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Couns Psychother Res. 2024;00:1–12.
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1wileyonlinelibrary.com/journal/capr
Received: 5 November 2023
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Revised: 6 Februa ry 2024
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Accepted: 8 February 2024
DOI: 10.1002 /capr.12746
ORIGINAL ARTICLE
‘Don't just magically assume you're going to get better as
a therapist as time goes on’: An exploration of the use of
deliberate practice
Daryl Mahon
© 2024 British Asso ciation for Counselling and Psychother apy.
Outcomes Matte r, Ireland
Correspondence
Daryl Mahon, Outcomes Matte r, Wicklow,
Ireland.
Email: darylmahon@gmail.com
Abstract
Purpose: Deliberate practice (DP) is an emerging concept in counselling and psycho-
therapy research that can be used to effectively help practitioners develop a host of
therapy skills and processes. However, to date, no studies have examined its use in
naturalistic settings with professionally qualified practitioners.
Methods: A qualitative descriptive approach using content analysis was employed
with a purposive sample of international practitioners who were using DP in natural-
istic settings. The sample consisted of therapists (N = 6) from five different countries,
identifying as male (N = 5) and female (N = 1).
Results: Six categories were developed from qualitative interviews: (1) motivation
for engaging in DP; (2) the impact of definition and operationalisation; (3) what
to practice; (4) how to practice DP; (5) use of supports to develop DP; and (6)
the emotional impact of DP. Deliberate practice is still in its infancy, and its defi-
nition may not translate into psychotherapy without modification. Participants
described using DP to develop a host of psychotherapy skills and processes, and
found support structures such as supervision and peers as helpful in the DP pro-
cess. However, DP was also described as challenging to practice and it can cause
those engaging in it to feel vulnerable and distressed. Implications are discussed for
practice and future research.
Conclusion: Deliberate practice is an emerging method used by practitioners to im-
prove their skill acquisition. However, a lack of consensus on its key features may
limit the extent of its dissemination and utility to practitioners in naturalistic settings.
Further research should seek to provide a definition of DP more consistent with the
practice of psychotherapy, and how to operationalise DP using methods that are in-
clusive for all practitioners whilst acknowledging the potential impact it can have on
their sense of self.
KEYWORDS
continuous professional development, counselling training, deliberate practice, psychotherapy
training, therapist competency, therapist development
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1 | INTRODUCTIO N
Training to become a professional therapist is a big commitment,
marked by academic attainment, personal development through
personal therapy or group processes, and reflective practice
through the use of professional supervision (Carr, 2007; Knox &
Hill, 2021). Post- education, therapists engage in lifelong and on-
going continuous professional development, with didac tic learn-
ing as one of the main pedagogical approaches used in workshop
settings (Rousmaniere et al., 2 016). It is suggested that this range
of activities help prepare therapists to work safely and ef fec-
tively with therapy clients across their careers. However, there is
scant evidence of the effectiveness of these training approaches
(Orlinsk y et al., 2005; Rousmaniere et al., 2016). Additionally,
there is a paucity of contemporary research regarding how these
com pete ncie s are taught during tr ai ni ng , as mo st research is da te d
(Knox & Hill, 2021). Indeed, there is no agreement on what the
optimal type or duration of psychotherapy training should be,
with lots of heterogeneity in the education provided (Callahan
& Watkins, 2018; Knox & Hill, 2021; Lambert, 2010; Rønnestad
& Ladany, 2006). Recent international comparative research
(Orlinsk y et al., 2023), while also noting the di ver sit y in educatio n,
does demonstrate some commonalities across training providers
in relationship- based practice, experiential learning, supervision
and case discussion processes.
Psychotherapists are often mandated through regulatory re-
quirements to engage in continuous professional development, find-
ing it beneficial and enjoyable (Neimeyer et al., 2009). Despite this,
Herschell et al. (2010, p. 448) note that ‘studies evaluating utility
of reading, self- directed training, and workshops have documented
that these methods do not routinely produce positive outcomes’. As
such, Tracey et al. (2014) suggest that the field of psychotherapy is
without expertise. In the light of this research, moving beyond the
treatment approach and some of the traditional methods used for
therapist development and exploring other variables associated with
expertise is necessar y.
2 | EXPERTISE
The trajector y of therapist development is marked by two phases:
initial formal training and continuous professional development
training (Knox & Hill, 2021). However, what it means to have exper-
tise in psychotherapy is challenging the way we view and conceptu-
alise the training and practice of the profession (Brown et al., 2015;
Tracey et al., 20 14; Wampold et al., 2 019).
It is argued that expertise should include an increase to some
extent in client outcomes due to training and related activities, such
as monitoring outcomes (Brown et al., 2015; Tracey et al., 2014).
These ideas of what expertise should look like have implications
when considered in the context of a longitudinal study by Goldberg,
Rousmaniere, et al. (2016) who demonstrated that practitioners'
outcomes may diminish slightly over time.
Other research informs us that years of practicing and level
of qualification are not predictive of psychotherapy outcomes
(Clement, 2008; Germer et al., 2022; Wampold & Brown, 2005).
