Deliberate Practice in Psychotherapy

Deliberate Practice in Psychotherapy

by Tony Rousmaniere
Psychotherapy researcher and clinician Tony Rousmaniere teaches us that 10,000 hours of psychotherapy doesn’t make you an expert; focused deliberate practice is the path to excellence.

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Editor's note: The following is an excerpt taken from Mastering the Inner Skills of Psychotherapy, by Tony Rousmaniere, published by Gold Lantern Books © 2018 and reprinted with permission of the author.


Could there be a better way for therapists to acquire the inner skills of psychotherapy?
Could there be a better way for therapists to acquire the inner skills of psychotherapy? To explore this question, let’s look to other fields. Most professions have developed specific exercises that help trainees acquire the capacity necessary for professional performance. For example, musicians rehearse challenging pieces repeatedly, so they will sound effortless during the actual performance. Pilot trainees spend hours intentionally stalling their plane, so they can practice recoveries. Athletes engage in physical conditioning, so they will have improved performance in competitions. In deliberate practice, therapists use practical exercises to build their inner skills and psychological capacity to improve their psychotherapy performance.

Deliberate Practice

I lead deliberate practice workshops around the world on developing therapists' psychological capacity. Participants who are new to the idea of psychological capacity often ask, "How can this help me be more effective with my clients?" To answer this question, let's begin with a case example of how deliberate practice helped me with a challenging case a few years ago.

My client was a man in his early twenties. He had recently been fired from his job and was discouraged about applying for work. He struggled with depression and had started to have thoughts of suicide. His goal for our work was to improve his mood and morale so he could find new employment.

My client and I formed a good working relationship in our first few sessions. However, despite my best efforts, he did not improve. Over the following weeks his mood gradually worsened, and he became more socially isolated. The outcome monitoring software I was using indicated that he was at a high risk of deterioration and possible suicide. With the client's consent, I recorded a video of one of our sessions and showed it to my supervisor.

When we reviewed the video together, my supervisor noticed that the client looked disassociated during our session. He said, "Notice that after you ask your client a question, his eyes glaze over and he is slow to respond? Notice how he is nodding his head but not really engaging your questions? This could be a sign that your client is experiencing so much anxiety that he is disassociating. He may be politely going along with you but not fully understanding what you are asking him or benefiting from the therapy."

As I watched the video closely, I could see what my supervisor was pointing out. My client's eyes were unfocused, and his speech was slow. Although he was able to follow our conversation, his comments seemed superficial or compliant, like he was going along with me rather than really expressing himself.
I was surprised that I had not seen these obvious signs of disassociation in session with my client. I had learned about disassociation years prior and had successfully helped many clients with these symptoms.
Why was I unable to help this client?
Why was I unable to help this client?

I said, "It's so strange that I didn't see these symptoms in session with my client. They seem so obvious when you point them out right now."

My supervisor replied, "I wonder if you may be having an unconscious internal reaction that is blocking your conscious awareness?"

I said, "How can I tell if I am having such a reaction?"

He replied, "They often are accompanied by thoughts, emotions, physical sensations or behavioral urges. You can look for these as signals."

"How?" I asked.

"I'll show you," he replied.

Seeing in Real Time

My supervisor said, "Play the video again. Turn the volume down low so you can hear the sound of your client's voice but not get caught up in the content of the conversation in the video."

I did as my supervisor instructed. It felt strange to watch the video without following the content of the conversation.

He continued, "Now, try to notice any thoughts, emotions, physical sensations, or behavioral urges you may feel while watching the video."

I tried this for a few seconds and noted that paying attention to my internal experience while simultaneously watching the video was hard. I said, "My attention keeps trying to follow what the client is saying."

"That's normal," he replied, "just keep trying."

I watched the video while trying to tune in to my internal experience. After a few moments, I noticed I was clenching my fists. I told my supervisor.

"Great," he said, "what else do you notice?"

"My chest feels tense," I replied.

"What else?" he asked.

"I'm holding my breath."

"What else?"

As I tuned in to my internal world, I realized that I was having many uncomfortable reactions I had previously not noticed
As I tuned in to my internal world, I realized that I was having many uncomfortable reactions I had previously not noticed. "My legs are tense, my mouth is dry, and my palms are sweaty. There's also a slight ringing in my ears."

He said, "Great that you can see all of these reactions within you. Let the video keep playing so you can continue. Do you notice any thoughts? You don't have to tell me the details, but it's important for you to see them."

