ArticlePDF Available

The Role of Deliberate Practice in the Development of Highly Effective Psychotherapists

Authors:
  • International Center for Clinical Excellence; Henry Street Centre (Western Australia)
  • International Center for Clinical Excellence
  • Colorado Center for Clinical Excellence

Abstract and Figures

Little empirical research exists about highly effective psychotherapists, and none about the factors that mediate the acquisition and maintenance of superior performance skills (e.g., Ericsson, 1996, 2006; Ericsson, Krampe, & Tesch-Romer, 1993). In the full sample, a 3-level multilevel modeling (Level 1: clients; Level 2: therapists; Level 3: organization types) of practitioner outcomes was used to examine the contribution of the therapist to treatment effectiveness. Consistent with prior research, in the full sample (n = 69 therapists; n = 4,580 clients) it was found that therapist effects explained 5.1% of the variance in outcome, after adjusting for initial severity. Therapist gender, caseload, and age were not found to be significant predictors. In a subsample of therapists, the relationship between outcome and therapist demographic variables, professional development activities, and work practices was analyzed (n = 17 therapists, n = 1,632 clients). Therapist characteristics (e.g., years of experience, gender, age, profession, highest qualification, caseload, degree of theoretical integration) did not significantly predict client-reported outcomes. Consistent with the literature on expertise and expert performance, the amount of time spent targeted at improving therapeutic skills was a significant predictor of client outcomes. Further, highly effective therapists indicated requiring more effort in reviewing therapy recordings alone than did the rest of the cohort. Caveats and implications for clinical practice, continuing professional development, and training are discussed. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
Content may be subject to copyright.
A preview of the PDF is not available
... Surprisingly, this does not generally seem to be the case for psychotherapists (Goldberg, Rousmaniere, Miller, Whipple, Nielsen, Hoyt & Wampold, 2016). For some reason, they do not appear to improve in terms of efficiency as time goes by -at least not unless they deliberately attempt to improve, for instance by applying systematic effect monitoring (Chow, Miller, Seidel, Kane, Thornton & Andrews, 2015). Some researchers have found that new psychotherapists display a significantly larger standard deviation compared to more experienced psychologists (Hougaard, 2019). ...
... The literature on expertise and expert performance shows that the amount of time spent specifically targeted at improving therapeutic skills is a significant predictor of client outcomes. Further, being a highly effective therapist requires more effort in reviewing therapy recordings alone (Chow, Miller, Seidel, Kane, Thornton & Andrews, 2015). Hence, a way forward for the psychologists in the Center for Quality of Life could be to focus more on improving effects in supervision sessions or alternatively to have group sessions for the psychologists specifically aimed at improving the effect of their psychotherapeutic efforts. ...
Conference Paper
Full-text available
The current longitudinal study investigates the effects of practice on the outcome of psychotherapy for elderly persons. It follows 4 psychologists for the first 143 clients of their professional lives to explore whether increased practice leads to better outcomes for their clients. The participating psychologists routinely monitor the effect of their work with different psychometric outcome measures and receive weekly supervision. The clients consist of 267 primarily elderly persons above the age of 65, who receive psychotherapy to improve their overall well-being. Well-being is measured with the WHO-5 Well-being Index. Regression analyses, with outcome improvement functioning as the dependent variable, were calculated as pre-treatment scores subtracted from post-treatment scores. There was no significant effect of the chronological rank of clients on the overall effect of treatment. Hence, no practice effects were found in terms of increased well-being. Variations in effect did not change either. However, the psychologists used significantly fewer sessions to achieve the same effect as time went on, as there was a significant effect of the chronological rank of clients on the number of sessions. Though significant, the size of this effect was small. Results are discussed in the light of the literature on expertise and expert performance, and possible ways to increase the effect in psychotherapy with elderly persons are suggested.
... The ability and the willingness to take part in deliberate practice of psychotherapy as a means to improve expertise has been mentioned as an additional weapon in the arsenal of effective therapists. Deliberate practice can take multiple forms such as participation in workshops, exercises, seeking supervision in multiple formats, and reading (Chow et al., 2015;Hill & Castonguay, 2017;Rousmaniere, 2017;Wampold et al., 2017). ...