Indeed, therapists routinely overestimate their effectiveness
and therapy outcomes (Chow et al., 2015; Longley et al., 2023;
Macdonald & Mellor- Clark, 2015; Walfish et al., 2012). Thus, the
question arises as to what psychotherapy variables support better
than average performance, and research on therapist effects is one
possible avenue to explore.
3 | INDIVIDUAL THERAPIST EFFECTS
Research continues to show that the differences bet ween individual
therapists are very large (Wampold & Imel, 2015); this is referred
to as therapist effects (Johns et al., 2019; Lutz & Barkham, 2015;
Mahon et al., 2023; Wampold & Brown, 2005). Therapist effects are
the differences found between therapists after controlling for other
variables, such as the technique/method used (Lutz & Barkham,
2015). In a study with almost 900 therapist s and 150,000 clients,
Mahon et al. (2023) demonstrated that therapist effects accounted
for 5% of the variance in outcome. In that research, client s seen by
therapists in the top quar tile were, on average likely to benefit twice
as much from therapy when compared to those seen by therapists
in the bottom quartile. Therapist effects operate across all the main
evidence- based relationship variables and psychotherapy methods.
In fact, those who demonstrate enhanced facilitative and interper-
sonal skills may tend to have better outcomes (Anderson et al., 2009;
Heinonen & Nissen- Lie, 2020; Wampold & Imel, 2021).
Learning to leverage these variables based on the individual
therapist need would seem to be an effective method to improve
therapist effectiveness, and emerging research on deliberate
practice (DP) with a focus on individualisation may be one way
to achieve this and improve therapist effectiveness (Chow et al.,
Implications for Practice and Policy
• Deliberate practice is an emerging concept used by
therapists to improve their acquisition of therapeutic
skills, processes and competencies.
• Engaging in deliberate practice is positioned as often
challenging and time- consuming, yet beneficial. Where
therapists are engaging in this developmental learning
method, they should seek out the support of supervi-
sors or peers who understand it s application.
• Based on the findings of this study, procedural learning,
behavioural repetition and feedback are key features
that can be applied to a host of skills and processes,
using a variety of learning methods.
• Institutes who provide education to therapist should
consider the policy implications of these findings.
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2015; Mahon, 2023; Miller, Chow, et al., 2020; Miller, Hubble, &
Chow, 2020; Rousmaniere et al., 2016; Wampold et al., 2019).
4 | DELIBERATE PRACTICE
Deliberate practice is a method used by individuals in diverse areas
of practice, from sports to music and chess. Anders Ericsson (1947–
2020), a social psychologist, was among the first to discuss DP as a
way to develop expertise and superior performance (Ericsson, 2008,
2018). Ericsson (2020) distinguished DP from structured practice
and outlined the elements he believed should be present in practice:
(1) tasks with clearly defined goals, (2) performance completed only
by the participant, (3) immediate informative and actionable feed-
back allowing adjustment, (4) repetition of the task and (5) practice
based on individualised feedback by an expert. Medical education
and training has embraced and noted the value of DP (McGaghie
et al., 2010, 2021), which is often achieved through simulation- based
learning.
Deliberate practice has been introduced as a method of training
psychotherapists to improve skill acquisition and outcomes (Chow
et al., 2015; Goldberg, Babins- Wagner, et al., 2016; Mahon, 2023;
Olsson et al., 2024). DP involves several activities that are generally
not part of therapist training and ongoing development. For instance,
the setting of learning goals is based on competencies just beyond
your ability; repetitive rehearsal and refinement of specific skills;
receiving feedback from a more knowledgeable other (MKO); and,
where possible, observing and assessing your progress through re-
cordings (Mahon, 2023; Miller, Hubble, & Chow, 2020; Rousmaniere
et al., 2016). This would seem to be consistent in operationalisation
with Ericsson & Pool (2016 , p. 157), who suggested that the distinc-
tive feature of DP ‘is that you tr y to do something you cannot do
– that takes you out of your comfort zone – and that you practice it
over and over again focusing on exactly how you are doing it, where
you are falling shor t, and how you can get better’.
Miller, Chow, et al. (2020) and Miller, Hubble, and Chow (2020)
have differentiated DP from other reflective methods (e.g.,
Kolb, 1984), wh i le Va z and Ro u s man i e re (2021) differentiate DP from
traditional learning in so far as DP focuses on procedural learning,
whereas traditional training may focus more on conceptual learning.
Of course, concep tu al lea rning fo r ps yc hoth er ap is ts is impor tant; at-
tending lectures, reading academic texts, taking notes and watching
simulated therapy sessions, and even practising skills are necessary,
but are not DP. While conceptual learning can occur alongside DP, it
is not a procedural approach that involves the repeated rehearsal of
a specific skill, the identification of deficiencies and direct feedback
from an MKO. Erics son (2008, p. 7) des cribes wh at this typ e of prac-
tice may look like:
‘Analysing a review of laboratory studies of learning and skill
acquisition during the last century, we found that improvement of
performance was uniformly observed when people were given tasks
with well- defined goals, were provided with feedback, and had ample
opportunities for repetition. These deliberate effort s to increase
one's per formance beyond its current level involve problem- solving
and find in g be tter me th ods to perf or m the tas ks. Whe n a pe rson en-
gages in a practice activity (typically designed by teachers) with the
primar y goal of improving some aspect of performance, we called
that activity deliberate prac tice’.
