Improving Therapy Outcomes: The Case for Deliberate Practice

In my previous post, I wrote about my history with imposter syndrome as a therapist—convinced that I wasn’t really a good therapist until I was confident. To resolve this self-doubt, I turned to expanding my knowledge in different ways of doing therapy. I did things almost all therapists do to learn more. I met with a peer or one of my mentors to learn new ways of responding to challenging client situations; I read books on and would take in-depth courses to learn therapies that were new to me.

At one point I was convinced that Schema Therapy was the answer to my imposter syndrome woes, then it was EMDR and then ACT. I simply wanted more tools and strategies to help more of my clients to get better, faster and more profoundly. Over time, my pool of knowledge expanded and I felt more confident and supported by my peers in knowing I could turn to them for answers.

Despite these helpful endeavours, there was one glaring issue that always remained, a fly in the ointment I could never fish out. My clients were not improving any faster or more noticeably than they had before. I would learn so much and yet my average number of sessions would hover around 4-6 in total. In Australia, clients get a referral from their doctor to have up to 10 rebated sessions with a psychologist (after COVID it became 20 sessions), but more often than not my clients would end therapy before finishing the 10 sessions.

It turns out I’m not alone. Research has been unearthing that most clients reach a clinical improvement approximately 20%-40% of the time. Clinical improvement or change means that when a client is given a measure to monitor therapy, such as the Outcome Rating Scale, they move from ‘dysfunctional’ to scoring consistent with a ‘normal’ population. These rates of clinical change are stagnant, they have been for a long time, more than 40 years (see Miller, Hubble, & Chow’s Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness). Yes, you heard that right. Forty years. Despite more experience, therapies, strategies and tools, the needle isn’t moving. We are reasonably effective—we just aren’t improving.

The rest of this piece is about how I finally managed to buck the trend and improve my outcomes as a therapist.

As a demonstration, below is the full suite of my outcome statistics, since 2021, which is when I dived into a system of development called ‘Deliberate Practice’. My chosen measure of change in therapy is the Outcome Rating Scale (ORS) and I use FIT Outcomes, a web-based outcome monitoring system, to track my outcomes.

Outcome Metric (Closed Cases) Research Established Benchmarks My outcomes (2021)

Total cases = 72

My outcomes (2022)

Total cases = 87

Average session # 6 4.16 8.7
Dropout % 20%-22% 20.5% 10.3%
Clinical change % 25%-40% 51.3% (n = 37) 65.5% (n = 57)

Based on this table, you can see that I doubled the number of sessions I had with my clients, cut the amount of unplanned dropouts in half, and improved the number who experienced clinical change from about half to about two-thirds of my clients.

What Is Deliberate Practice?

A system of development has begun to emerge in the therapy space over recent years coined ‘Deliberate Practice’. There is a good chance you have heard about it by now. Folks like me and the pioneers who came before, have been trumpeting its message of hope for some time—that it is possible for therapy outcomes to improve.

Deliberate Practice is not a new idea; it has been present in domains of performance for quite some time, such as in music and sport. These domains are very well versed in how to apply Deliberate Practice and its core components, which there will be more on later in this piece. While Deliberate Practice is not new, it was only recently unearthed and defined. It was the late and great K. Anders Ericsson that discovered this species of development. I believe what Charles Darwin was to discovering evolution, K. Anders Ericsson will be to discovering a system of development. He had a keen interest in learning about what separated the very top of performers from the rest of their respective field. Ericsson found that these top performers applied Deliberate Practice, where others did not.

Anders Ericsson defined deliberate practice as: “individualized training activities especially designed by a coach or teacher to improve specific aspects of an individual’s performance through repetition and successive refinement. To receive maximal benefit from feedback, individuals have to monitor their training with full concentration, which is effortful and limits the duration of daily training.”

It turns out that there is much that those of us in the therapy space can learn from our older brothers and sisters from music and sport. It was Scott Miller, a therapist and researcher, who, with Ericsson as his guide, pioneered Deliberate Practice in the therapy space. Even though Deliberate Practice targeting therapy is in its infancy, it is being shown as a difference maker in improving therapy outcomes, unlike anything before.