Chapter
Full-text available
Counseling and psychotherapy training in countries around the world have been imbued with theories and models developed in the Euro-American perspective. This chapter looks at the role of the therapist, therapist competence, and development as integral to therapy process and outcomes, from the perspective of developing countries in Asia. Training and education for counselors and therapists with reference to models of training, entry points, content of training programs, supervision, personal therapy, and deliberate practice have been examined. The lack of regulation and licensing and their impact on the professionalization of the field have been commented on. Encouraging open communication and dialogue across countries can help facilitate a culturally grounded approach to the training and supervision of therapists. Creating national bodies with the mandate of examining pedagogy and curriculum development in counseling training institutes across Asia may further help to establish common goals as well as enable sharing unique sociocultural specific practices and insights. Recommendations have been laid out for meeting the challenges to global mental health resulting from the sociopolitical changes of the twenty-first century. The need to develop multicultural sensitivity and locally relevant codes of ethical standards is paramount.
... Las diferencias entre profesionales explican más resultados que el modelo de tratamiento (Okiishi et al., 2003, Baldwin e Imel, 2013. Incluso se ha escrito que las variables demográficas del terapeuta (edad, genero, cualificación, profesión, años de experiencia (Chow, 2014), el tipo y cantidad de entrenamiento y la orientación teórica (Okiishi et al., 2003) no predicen resultados. ...
Article
Full-text available
Resumen En los últimos 20 años el debate entre los Factores Comunes y los Tratamientos con Apoyo Empírico (TAE) ha sido uno de los más relevantes para la práctica clínica. El enfoque TAE con origen en la investigación sobre fármacos (Medicina Basada en la Evidencia), promueve el uso de técnicas específicas y protocolos de tratamiento. Los Factores Comunes, por el contrario, señalan la validez de múltiples psicoterapias, la cual estaría basada en dimensiones comunes a todo tratamiento, y no tanto en el uso de técnicas específicas. El proceder médico y farmacológico encaja razonablemente dentro de un marco de acción instrumental, en el que el acto sanitario se ejerce a fin de modificar ciertos parámetros fisiológico-anatómicos. Pero la psicoterapia es mejor entendida como una relación entre sujetos, ya que el paciente, el objeto de la acción terapéutica, es también un sujeto, y no un parámetro. Por ello los protocolos como secuencias prefijadas de acciones del terapeuta (ideal para la investigación por su replicabilidad y pertinencia metodológica), implican una suerte de eliminación del sujeto. Cabe entonces entender el sentido de los protocolos de tratamiento como marcos de sentido, de problemas pertinentes, de soluciones indicadas. Como una forma de conocimiento flexible sobre el problema y su funcionamiento y manejo. Abstract Psychotherapy as a relationship between subjects and the role of treatment protocols The EST approach is an extension to psychotherapy of the methodology used in drug research (Evidence-Based Medicine) and promotes the use of specific techniques and treatment protocols. The Common Factors indicate the validity of multiple psychotherapies, which would be based on dimensions common to all treatment, and not so much on the use of specific techniques. The medical and pharmacological procedure fits reasonably within a framework of instrumental action, in which the medical act is exercised in order to modify certain biologicals parameters. But psychotherapy is better understood as a relationship between subjects, since the patient, is not a parameter. For this reason, protocols as predetermined sequences of actions by the therapist, could imply a kind of elimination of the subject. It is therefore necessary to understand the meaning of the treatment protocols not as a script of action but as frameworks of meaning, of pertinent problems, of indicated solutions. As a form of flexible knowledge about the problem and its functioning and management.