While this type of practice can occur in a training session, it can
equally occur in isolation using video- simulated cases (Mahon, 2023;
Murphy et al., 2020; Rousmaniere et al., 2016). However, the timing
of feedback is essential (McLeod, 2022; Murphy et al., 2020), which
may have implications for solitary DP, which is often considered a
key aspe c t of the ap pro ac h (Mi ll er, Ch ow, et al., 2020; Miller, Hubb le,
& Chow, 2020; Mahon, 2023; Rousmaniere et al., 2016).
The seminal study of DP in psychotherapy was first published by
Chow et al. (2015), who demonstrated that time spent on DP was
a significant predictor of outcomes. Similarly, when supervision is
utilised as part of a DP framework, therapists' overall year- on- year
outcomes are enhanced (Goldberg, Babins- Wagner, et al., 2016).
Since the seminal study based on pre- post outcomes was published,
DP has been used in a variety of control trials, in university settings,
and with trainees during workshops (Anderson et al., 2009; Larsson
et al., 2023; McLeod, 2022; Murphy et al., 2020; Newman et al.,
2022; Perlman et al., 2020; Rosén, 2019; Young et al., 2023). Much
of the research to date has focused on quantitative methods in order
to demonstrate efficacy and effectiveness.
DP has been shown to be more effective in the development of
empathy than traditional workshop methods (Larsson et al., 2023).
Ogles et al. (2023) demonstrated that DP could be used to success-
fully train therapists in ethical situations using simulated case sce-
narios. Newman et al. (2022) provided evidence for the use of DP
for developing micro- skills, while Westra et al. (2021) highlighted
the utility of DP for becoming responsive to resistance. Likewise,
Di Bartolomeo et al. (2021) found that when compared against tra-
ditional methods of training practitioners in the use of motivational
interviewing, those in the DP group elicited less resistance.
Other studies examined DP in randomised controlled trials to
improve various psychotherapy processes and skills (Barrett- Naylor
et al., 2020; Shukla et al., 2021). For example, Perlman et al. (2020)
found that par ticipants in the DP group had higher levels of post-
training therapist skills, such as alliance bond capacity, and alliance
ru pt ure repa ir an d em pat hy. Su mma ri sin g the DP li ter atu re in a sco p-
ing review, Mahon (2023, p. 1) suggests that DP ‘compares more fa-
vourably than usual didactic workshops for skill acquisition across
variables such as techniques, communication skills and interpersonal
and evidence- based relationship factors’.
Assessing the experiences that therapists or supervisors have
had with DP is a little more difficult as there is a relative dearth of
qualitative studies in this area. McLeod (2022) notes that students
in her study used DP beyond the classroom for personal develop-
ment related to becoming a therapist. The students in that study also
found it initially difficult to internalise DP, and when they did, they
often found it stressful to practice DP. Barrett- Naylor et al. (2020)
document that some participants in their study were a little uncom-
fortable with DP role plays.
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Newman et al. (2021) found that online DP exercises mitigated
against participants' feelings of anxiety, stress or pressure when
learning and practising new DP skills in class. Similarly, Rosén
(2019) and Axelsson et al. (2023) found that incorporating self-
compassion into DP training can help therapist s and supervisees
to become more compassionate with themselves while using DP
exercises and while soliciting and receiving feedback. Thus, while
DP is not without its challenges, there are methods that can help
mitigate against distress when engaging in DP. However, there is
little known about how therapists outside clinical trials or studies
experience DP.
5 | CONTEXT
While the previously cited research represents important studies
which have added to the extant literature, there has been no re-
search to date exploring the experiences of practitioners outside
the universit y or control setting. As such, there is a paucity of re-
sea rch on DP as used by practiti oners in rout ine setting s. The pre -
sent study seeks to address this gap in the literature by exploring
qualitatively the experiences established practitioners have had
with DP in naturalistic settings. Findings from this study can help
to ide ntify how DP is bei ng us ed by est ablished profession als, and
this can inform future research agendas and inform the practice
of DP.
6 | STUDY DESIGN
The study is informed by a qualitative descriptive approach which
allows the researcher to explore and frame the findings in the lan-
guage of the participants (Bryman, 2015; Ritchie & Lewis, 2003),
while also maintaining proximity to the surface of the phenomenon.
‘Qualitative research uses a naturalistic approach that seeks to un-
derstand phenomena in context- specific set tings, such as real world
settings where the researcher does not attempt to manipulate the
phenomenon of interest’ (Golafshani, 2003, p. 600). The context-
specific setting in this study relates to the exploration of DP from
the perspectives of the participants involved in its practice. Ethics
approval was provided by the researcher's institute.
6.1 | Data collection
I contacted participants (N = 6) using a purposive sampling approach.
Purposive sampling is a deliberate research method that seeks to
engage participants who have a characteristic of interest in the area
of study (Bryman, 2015). I sent an email to a DP training institute
and asked for it to be sent to members who were involved in DP. In
addition, a call to par ticipate in this study was also made on social
media sites where it was known to me that those with experience
of DP frequented. All participants who took part in this study were
accessed through social media. Once identified, I sent par ticipants
an email outlining the scope of the study, and an informed consent
form detailing confidentiality and how data would be managed. In
addition, an over view of DP was provided in the study information
leaflet. All participants who took part in the study signed informed
consent forms and had an opportunity to ask questions prior to in-
terviews. The sample consists of practitioners with varying degrees
of DP knowledge and skills, from relatively new to DP to experienced
users. Moreover, the sample was made up of five males and one fe-
male from five different countries: Australia, Norway, Sweden, New
Zealand and Ireland.