My Deliberate Practice Journey

Throughout my Deliberate Practice journey, I have embarked on learning objectives that were targeted towards improving my outcomes as a therapist—to lower my client dropout rate and increase the percentage that were achieving reliable improvements in their well-being. I have listed out my learning objectives, in the order I started them:

  1. Obtaining client feedback and outcome data to better react to an individual’s therapy needs and identify which fundamentals of good therapy I need to address.
  2. Strengthening my goal-setting process with clients to better align with their wants and preferences and thereby increase their therapy ‘buy in’.
  3. Catching my tendencies to try to problem solve on behalf of the client, instead of encouraging them to explore their challenges for themselves, by encouraging myself and them to turn towards challenging emotions and experiences:
    1. The ‘You feel x’ response to client emotions.
    2. Dropping anchor in response to me going into my fix-it and over-explaining modes.
    3. Asking questions prior to providing psychoeducation (e.g., “What do you know about the fight vs flight response?”).

In my opinion, tackling the above learning objectives has been an essential mechanism for me to improve my effectiveness as a therapist. There has been plenty of toil and frustration, I am more often than not out of my comfort zone, but it has also been the most gratifying experience of personal growth and pride. My confidence has reached new heights, but I still maintain a healthy level (mostly) of self-doubt. My relationship with my self-doubt has also transformed, from seeing it as the bane of my existence, to now seeing it as one of my strongest allies. Deliberate Practice has been worth every struggle and it’s something that I feel compelled to share and teach to others, so that you can experience the growth that I continue to experience.

The Four Core Components of Deliberate Practice

The remainder of this piece will lay out the four core components of Deliberate Practice—its main ingredients, with examples from my own journey. I hope you enjoy the ride and please do not hesitate to contact me if you would like to learn more. I am more than happy to provide what support and assistance I can to engaging in Deliberate Practice as a therapist.

Developing these components of Deliberate Practice can be a significant challenge. After all, true growth is difficult and slow. With guidance, however, they can be achieved, especially if they are broken down and pursued at a manageable pace. It is my hope that in defining these components, you will begin to see Deliberate Practice as achievable. It is here that our current system of learning can fall. In the current system we use, it is all too easy for these elements to be missing, either in part or in full. All four components are required for growth to succeed.

Individualised Learning Objectives
Step out of your comfort zone—tackle your weak spots

It’s essential that when you address your weak spots, that you also step out of your comfort zone. If you’re comfortable, you’re not growing. Growth triggers us to feel vulnerable, which inevitably kicks off our fight vs flight response. However, if you have the urge to shut down or give up when challenging yourself, it means that you’re in the ‘panic zone’ and pushing yourself too hard. Pushing into the panic zone may work at times for athletes, but it’s not necessary for a therapist trying to improve a skill. This means that there’s a ‘sweet spot’ of discomfort when attending to a weak spot; this is called the ‘zone of proximal development’ or ‘learning edge’. It’s the space that sits between our comfort and panic zones.

When we are at our learning edge, we experience discomfort to some degree. There may be an urge to withdraw, but it is not overpowering. That’s the space you want to be in whenever you’re addressing your weak spots, because being in our learning edge means we’re growing while not becoming overwhelmed.

When it comes to my own growth, I don’t expect myself to address any more than one behaviour at a time. Taking on any more than this increases the risk that I dip into my panic zone. This is especially important because whenever I’m about to start practicing a desired behaviour, I’m at my most apprehensive, but over time as I repeat the behaviour, I become more confident and comfortable with it. I repeat and practice over and over, for as long as it takes, even months if needed, until I become comfortable enough with the behaviour, often so comfortable that I start to enjoy enacting the desired behaviour. I now enjoy something I once feared—how cool is that!

Now you start to understand the power I find in not just setting individualised learning objectives that are consistently manageable, but in the entire process of Deliberate Practice. I have never before experienced such a strong feeling of sustained growth. I remember in the past when I completed a course in how to do a certain kind of therapy, like trauma-focused CBT, I would be given all these modules, filled with different topics and techniques. I would feel overwhelmed and unsure about which technique is best for me to concentrate on.