... We argue that competence/integrity-outcome associations increase through the integration of (1) detailed awareness of psychological treatment protocols, (2) routine outcome monitoring, (3) generation of regular and routine self and supervisor ACI ratings using valid and reliable measures, (4) provision of corrective and specific supervisor feedback and (5) deliberate and sustained practice of micro-skills. Research in the fields of clinical supervision/training (Bradley & Becker, 2021;Milne et al., 2011) and deliberate practice (Chow et al., 2015) indicate that the above methods optimise learning transfer and lead to measurable improvements in clinical skills and thus therapist competence. The present findings lend support to clinical guidelines that require practicing therapists to formally monitor and demonstrate competence and/or integrity as part of their accreditation and employment requirements (e.g., National Collaborating Centre for Mental Health, 2020). ...
Article
Objective: To provide a comprehensive assessment of the association between psychological treatment adherence/competence/integrity (ACI) and clinical outcomes. Method: The review protocol was preregistered (CRD42020193889). Studies that assessed ACI-outcome relationships for adult psychotherapy were searched across three databases (Scopus, PsycINFO, MEDLINE). Random effects meta-analyses were conducted on adherence-outcome, competence-outcome, and integrity-outcome relationships. Separate analyses were performed for studies with hierarchical (i.e., patients nested within therapist) versus nonhierarchical study designs. Moderator analyses were performed according to predefined clinical and methodological features. GRADE assessments rated the quality of each meta-analytic comparison. Results: The review identified 62 studies suitable for inclusion (45 adherence-outcome, 39 competence-outcome, and seven integrity-outcome effect sizes; N = 8,210 across all analyses). No significant adherence-outcome association was found. A small significant positive association was found only in nonhierarchical studies between competence and outcome, r = 0.17, 95% CI [0.07-0.26], p < .001, ∼d = .34, GRADE = moderate. Small-to-moderate significant positive associations between integrity and outcome were found for both nonhierarchical, r = 0.15, 95% CI [0.06-0.23], p < .001, ∼d = .30, GRADE = high, and hierarchical study designs, r = 0.23, 95% CI [0.01, 0.43], p < .044, ∼d = .47, GRADE = low. Diagnosis, treatment modality and year of publication significantly moderated the strength of ACI-outcome correlations. Conclusions: Competence and integrity are significantly associated with clinical outcome, with a magnitude comparable to wider common factors. Further research is required to study these process-outcome associations with greater precision in routine-care settings and to understand the role of moderating variables. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... DP research spans a wide range of topics (e.g., music, sports, chess), with a few recent studies applying DP to psychotherapy. For example, Chow et al. (2015) found that DP significantly improved psychotherapists' therapeutic skills, which, in turn, predicted better outcomes for their clients. In another study, Westra et al. (2020) found that DP increased psychotherapists' motivational interviewing strategies to address client resistance, which resulted in client reports of greater psychotherapist empathy. ...
Article
Consultation is a key competency area for school psychologists, though much is unknown about how school psychologists develop the competency to consult. Deliberate practice (DP) is a promising approach to enhance use of communication skills, thereby supporting consultation competence. DP training included multiple opportunities for video-recorded consultation practice in response to a consultee's request for assistance, self-reflection on skill application, and corrective supervisory feedback. In this randomized controlled trial, 109 school psychology graduate students across 45 training programs received either consultation training as usual delivered through their first consultation course (control group; n = 61) or a supplemental DP training intervention in addition to their first consultation course (treatment group; n = 48). Students who completed the DP training significantly increased their use of communication skills during a simulated practice opportunity, while the control group participants did not. Students in the DP condition also reported significantly greater self-efficacy than students in the control group, although students in both groups reported significantly greater self-efficacy over time. DP participants also reported high levels of training satisfaction. Implications of these findings for the design and delivery of consultation training and supervision are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... Так, базовые помогающие навыки содержат поведенческие описания каждого компонента, которые могут применяться даже неопытными консультантами. Наконец, формулирование пунктов опросника согласуется с аналогичными формулировками в других концепциях самоэффективности (Chow et al., 2015;Larson, Daniels, 1998) и отражает содержание поведенческих и когнитивных навыков, что обеспечивает конструктную валидность инструмента. ...