Participants were invited for an unstructured interview of
45–60 min using an online platform. Data were transcribed ver-
batim for analysis. In qualitative research, interviews are used to
‘unfold the meaning of people's experi ences , opinions , attit udes, be-
haviours’ (Gill et al., 20 08).
Unstructured interviews are ideally placed to examine phenom-
ena when there is not much known about the topic; however, the
researcher needs to be knowledgeable of the topic and have good
interview skills (Bryman, 2015). One question was asked to all par-
ticipant s to open the conversation on DP. Follow- up questions were
then asked based on the interviewees' answers, and the interview
was conducted based on my extensive knowledge of DP. I simply
asked the interviewees:
Q.1 Can you tell me how you came to be interested in deliberate
practice?
6.2 | Data analysis
Once the interviews were completed, they were transcribed ver-
batim, and I read and re- read them to become familiar with the
content (Nowell et al., 2017). Transcripts were uploaded to NVivo
for analysis. Data were analysed using qualit ative content a nalysis
to explore and describe participants' experiences with DP (Drisko
& Maschi, 2015; Kim et al., 2017). During the first phase of anal-
ysis, I used an open coding, line- by- line approach and I derived
codes based on an inductive approach to analysis (Bryman, 2015).
The unit of analysis was words and sentences, which were coded,
and as m ore data wer e anal ys ed , I collapse d these codes into ca te-
gories and subcategories that best describe the data. For example,
code s we re de ve lo ped for sh am e, up se t, di stres s and stre ss . The se
codes were then collapsed into an overarching categor y, namely
the emotional impact of DP.
6.3 | Trustworthiness and reflexive statement
I am a former practising psychotherapist who has a professional in-
terest in DP and psychotherapy process and outcome research. I'm
a lec turer and researcher and have conducted previous research in
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this area. I believe that DsP has the potential as one important el-
ement of counselling and psychotherapy training, and that its use
may extend beyond the classroom and clinical trial settings. As such,
this article should be read with this potential bias in mind. However,
there are various steps that were taken to ensure that the find-
ings and methods used in this study are trustworthy. Throughout
the research process, I documented my internal states with regard
to the study and individual interviews by taking notes to help the
analysis process and for reflexivity purposes (Br yman, 2015; Tobin
& Begley, 2004).
This reflexivit y also helped with defining categories based on
initial codes. For example, during the first phase of becoming famil-
iar with the data through the reading and re- reading of transcript s,
notes were taken to describe my initial thoughts of the emerging
categories and how these were related to each other. As categories
emerged, they were continuously compared with other categories
and the codes were checked to ensure they fit the overarching cat-
egory (Nowell et al., 2017). During the writing- up process, verba-
tim quotes (2–5) were used to support the validity of each category.
Table 1 provides examples of how codes and categories were
developed.
7 | RESULTS
This qualitative descriptive study using qualitative content analysis
sought to investigate established practitioners' experiences of en-
gaging in DP. Results are discussed across six categories: motivation
for DP; the impact of definition and operationalisation; how to prac-
tice; what to practice; use of supports to develop in DP; and the
emotional impact of DP.
7.1 | Motivation for DP
The motivation to engage with DP was discussed by several partici-
pants. While participants spoke, in general, about their enjoyment of
learning, a desire to improve often driven by an ethical imperative to
TABLE 1 Example of codes and categories.
Code Category
‘integrity and ethics’ (DP5).
‘Don't just magically assume you're going to get better as a therapist as time goes on, question yourself and think about
ways of getting bet ter’ (DP 4).
Motivation for DP
‘In first being introduced to DP where like I just heard it how he explained it at least and my initial reaction was like,
I'm already doing that, that's obvious. So I very much just assumed incorrec tly, that I was doing deliberate practice’
(DP2).
‘To practice DP, you know, to watch videos and you respond to videos, you need to do this, you need to do that, some of
that stuff doesn't really appe al to me as much and I'm just how is deliberate prac tice become that?’ (DP3).
‘It's not like prac ticing the guit ar when you're thinking, I played that note a bit wrong… You're think ing, oh, that
incredibly suicidal client dropped out of therapy. What could I have done differently?’ (DP3).
‘because in the early literature DP is presented as a st ruggle, like it's hard, it's painful, it's like you have to need grit ’
(DP4).
‘it's so exclusive that it's really too hard to engage in because of the time consuming methods that are described’ (DP1).
The impact of
definition and
operationalisation
‘And I nominated emotional experiencing… and he sort of s aid to me okay, for this month you're going to systematically
think about emotional experiencing in your sessions. You're going to rate yourself on emotional connection and
you're gonna try and get better at emotional connection’ (DP3).
‘it's about meta communicating that the client is passive, I have learned how to address it but when I used to sit there
with the clients I would out of politeness not bother the client with this, this felt confrontational to me. So that 's one
example of our inner inhibition of an interpersonal skill’ (DP1).
