s impact on client outcome (Rast, Herman, Rousmaniere, Swift, & Whipple, in review).

While supervisees and supervisors may be largely convinced that supervision improves client outcomes, the research literature in this area is, unfortunately, less clear. Some studies have suggested that supervision may improve clinical effectiveness (e.g., Bambling, King, Raue, Schweitzer, & Lambert, 2006; Callahan, Almstrom, Swift, Borja, & Heath, 2009; Reese et al., 2009). However, three large reviews of the literature in this area all raised concerns about the reliability of these findings. Likewise, supervision scholars voiced caution in assuming that supervision improves client outcomes. Ladany and Inman (2012) urged modest expectations for supervision’s impact on client outcome: “Supervision may have an effect on client outcome; however, supervisors should recognize that the effect in many instances may be minimal” (p. 195). Beutler and Howard (2003) stated simply, “Supervision does not work” (p. 12). In his review of the literature in this area, noted supervision scholar Ed Watkins (2011) summarized this perspective more diplomatically, “We do not seem to be any more able now, as opposed to 30 years ago, to say that supervision leads to better outcomes for clients” (p. 252).

Fortunately, I had not read this literature, so my faith in supervision was undeterred.

My supervisor was smart, friendly, and approachable. He had over three decades of experience as a therapist and supervisor. We met for an hour each week to discuss my cases, and I also had two hours of group supervision with five of my peers. The group felt comfortable and supportive. We were all genuinely trying to learn how to be better therapists. There was very little competition among trainees.

I told my supervisor and the group about my concerns regarding my “other 50%”—the clients who stalled, deteriorated, or dropped out. My supervisor listened compassionately. He told me that my experience was common, which was simultaneously both relieving and disheartening. In retrospect, I now know that my supervisor’s comment about my experience being common was correct: clinical research has shown that trainees (like all therapists) can have poor outcomes. In a striking example, my colleague Jennifer Callahan at the University of North Texas published a study that showed dropout rates of up to 77% at a training clinic (Callahan, Aubuchon-Endsley, Borja, & Swift, 2009).

As I talked about my dropouts and deteriorations, I saw a look of recognition in the eyes of my peers. I could tell I was not alone in my clinical failures. I felt support and camaraderie, which was helpful. Unfortunately, support and camaraderie do not themselves lead to improved effectiveness.

BIASED DATA

In supervision we discussed my challenging cases in detail. Unfortunately, the detail was highly biased. I say biased because my description of the session was based on my memory and notes; I did not have videotapes of the session. A large body of research has repeatedly shown that human memory has extensive biases in self-appraisal (Myers, 2015; Greenwald, 1980) and is generally as truthful as a politician giving a press conference (Chabris & Simons, 2014).

Our memory is a petri dish of biases, blind spots, ulterior motives, and projections—all totally unconscious—driven by our desires, fears, past experiences, self-image, vanity, shame, and God knows what else. Memory researcher Charles Fernyhough describes memories as “shaped by who we are now. They’re shaped by what we feel, what we believe, what our biases are” (Martin, 2013). Importantly, memories reported in supervision are subject to distortion at two stages: once when the memory is encoded during the initial experience of the event (the therapy session) and then again during the memory retrieval in supervision (Buchanan, 2007).

I cannot stress this eno...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Prologue
• Acknowledgments
• Part I: The Path to Deliberate Practice
• Part II: The Science of Expertise: Learning from Other Fields
• Part III: Developing Your Own Deliberate Practice Routine
• Part IV: Sustaining Deliberate Practice
• Epilogue
• Appendix: Videotaping Psychotherapy
• References
• Index