Article
В литературе представлены данные о связи самоэффективности психолога-консультанта (психотерапевта) с его профессиональной и образовательной успешностью. При использовании имеющихся шкал оценки самоэффективности возникают проблемы, связанные с самооценкой навыков по решению консультативных задач разного уровня сложности специалистами разного уровня подготовки. Отсутствует русскоязычный инструмент оценки самоэффективности психолога-консультанта (психотерапевта). Авторы разработали русскоязычный инструмент по измерению самоэффективности в трех областях деятельности психолога-консультанта (психотерапевта): навыки предпрактической подготовки, навыки по управлению сессией, навыки по управлению сложными клиническими ситуациями. Исследование включало следующие этапы: 1) перевод и адаптацию опросника Counselor Activity Self-Efficacy Scales (CASES — Шкала самоэффективности консультанта); 2) проверку надежности-согласованности и структуры шкал в переведенном опроснике при помощи методов математической статистики; 3) проверку валидности при помощи опросника эмоционального интеллекта Д.В. Люсина, опросника эмпатии Дэвиса в адаптации Т.Д. Ка­ря­гиной, Н.В. Кухтовой и шкалы позитивного и негативного аффекта (ШПАНА) в адаптации Е.Н. Осина. Выборку исследования составили 412 практикующих психотерапевтов и психологов-консультантов. Получен­ные результаты сопоставимы с данными по оригинальной версии опросника CASES и позволяют говорить о конструктной валидности русскоязычной Шкалы самоэффективности. Разработанный опросник может быть использован для оценки самоэффективности русскоязычных психологов-консультантов (психотерапевтов). Полученный опросник позволяет решать следующие практические и теоретические задачи: мониторинг естественного прогресса в консультировании обучающихся, изучение факторов, способствующих повышению самоэффективности психологов-консультантов (психотерапевтов), исследование степени варьирования оценок самоэффективности в зависимости от конкретных клиентских случаев.
... Second, this study contributes to the counseling profession by disrupting current practice (Tadajewski & Hewer, 2011). Research has also found that counselors do not improve their effectiveness through practical cumulative experience over their career (Chow et al., 2015) or understand why specific counselors can create and sustain a stronger therapeutic alliance than can their colleagues. The findings of this research could enable counselors and counselor educators to gain insight into this key practice dynamic and develop strategies to improve their therapeutic bond and efficacy (Newhill et al., 2000). ...
Preprint
Full-text available
This study was designed to further understand rupture events that counselors encounter during a counseling session that ultimately impact the quality of the therapeutic alliance. We employed a cross-sectional analysis of a linguistic corpus created from mock counseling transcripts embedded in a website administered by a peer-reviewed expert in the psychology field and three video recorded sessions of Carl Rodgers, Fritz Pearls, and Albert Ellis. The content of the corpuses was analyzed using Linguistic Inquiry and Word Count software. The results showed a significant difference between she/he words, or third-person singular pronouns, and certainty words when comparing withdrawal and mixed rupture corpuses with a confrontation rupture corpus. In addition, we found a significant differences between positive emotion words and discrepancy words when comparing a rupture-infused psychotherapy corpus to a general psychotherapy corpus. Several implications for counseling and research are provided in response to these findings. Keywords: corpus linguistics, therapeutic alliance, alliance rupture, rupture event, LIWC
... THERAPIST PERSPECTIVES ON DEVELOPMENT (Youn et al., 2015). We chose a cutoff score of 25%, consistent with past research, because we were interested in the clinicians whose clients were most likely to report improvement (see Chow et al., 2015). Clinic leaders were not required to produce evidence of a nominee's performance and only one participant could be nominated by each site. ...