‘immediately from those closed cases and the data that was coming through is that my goal setting with clients wasn't
aligning, like I was get ting fe edback of I don't know where we're going with this?’ (DP2).
What to practice
‘I think they have a function as a part of a DP system but there's not really an opportunity for that individualized direct
feedback…but on the other hand, it's an opportunity to really override the shame components, like it's over writing
the per former. Some people feel it 's easier to play around with different responses in that format’ (DP1).
‘I really star ted to notice that in terms of looking at recordings from some sessions and some feedback from clients as
well, and that's where the next phase of my learning edges star ted to come in’ (DP2).
‘I noticed that when people engage in d yads they are vitalized by the dyads, they are interested, eager, happy engaged…
And I think that's a key difference between solitary work with videos and peer work’ (DP6).
How to prac tice DP
‘supervision, super integral at least in terms of maximizing the DP process’ (DP2).
‘I star ted a peer group so they can really help me point out blind spots, and we met twice every week to do
interchangeably solitary practice and watch our videos together’ (DP6).
Use of supports to
develop in DP
‘I found thinking about the things that I'd hadn't done well, really upsetting’ (DP3).
‘taking the shame out of learning ’ (DP1).
‘when a supervisor said you did that badly I'd find that really upsetting’ (DP3).
The emotional
impact of DP
Abbreviation: DP, deliberate practice.
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provide better therapy to clients and move beyond the status quo
was highlighted. Mastering therapy skills was viewed as an ongoing
process, which, for this participant, is rooted in ‘integrity and eth-
ics’ (DP5). Participants drew on the extant literature, noting that
research on expertise and therapist outcomes demonstrates that
psychotherapists do not necessarily improve with time and experi-
ence, but it was this knowledge and urge to become better and more
proficient that drove some participants: ‘Don't just magically assume
you're going to get better as a therapist as time goes on, question your-
self and think about ways of getting better’.
7. 2 | The impact of definition and
operationalisation
The data to emerge in this category highlight the difficulty in defin-
ing and operationalising DP. While many of the features of DP were
discussed as being used, there were often inconsistencies between
definitions, and some participants described initially believing that
they were already using DP without ever being introduced to it:
In firs t being introduced to DP w here like I just heard i t how he explained
it at least and my initial reaction was like I'm already doing that, that's ob-
vious. So I very much just assumed incorrectly, that I was doing deliberate
practice (DP2). For those participants who were still quite new to DP,
this often led to difficulty in accepting some methods of DP: To p rac tice
DP you know to watch videos and you respond to videos, you need to do
this, you need to do that, some of that stuff doesn't really appeal to me as
much and I'm just how is deliberate practice become that? (DP3).
Once participants began to internalise DP, they spoke about how
the definit ion of DP often made its pr ac tice ver y diff icult , wit h par tici-
pants being unsure where to begin or what to prac tice. This was often
traced back to the initial definition by the originator and some of the
more contemporary definitions in the field applying Ericson's initial
definition to psychotherapy wholesale. This participant describes how
DP in psyc hotherapy may not be like other fie ld s of pr ac ti ce where DP
is used: It's not like practicing the guitar when you're thinking, 'I played
that note a bit wrong'… You're thinking 'Oh, that incredibly suicidal client
dropped out of therapy. What could I have done differently?' (DP3).
This participant describes how the early definition can be very
rigid and make engagement with DP very difficult: because in the
early literature DP is presented as a struggle, like it's hard, it's painful,
it's like you have to need grit (DP4). This level of dif ficulty was experi-
enced as having the potential to both exclude people due to elitism
and put practitioners off due to how overwhelming the methods can
become: it's so exclusive that it's really too hard to engage in because of
the time consuming methods that are described (DP1).
7.3 | What to practice
Pa r t ici p ant s de s cri b ed a ho s t of sk il l s and proce sse s th at th e y eng a ge d
in using DP. Consistent with the various definitions described across
part icipants , two main areas se em ed to develop, an d although the use
of one method of practice did not exclude using the other, there was
often a preference for one of these. Participants identified a range of
interpersonal and intrapersonal skills that they used DP to hone. The
use of techniques and evidence- based relationship variables, such as
empathy, alliance rupture repair, meta- communication, emotional ex-
perience and goal collaboration, were identified as important factors
due to the extant literature supporting their effectiveness:
And I nominated emotional experiencing… and he
sort of said to me 'okay, for this month you're going to
systematically think about emotional experiencing in
your sessions. You're going to rate yourself on emo-
tional connection and you're gonna try and get better
at emotional connec tion'.
(DP3)
Intrapersonal skills were discussed as being important components
of effec tive therapy that could be improved with the use of DP.
Participants describe instances of how deficiencies in their internal
states were negatively impacting their abilit y to engage clients in ef-
fective interventions and were therefore leveraged as areas for DP.
This participant describes how using DP to work on internal states has
helped them to engage in interpersonal processes more effectively: it's
about meta communicating that the client is passive, I have learned how to
address it but when I used to sit there with the clients I would, out of polite-
ness, not bother the client with this, this felt confrontational to me. So that's
one example of our inner inhibition of an interpersonal skill (DP1).
