What is Deliberate Practice?

In my graduate program, we were able to start our fieldwork experience—and begin seeing actual, live clients—in our second semester. This is true for most MFT programs in California. Once you’ve taken Law and Ethics, off you go!

This absolutely terrified me. After three academic courses and one semester of “Clinical Skills,” in no way did I feel ready to start seeing clients. I was surprised that this was how grad school was set up, honestly. I assumed the whole point of graduate school was that some authority had figured out the best way to train therapists, and if I really applied myself, by the time the program said I could see clients, I would feel ready to see clients.

Turns out, a 4.0 GPA does nothing to make you feel ready to see clients.

Frequent readers of this blog know what I did not know when I started graduate school—the field doesn’t even really know what constitutes the “best therapy,” nor what makes the “best therapists,” let alone know the “best” way to train therapists to become the best therapists doing the best therapy. Mostly, everyone is just throwing spaghetti at the wall and…well…hoping for the best.

But I didn’t know that then, and I wondered what I was doing wrong that I felt so unprepared. In my Clinical Skills class (supposedly where I was supposed to be learning how to actually do therapy), we would occasionally do role-plays of therapeutic “skills.” The problem is, these role-plays that we did all throughout grad school didn’t really prepare me to be a better therapist. We were all so concerned about looking stupid in front of our classmates or getting a bad grade that we were just fixated on getting it “right,” not on actually learning any skill. And it’s not like we would actually practice anything—if we didn’t do it right, our professors would give us feedback, but then we’d just move on to the next student. That didn’t work for me, because I would literally never be able remember that feedback to be able to incorporate it into my work at some future date.

Then, one day, I was on a plane reading a book my friend (and future podcast co-host) had suggested called Deliberate Practice for Psychotherapists, by Tony Rousmaniere. It gave me so much hope! Here was an established authority in the field of psychotherapy, admitting to his own feelings of unpreparedness as a clinician and proposing a new way of training therapists to address the problem!

I desperately wish this had been the approach in my own graduate program, because this would have eased SO MUCH of my anxiety—not to mention my first clients would have received MUCH better therapy!!!

So what is deliberate practice for psychotherapists??

It’s kind of a simple idea, really. Once I describe it, I bet you’re going to think, “um, how is that NOT what they use in EVERY program?” And I couldn’t agree more.

You’ll recognize the approach from other disciplines you may have trained in, such as sports or music. Basically, you break down a meta-skill (like playing basketball, or doing therapy) into its component sub-skills (like shooting free throws, or—in the case of therapy—maybe paraphrasing a client’s statements). Then, you figure out the criteria necessary for accomplishing each of those little skills. I don’t know a ton about throwing free throws, but I think it involves how you flick your wrist when you release the ball, how you visually spot the backboard and hoop, and how you ground/calm yourself when the opposing team tries to psych you out. So then you figure out how to do each of those little things, then you string them together to form the skill. Then, you try the skill! But most importantly, YOU GET SOME HELP FROM SOMEONE WHO KNOWS WHAT THEY’RE DOING TO HELP YOU ANALYZE YOUR WORK. Your coach watches you shoot, and maybe they say, “form looked good but you looked tense, maybe you should work on breathing so you don’t get all freaked out before you shoot.” Or “looked like you were focused and calm, but you released the ball a second too late, next time try to release it just a bit sooner.” And then, you try again, incorporating the feedback. And you keep doing that…over and over again.

This is such an obvious way to approach getting better at basketball that there are probably thousands of basketball training camps at all levels all over the country.

How many psychotherapy training camps do you think there are?

None.

“But wait!” you might be thinking. “There are therapist conferences, and continuing education training, and you can get certified in certain approaches, and isn’t graduate school one big training camp??”

I wish. Unfortunately, the way we approach training for therapy looks like if we had you read a chapter in a textbook on free throws, get you on the local practice court one time and try a free throw, have a coach tell you ALL the things you did wrong, then send you home. Then, expect you to suit up for an NBA game the next day.

Here’s a quick little video that probably explains it better:

It’s kind of like my fiancé, who knows a WHOLE LOT about football in order to manage his fantasy football team, but if you put him in an ACTUAL football game…it wouldn’t be pretty.

In grad school, I would be in class at night, MAYBE do a role-play (because we only did them every once in awhile) where I would get told what I did right and wrong, then the next day have to work with a real client—in my opinion, this is absolutely the therapist equivalent of an NBA game. But I would have had no opportunity at all to learn anything from the night before.

Deliberate practice in psychotherapy breaks down the “art and science” of therapy into its component skills. There are some skills that seem to be in common across all forms of therapy—these are usually derived from “the common factors,” or the things that different approaches to therapy have IN COMMON that contributes to client success. So whether you’re doing Cognitive-Behavioral Therapy (CBT), Motivational Interviewing (MI), eye-movement desensitization and reprocessing (EMDR), psychodynamic/object relations therapy, or structural family therapy, there are going to be some basic skills you need to be reliably good at. Like “joining,” or connecting with your clients in a supportive, empathic way that makes them feel like they can trust you and want to emotionally invest in therapy. That needs to happen at the beginning of therapy, no matter what “flavor” of therapy you decide to practice. I think it would be GREAT if a graduate program were to identify these core, foundational skills, develop a curriculum that uses deliberate practice to effectively coach students to mastery of these foundational skills, and provide a lot of supportive feedback along the way. Frankly, I think this would have been much more helpful than some of the papers I wrote in grad school, or some of the group projects we had to do.

Here’s a great short animated video about some of these foundational skills that we can actually LEARN (they don’t just magically exist):

Some approaches to therapy have specific skills that other approaches don’t share. For example, assigning and reviewing homework is a key part of CBT that isn’t shared by, say, object relations therapy. For therapists who are interested in specific approaches like this, Rousmaniere and his co-editor, Alex Vaz, are releasing a series of books published by the American Psychological Society (APA) that focus on skill-building for specific approaches. If this sounds interesting to you, here’s a YouTube video they created that shows one of the CBT authors acting as a "supervisor” and giving feedback to two “trainees” who are practicing the CBT skill of assigning and reviewing homework (I’ve set it to start at the relevant moment, but you can watch from the beginning for all the psychotherapy jargon):

You’ll notice that Rousmaniere and Vaz are serious experts in this field, and the amazing thing is that they’re on a mission to make deliberate practice accessible to the entire field of psychotherapy. One of the the ways they’re doing this is through the Sentio Institute, which makes available a ton of free resources. For example, you can check out videos of “clients” saying something to you like you are their therapist—then you can practice how you would respond to them! Here’s what that looks like:

I think these are a great resource if you’re applying to MFT grad programs and want to prep for an interview, or if you’re already in grad school (or beyond!) and are struggling with impostor syndrome. Being able to practice skills like this in a low-stakes way makes learning SO MUCH EASIER.

I hope this has been helpful, and I also hope that if you’re in your grad program and having feelings of not being fully prepared, you know that you’re not alone!!!