So, as a safety behaviour, I would automatically try to “play it safe” by learning everything the course offered all at once. Inevitably my brain would become like an overfull glass of water and the knowledge would start to spill. At best I would come away from a course that totalled 12+ hours’ worth of content, likely only remembering one or two concepts or techniques. I may as well just start taking one bite of a burger then walk away! It’s essentially the same effect. But instead, these therapy courses would cost me $600, so that’s a very expensive bite of knowledge.

This is a major factor why I have been a whole lot pickier in determining which courses to undertake. Why would I spend so much money on a course which won’t help my outcomes and will just feel overwhelming, when I can continue to follow my deliberate practice system? After all, my therapeutic outcomes never improved until I started Deliberate Practice anyway.

Focus on what matters most—the fundamentals

To maximise the effectiveness of one’s goals, the goals should focus on addressing what matters most to improve outcomes—on the fundamentals of what we do. The fundamentals in therapy include creating a therapeutic relationship with a client, working on what the client is motivated to work on (goal alignment), agreement with the client on the means to working on their goals (process alignment) and creating hope for the client that they can improve, among others.

Before I started Deliberate Practice, I couldn’t say with confidence which of these fundamentals I was weakest in. Which is why my first learning objective pertained to gathering client feedback in the hopes of clearing up this picture. After some time collecting clients’ data via the Outcome Rating Scale (ORS) and Session Rating Scale (SRS), I noticed that the score for goal alignment on the SRS was often the lowest score clients were giving me.

This was supported by client’s qualitative feedback as well, as they would say things like “I’m not quite sure what we’re supposed to be working on” or “I don’t know where all this is going”. It was from such feedback that my next learning objective was born, which was to strengthen my goal-setting process with clients. Deliberate Practice helped me realise that my goal setting with clients was almost non-existent!

Focus on the steps to the destination, not just on the destination itself

Goal setting is an integral feature of deliberate practice, but goals must be tailored to the individual. One needs to be mindful of their desired outcome when seeking to improve their effectiveness. My first outcome goal in this journey was to gain actionable, qualitative feedback from my clients at the end of each therapy session as much as possible.

However, it’s not enough to identify a desired outcome alone. Research supports that the best performers set most of their attention on the ‘process steps’ to an outcome goal. If goal setting were like a ladder, they focus on the rungs from the bottom step to the top, not just the top step. Focusing on the process is vital to helping change be more focused and manageable. As a result, I’m far more likely to sustain positive levels of engagement and motivation in pursuing my goals. For the above-mentioned outcome goal, my process steps looked something like this:

  1. Pick measures for gaining client feedback (Outcome Rating Scale and Session Rating Scale).
  2. Pick a software program to track client session feedback and my outcome statistics.
  3. Identify an introductory spiel to give clients for the ORS and SRS.
  4. Practice the intro spiels until I was comfortable with them.
  5. Use client feedback from the ORS and SRS to inform my learning objectives.

I have had numerous outcome goals (learning objectives) in my Deliberate Practice journey so far, and each of them have contained process steps like the example above. Below I’ll elaborate on successive refinement to lay out how my process steps would evolve from where they started over time.

A Coach

As human beings, we are notoriously not very good at being able to self-assess our weak spots, as our own biases and self-protective tendencies can get in the way. What can help work around this, is to have someone other than ourselves, who is an expert in the area we want to improve in and can therefore guide you in tackling your weaknesses. In Deliberate Practice this person is called a ‘coach’.

Coaches can be found in every performance domain, such as music and sports. Coaches help us not only see what we cannot about ourselves but can help us come up with strategies that we may never have considered on our own. A coach can observe from the outside, with a vantage point to guide us around the roadblocks we are blind to. When we apply such coaching to therapists, a coach will focus on the factors related to the therapist, not the client. A coach will focus on applying core fundamentals and principles, instead of encouraging the mastering of a specific technique.

I had a fantastic coach, Nathan. He helped me identify and keep in contact with my learning edge, gave gentle correction without being critical, created a safe environment for me to be vulnerable, encouraged me to find my own style and modelled by being open to feedback himself. I can’t overstate how game-changing these approaches were for me. I felt a sense of adrenaline from growth that I had never felt before in other forms of professional development, I think because the coaching allowed me to experience growth in my weak spots in real time.