The use of outcome measures to help support DP was discussed
by several participants; some were just beginning this process, while
others used it to assist those clients not making progress or benefit-
ing from treatment. This participant explicates how the use of such a
system offered them a way to identify areas to direct their DP, which
may have other wise gone unnoticed: immediately from those closed
cases and the data that was coming through is that my goal setting with
clients wasn't aligning, like I was getting feedback of 'I don't know where
we're going with this?' (DP2).
7.4 | How to practice DP
A wide range of methods were identified as being effective DP ex-
ercises. While some, such as journaling and note taking, are more
reflective of the conceptual learning method, it was discussed that,
irrespective of the methods used, procedural learning characterised
by behavioural repetition within the zone of proximity was beneficial
when used in conjunction with some types of behavioural stimuli
to respond to, along with feedback from others. Solitary practice
was discussed as being helpful, while also highlighted as a potential
threat to the feedback loop. Recordings of therapy sessions were
experienced as helpful to reflect on with the support of others.
Participants identified a range of methods to use to support the
practice of DP. These methods were often based on trial and error,
and indeed preferences. Video stimuli are often leveraged to use as
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solitary DP exercises across a multitude of evidence- based relation-
ship variables. This participant describes both the benefit and po-
tential drawback of using these solitary exercises: I think they have
a function as a part of a DP system but there's not really an opportunity
for that individualized direct feedback…but on the other hand, it's an op-
portunity to really override the shame components, like it's overwriting
the performer. Some people feel it's easier to play around with different
responses in that format (DP1).
Participants underscored the importance of recording sessions
through video, audio or having a supervisor sit in on a session in
order to gather more individualised DP goals. Recordings were ex-
perienced as integral to the DP process, and clients are ver y open
to the process. Participants described using recordings to iden-
tify their individual growth edge needs and to build on DP: I really
started to notice that in terms of looking at recordings from some ses-
sions and some feedback from clients as well, and that's where the next
phase of my learning edges started to come in (DP2).
Behavioural repetition was described across the dat a as a
key component of DP; exercises were often engaged in based
on video stimuli, in supervision, or by using computer- generated,
text- to- voice stimuli that were self- developed to practice drills.
This method of procedural learning was identified as integral to
DP. However, this par ticipant notes how introducing another per-
son into a dyad to act as the stimuli can be helpful, and for them,
it may offer more benefit than the video stimulus: I noticed that
when people engage in dyads they are vitalized by the dyads, they are
interested, eager, happy engaged… And I think that's a key difference
between solitary work with videos and peer work (DP6).
7.5 | Use of supports to develop in DP
The use of social suppor t was discu ssed as essent ial by part icipants.
The inherent difficulty in starting and maintaining a DP regime was
described as benefiting from the guidance of a supervisor, coaching
and peer support. Supervisors were discussed as being important
to the DP process; they could help participants identify blind spots,
motivate participants to keep going by providing direction and by
helping participants to develop skills during DP: supervision, super
integral at least in terms of maximising the DP process (DP2).
This participant discusses how they formalised a peer support
group in their place of wo rk to help develo p their DP sk ills; the added
presence is experienced as supportive and helpful for pointing out
mistakes that can be developed into DP exercises: I started a peer
group so they can really help me point out blind spots, and we met twice
every week to do interchangeably solitary practice and watch our videos
together (DP6).
7.6 | The emotional impact of DP
Engaging in DP was identified as having an emotional impact on
practitioners, both through its conceptualisation and through its
inherent dif ficulties, but also due to the impact of reflecting on
practices that were experienced as not being ideal. This participant
hig hlights how the ref le ct iv e nature of DP ca n be dif ficult whe n zon-
ing in on deficiencies in skills: I found thinking about the things that I'd
hadn't done well, really upsetting (DP3). Taking people out of the per-
forming zone and into the learning zone was discussed as one way to
normalise making mistakes that can help with ‘taking the shame out
of learning’ (DP1). Another participant spoke about how the supervi-
sion process could also cause distress: when a supervisor said you did
that badly I'd find that really upsetting (DP3).
8 | DISCUSSION
The present study using qualitative interviews (N = 6) with key in-
formants sought to explore the use of DP by professional therapist s.
Findings across six categories identified motivations for engaging
with DP, and that DP is still a relatively new concept that can have
slightly different meanings to practitioners. Moreover, the defini-
tion and operationalisation of DP are difficult to nail down, and its
practice is often discussed as challenging if one is to maintain fidel-
ity to some of the original conceptualisations as applied to therapy.
Participants described a host of methods to engage with DP, in ad-
dition to a range of practices across evidence- based variables and
processes thought to make therapy effective. The role of supervi-
sion and peer suppor t were equally identified as integral, while the
emotio nal impact of en gaging with DP coul d be chal lenging at times.
One of the main findings in this study relates to the inherent dif-
ficulties with defining and operationalising DP. Clements- Hickman
and Reese (2020) note that the original definition of DP will likely
need to be adapted for psychotherapy, and the initial findings in
this study suggest that practitioners have already begun to do this.
McLeod's (2022) DP study with college students had similar findings,
whereby participants used DP to develop skills related to therapy
outside the classroom setting and used a host of supports that were
not supervisors or coaches. As the literature has not yet provided a
concrete method and conceptualisation, there is a risk that DP will
become any t ype of intentional practice, which some of the findings
in this study confirm. Consequently, a definition with steps that are
more aligned with therapy training may be useful and may provide
DP with more utility and easier diss emi nation . However, su ch a defi-
nition should include a range of methods that encourage its uptake.