Article
Scholars note that therapist performance is one of many factors that contribute to client treatment outcomes. Given that the performance of therapists matters, researchers have identified several methods and models for improving therapist effectiveness. However, scholars have yet to explore highly effective therapists' perspectives on their motivation to develop, the methods they use, and the impact of their efforts to develop. The present study used a consensual qualitative research (Hill & Knox, 2021) approach to explore dynamics underlying therapist development of expertise. Semistructured interviews were conducted with 12 therapists whose outcome data placed them in the top 25% of clinicians of their respective clinics, according to their supervisors. The researchers reached consensus at each stage of analysis as they organized data into domains, core ideas, and cross-analysis. Domains and corresponding subdomains were: (a) struggle with personal, external, and response to barriers subdomains, (b) therapist characteristics with striving, presence, skills, and values subdomains, and (c) development with early career, formal, feedback, relational, personal/identity subdomains. Implications for practice and areas for future research are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Article
In this mixed-methods study, we analyzed data from 351 couple therapists who completed our Therapists’ Experiences Treating Infidelity (TETI) survey. The present survey is a follow-up of previous iterations that examined therapists’ attitudes toward infi- delity and affair recovery treatment. Our TETI survey provided additional questions pertaining to therapists’ personal history with affairs and perceptions on current research and training standards. Results showed that various therapist and couple fac- tors serve to impede affair recovery treatment. Additionally, this survey revealed several similarities in therapists’ attitudes from prior surveys, despite decades having passed between when the present survey and previous versions. In this article, we (a) out- line findings from this mixed-methods survey, (b) discuss implications for the field, and (c) offer directions for future research.
Article
Full-text available
Assessment in clinical psychology typically relies on global retrospective self-reports collected at research or clinic visits, which are limited by recall bias and are not well suited to address how behavior changes over time and across contexts. Ecological momentary assessment (EMA) involves repeated sampling of subjects' current behaviors and experiences in real time, in subjects' natural environments. EMA aims to minimize recall bias, maximize ecological validity, and allow study of microprocesses that influence behavior in real-world contexts. EMA studies assess particular events in subjects' lives or assess subjects at periodic intervals, often by random time sampling, using technologies ranging from written diaries and telephones to electronic diaries and physiological sensors. We discuss the rationale for EMA, EMA designs, methodological and practical issues, and comparisons of EMA and recall data. EMA holds unique promise to advance the science and practice of clinical psychology by shedding light on the dynamics of behavior in real-world settings.
Article
The theoretical framework presented in this article explains expert performance as the end result of individuals' prolonged efforts to improve performance while negotiating motivational and external constraints. In most domains of expertise, individuals begin in their childhood a regimen of effortful activities (deliberate practice) designed to optimize improvement. Individual differences, even among elite performers, are closely related to assessed amounts of deliberate practice. Many characteristics once believed to reflect innate talent are actually the result of intense practice extended for a minimum of 10 years. Analysis of expert performance provides unique evidence on the potential and limits of extreme environmental adaptation and learning.
Article
As one of the great inventions of the last half of the 20th century, counseling offers great hope and promise. Yet for counseling practitioners, within this hope and promise, there is confusion about how to help and what constitutes mastery and expertise. It is like being in a fog and searching for mastery. And it matters because the counselor's contribution to counseling outcome is significant. Factors in counselor mastery and expertise are explored.
Article
• This study examined the relatively unexplored contribution of the therapist's performance in determining outcomes of treatment. Nine therapists were studied: three performed supportive-expressive psychotherapy; three, cognitive-behavioral psychotherapy; and three, drug counseling. Profound differences were discovered in the therapists' success with the patients in their case loads. Four potential determinants of these differences were explored: (1) patient factors; (2) therapist factors; (3) patient-therapist relationship factors; and (4) therapy factors. Results showed that (1) patient characteristics within each case load (after random assignments) were similar and disclosed no differences that would have explained the differences in success; (2) therapist's personal qualities were correlated with outcomes but not significantly (mean r=.32); (3) an early-in-treatment measure of the patienttherapist relationship, the Helping Alliance Questionnaire, yielded significant correlations with outcomes (mean r=.65); (4) among the therapy techniques, "purity" provided significant correlations with outcomes (mean r=.44), both across therapists and within each therapist's case load. The three therapist-related factors were moderately associated with each other.
Article
A General ModelAttributing Structure to Var(y)Estimating Fixed Effects for V KnownEstimating Fixed Effects for V UnknownPredicting Random Effects for V KnownPredicting Random Effects for V UnknownANOVA Estimation of Variance ComponentsMaximum Likelihood (ML) EstimationRestricted Maximum Likelihood (REML)ML or REML?Other Methods for Estimating VariancesAppendixExercises