Coaching sessions would start with me identifying a desired behaviour I wanted to generate in a therapy session or a client scenario I wanted to improve in. After choosing a target, Nathan would give me space to practice my desired behaviour through a form of role-playing. He would offer guiding principles and feedback that would help me sharpen and focus my desired behaviour. Once I was happy with what I had created, he would then guide me through practicing the desired behaviour multiple times to help it consolidate and sink in. Then, in the final stages of the coaching session, Nathan would guide me in formulating a plan to practice my desired behaviour until we met again.

The coaching I received was so effective that I eventually built up enough confidence to continue this portion of my deliberate practice journey without any formal coaching, as I have decided to trust myself and what I had learnt. I know this is a risky proposition, but I have watched my outcome statistics continue to gradually improve since I finished with Nathan about six months ago. I also know that I can return to coaching if my outcome statistics ever start to stagnate.

Feedback

We all know feedback is important. Those that are open to the feedback of others tend to improve more effectively than those that ignore it. However, as Scott Miller and his co-authors proposed, it also must be the ‘right kind’ of feedback if it is to help one increase their ability. There are certain characteristics of feedback that are more likely it to be beneficial, they write:

“Feedback is more likely to be effective when it is timely, immediate, continuous, individualized, focused on specific goals, includes a plan of action, task versus person oriented, designed for remediating deficits or reducing given behaviours versus reinforcing or enhancing existing strengths, and delivered by a trustworthy and respected authority. Similar findings have been reported in psychotherapy research. As is introduced in Chapter 7, studies of routine outcome monitoring—soliciting feedback from clients on an ongoing and formal basis—have shown it decreases dropout and improves outcomes”.

Good feedback helps us see into our blind spots and sets the path to tackling where we are weakest. One of the trickiest elements to gaining feedback is opening to it in the first place. It’s easy to feel turned away at the prospect of exposing ourselves to vulnerability or by the idea that clients will see us as lacking competence. However, the effect of eliciting feedback is more often a feeling of empowerment, for both you and the client. It helps us feel more capable of strengthening ourselves, can become a fantastic tool for modelling an adaptive response to growth and for clients to feel a sense of agency in designing their therapy. Before, I felt an urge to avoid discussing why a client’s session rating scores had dropped, whereas now I feel compelled to see these occurrences as an opportunity for improvement that can benefit both me and the client. The benefits of good feedback far outweigh the costs.

Successive Refinement

Repetition alone does not equal improvement—that’s the core premise of successive refinement. For successive refinement to happen, the three other components of Deliberate Practice need to combine. Successive refinement may sound obvious, but a key to Deliberate Practice is to not take it for granted. We must consistently observe whether our efforts are working, to inform if we need to try something different, even if just making subtle behavioural changes.

The urge to disengage from these efforts and stay put in our comfort zone is a natural urge that doesn’t go away. If you’re finding yourself unwilling to make an intended change, you may be expecting too much of yourself. In that case it’s ok to ask yourself what the roadblocks are or to reduce the size of your desired behaviour. Being psychologically and mentally flexible; allowing yourself to take smaller steps when you’re overwhelmed and to go bigger when you have the energy to do so, I believe, is the beating heart of sustaining growth. It’s when we feel like we can’t be flexible, or we don’t allow ourselves to be, that will cause growth to perish.

Despite the fact the Halloween was not so long ago, I’m not ending on such a dark note. I’d much prefer to end with a message of hope. Deliberate Practice is hard—no bones about it. This is because growth is hard. I know that it’s possible to keep trudging onward through the winter storm of vulnerability and fear that tells us to turn back for the safety and warmth of our comfort zone.

I have been walking through this storm with Deliberate Practice for almost two years now. I strongly believe that to change, I had to dig deep. It’s been frustrating, uncomfortable and at times exhausting. While I take pride in the fact that my outcome statistics have improved, it’s the sense of self-acceptance and belief I now feel, that makes it all worth it. To know that I can now muster the courage to face my fears, and that with time the changes will come if I stick to my system. The strength of perseverance this journey has given me is something I will always treasure.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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