The extant literature suggests that DP is perceived as effective
and can help build self- ef ficacy (e.g., Newman et al., 2021, 2022),
but DP can also be experienced as challenging (McLeod, 2022).
For example, in the Goldberg, Babins- Wagner, et al. (2016) study,
40% of the therapists left the agency within 4 months of a mea-
surement policy being introduced as they did not want to use feed-
back measures. Similarly, Axelsson et al. (2023), in their study of
psychotherapy students' experiences of supervision based on DP
and feedback- informed treatment, found that focusing on perfor-
mance and feedback could be experienced as stressful and anxiet y-
provoking by therapists. The present study illustrates that therapists
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in naturalistic settings have similar experiences with hearing feed-
back and the emotional impac t of DP.
One method that may be helpful in alleviating some of the dis-
tre ss associated with usi ng DP is self- co mp assion. Rosén (2019) con -
ducted a study of DP and feedback- informed treatment and found
that supervisors modelled how to solicit feedback with the use of
structured alliance measures, which was correlated with partici-
pants' development of self- compassion when seeking feedback from
clients. Likewise, Axelsson et al. (2023) found that self- compassion
was an integral component for therapists engaged in DP. As such,
supervisors and those who engage therapists in DP should consider
how they can incorporate self- compassion into their delivery.
Professional super vision is rated as the second most important
learning and development tool, after direct client practice (Norcross
& Popple, 2017 ), and the professions' signature pedagogy (Watkins,
2018).
Despite this, two studies illustrate that the supervision–client out-
come correlation is between 0% and 1% (Rousmaniere et al., 2016;
Whipple et al., 2020). As such, integrating DP and measurement into
supervision may be one way to improve its effectiveness. Yet, there is
little by way of empirical research exploring how supervision can sup-
po r t the up t ake and ef f ecti v ene s s of DP. Ho wev e r, Rou sma n ier e (2016,
2018) does provide conceptual ideas by describing how a framework
of DP can be applied in supervision focused on suppor ting the super-
visee to identify deficits highlighted through client feedback.
This is reflective of perhaps the only empirical study that found
supervision- informed DP helped improve practitioners' outcomes
(Goldberg, Babins- Wagner, et al., 2016). In the present study, su-
pervision was described as integral, especially in star ting DP and in
identif ying areas to work on, reviewing recordings, and engaging in
procedural learning and behavioural repetition. However, this ap-
proach is more akin to the apprentice model (Ericsson & Pool, 2016),
and if used solely, it may limit other oppor tunities for dispersed
learning through peers and knowledgeable others (McLeod, 2022),
such as peer gro ups in th e pr esent stu dy that wer e found to be help-
ful for DP learning.
The emotional impact of DP is something to consider; partici-
pants in this study identified the potential of DP to cause distress-
ing experiences. Firstly, DP was discussed as having the potential
to cause feelings of shame when a practitioner may not be able to
de mo nst r at e mas ter y in fr ont of pe e rs or sup ervi sor s. Wh ile the pr o-
cess of DP could also cause distress due to reflecting on learning
edges and deficiencies, these findings are similar to McLeod (2022),
whose students also experienced a level of distress when engaging
in DP. Supervisors and those supporting therapists to engage in DP
need to be aware of the potential difficulties therapists face when
engaging in its practice and provide support accordingly, which can
include self- compassion training and development.
Mahon (2023) synthesises the evidence for DP and identifies that
using video stimuli is a helpful method as part of DP training, espe-
cially for skill development with challenging encounters and evidence-
based relationship variables. Although such methods were identified
as helpful in this study and can possibly reduce per former shame,
such exercises as currently delivered tend to lose the feedback loop
to support refinement during procedural learning and repetition.
Thus, without some t ype of coaching or super vision to provide a
feedback loop, the usefulness of these exercises may be diminished
and individualised learning lacking, meaning blind spots could go un-
noticed. However, some of this could be of fset against the benefit of
the solitar y environment which can provide a level of safety to prac-
titioners, meaning they may be less likely to stay in the often shame-
based performing zone and move to a more procedural learning zone
associated with DP (Vaz & Rousmaniere, 2021). Again, self- compassion
would seem to be essential for therapists to practice, to possibly miti-
gate against these issues (Axelsson et al., 2023; Rosén, 2019).
While there is evidence for learning a host of facilitative inter-
personal skills with these video stimuli (e.g., Anderson et al., 2009;
Barrett- Naylor et al., 2020; Perlman et al., 2020; Shukla et al., 2021),
recent research demonstrates that therapists using these methods
often overestimate their ability when developing hope, emotional
expression, warmth and acceptance, and understanding, empathy,
alliance bond capacity and rupture- repair responsiveness (Longley
et al., 2023). A s these variables and others are supported by meta-
analyses as effective therapy components, their acquisition would
seem to be integral (Constantino, Coyne, et al., 2018; Constantino,
Vâslă, et al., 2018; Elliott et al., 2018; Eubanks et al., 2018; Farber
et al., 2018; Flückiger et al., 2018; Gelso et al., 2018; Hayes et al., 2018;
Hill et al., 2018; Kolden et al., 2018; Peluso & Freund, 2018; Tr yon
et al., 2018). In d ee d , th era pis t s in thi s stu dy note d ho w they le ve rag ed
variables such as goal setting, emotional expression and immediacy,
am on g oth ers . As su ch, a cor e par t of DP can be con si der ed to ide nti f y
idiosyncratic skills deficiencies related to such variables.
The emergence of artificial intelligence may be one avenue that
can support DP; recent research (Maur ya, 2023) has demonstrated
that ChatGPT, while not without some limitations, can play the role
of a client quite well. Another possibility may be to use video stimuli
as part of a wider DP regime, in which videos are practised in iso-
lation prior to working directly with the supervisor, or before pro-
fessional development workshops where a more procedural training
based on repetition and feedback can be more closely observed and
provided; this may also help with taking the shame out of learning
and provide therapists with an initial feeling of safet y, as described
in Newman et al.'s (2021) study. Indeed, a recent study of ma-
chine learning has demonstrated that the multicultural orientation
framework can be taught quite effectively using machine learning
(Goldberg et al., 2024), which has implic ations for DP going forward,
especially as technological advances progress.
9 | IMPLICATIONS FOR PRACTICE
Using a DP regime to improve the acquisition of therapy skills and
processes does not mean that other training methods and concep-
tual learning opportunities are discounted. Rather, the philosophy
of DP can be integrated into a lifelong learning process. However,
it is important that DP does not become conceptualised to mean
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any intentional practice in which effort is exerted. In the absence
of a coherent framework for DP in psychotherapy, and based on the
findings of this and other research, DP should be considered a broad
concept that can be applied to any psychotherapy skill, process or
competency across intra- and interpersonal domains. Key to this
method is procedural learning based on behavioural repetition and
fee db ack while attempting a skill or pro cess ju st beyond one's ab ilit y.
Once these key features are met, practitioners can engage in a
variety of methods and exercises to support their DP in solitary prac-
tice, with supervisors, peers or knowledgeable others. Where DP is
being used in supervision or in continuing professional development
workshops, awareness of the difficulties that some therapists may
face is needed. Normalising failure and encouraging therapists to
move out of the performing zone and into a learning zone should be
encouraged, while also helping therapists or supervisees to develop
self- compassion as this may help mitigate against distressing feelings
when engaging in DP.
10 | LIMITATIONS AND FUTURE
RESEARCH
While important information was gleaned in this study, it remains
that it was a small sample based on a purposive qualitative research
design. Therefore, the transferability of the findings into other set-
tings or with those outside this study should be considered care-
fully. Future research will benefit the DP field by seeking to develop
consensus on the definition and operationalisation of the approach,
and from this perspective, a Delphi study may help clarify the key
features. Still, other research can examine DP as practised by those
in naturalistic settings in longitudinal research; this may help us un-
derstand how therapists develop in their DP journey, the amount of
time spent engaging in DP and what barriers and facilitators they
experience, while case study research can provide impor tant infor-
mation regarding how therapists go about implementing DP in natu-
ralistic settings.
Other research can explore whether different DP exercises or
methods produce different results, or whether different practices
provide added benefit based on the therapist's experience level or
stage of DP development. More broadly, DP is still in its infancy
as applied to psychotherapy, and although there is mounting re-
search demonstrating its effectiveness for skill acquisition, there
is no experiential research demonstrating its impac t on client out-
comes; as such, further research is needed in this area. Emerging
technology has the potential to help f acilitate and disseminate DP
into wider practice and further research might examine how such
technology can benefit professionals in naturalistic settings.
11 | CONCLUSION
Deliberate practice as applied to psychotherapy is still very much in
its infancy. As with most emerging concepts, DP still suffers from
inconsistencies in definition, conceptualisation, operationalisation and
application. At the same time, these limitations can make DP more dif-
ficult and challenging for therapists in naturalistic settings. Despite
these understandable drawbacks, participants in this study described
different methods of engaging in DP. However, based on the findings
of this research we ca n tent atively con cl ude th at DP is be in g em br ac ed
by various therapists who are eager to improve their effectiveness;
however, initial conceptualisations of DP can make engagement dif-
ficult and challenging. As such, the findings of the present study sup-
port a wide application of DP across a host of psychotherapy skills,
processes and competencies using procedural learning, behavioural
repe ti tion and feed ba ck from a wide range of so cial supp or ts, in cludi ng
supervisors and peers. This is the first known study of DP in naturalis-
tic se tt ing s; as such, more research is ne eded across various aspe ct s of
this construct using different methodologies and research aims.
CONFLICT OF INTEREST STATEMENT
None.
ORCID
Daryl Mahon https://orcid.org/0000-0002-2519-2155
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AUTHOR BIOGRAPHY
Daryl Mahon is a lecturer and researcher from Wicklow, Ireland.
One of his research interests is psychotherapy processes and
outcomes, in addition to expertise in psychotherapy and the
training of therapists.
How to cite this article: Mahon, D. (2024). ‘Don't just
magically assume you're going to get better as a therapist as
time goes on’: An exploration of the use of deliberate
practice. Counselling and Psychotherapy Research, 00, 1–12.
https://doi.org/10.1002/capr.12746