I noticed I was having strong doubts about myself as a therapist. How could I be effective if I was having all these unconscious reactions? Was something wrong with me? Should I give up and leave the profession? I felt some shame and didn't want to reveal the details of all these thoughts to my supervisor. Instead, I simply said, "I'm having negative thoughts about myself."

My supervisor could probably tell that I was experiencing some shame. He looked at me with kind eyes and normalized my experience, saying, "Great that you can notice those thoughts. Self-doubt, shame, or other negative thoughts about yourself are a normal and very common response to reaching your own psychological capacity limits. Consider these thoughts to be like how an athlete will sweat or get out of breath during a tough workout. It's just part of the process."

He continued, "Do you notice any behavioral urges? Again, you don't have to tell me the details. Just try to notice them within yourself."

I noticed I felt the urge to stop following his instructions. I was glancing at the clock out of the corner of my eye and hoping our consultation would end soon. I was also surprised to notice that I was starting to feel frustrated with my supervisor. This felt awkward, as I liked him a lot personally and trusted his advice. I didn't feel comfortable telling him all of this, so instead I just nodded my head.

My supervisor paused the video. "Congratulations," he said, "you were able to observe your own experiential avoidance in real time as you had it. This is not easy! However, it is a very important skill for effective psychotherapy."

I took some deep breaths. I felt shaken from this experience and a bit confused. "How can this help me with my client?" I asked.

He replied, "Your ability to be empathic and attuned with this client is being limited by the discomfort and experiential avoidance that he stirs up in you. To address this, we need to increase your ability to see your own experiential avoidance in real time. This will let you downregulate your emotional state, so you can be more empathic, attuned and helpful."

He continued, "You know how to assess and treat disassociation. You could write a paper about it. You can perform it proficiently with many of your other clients. You could teach it to beginning trainees. However, we have discovered that your proficiency in this skill is conditional on your psychological state. When you have particularly strong experiential avoidance—such as with this client—you lose your ability to be helpful. We call this your psychological capacity threshold."

"How can I increase my threshold?" I asked.

He replied, "By practicing therapy skills with stimuli that provoke your experiential avoidance. This is called state dependent learning. For example, this video will work well for practice. I'll show you how."

Engaging the Client

My supervisor said, "You are going to practice engaging the client with anxiety regulation techniques while simultaneously noticing your experiential avoidance. Do you remember the somatic anxiety regulation techniques we reviewed last week?"

I replied, "The technique where I ask the client where he notices his anxiety in his body?"

"Yes, we'll use that," he said, "Start the video again at low volume. Now, while watching the video, take a moment to notice your internal reactions. Raise your hand when you notice any experiential avoidance."

After a few moments watching the video, I noticed my chest tightening and breath restricting. I raised my hand.

"Good," he said, "now use the first technique we discussed last week."

"Just say it to the video?" I asked.

"Yes," he replied, "just say it to your client in the video."

Looking at the video, I said, "Right now, where physically do you notice any anxiety in your body?" I felt strange talking to the video.

"Good," said my supervisor, "now watch the video for about twenty more seconds while noticing your inner reactions."

My supervisor used his watch to count down twenty seconds and then said, "Now use the anxiety regulation technique again."

"The same one?" I asked.

"Yes," he said, "you can play with the words if you like."

Looking at the video, I said, "Right now, where do you notice any anxiety, physically in your body?"

"Good," said my supervisor, "do this process again: twenty seconds of self-observation, followed by engaging the client."

I watched the video for twenty seconds while noticing my inner reactions and then said, "Do you notice any anxiety physically in your body right now?"

"Good," my supervisor said, "again."

I repeated the process.
"Again," he said.

As I repeated the process, I noticed I had conflicting feelings toward my supervisor: I was simultaneously frustrated at him and appreciative of his help.
"Again," he said.

I repeated the process and noticed I was starting to feel fatigued.

"Okay, pause," he said. "What did you notice while repeating the exercise?"

"It got easier," I replied.

"Great!" he said. "
You are building your psychological capacity to engage the client
You are building your psychological capacity to engage the client while you have experiential avoidance."
I asked, "Why does this client provoke such a strong reaction in me?"

He replied, "We don't know yet. I'll give you some deliberate practice exercises to do as homework, and maybe you'll find out."

Doing the Homework

My supervisor said, "Between now and our next supervision session, try to do an hour of the same deliberate practice exercise we just did together. Doing these exercises on your own may be more challenging than it was here with me, so try to be patient and self-compassionate. Remember that the goal is just to notice your reactions and practice engaging the video. Do not try to change or 'fix' any of your reactions."

Over the following week I did the deliberate practice homework in three sessions of twenty minutes each. Doing it myself was much harder than it had been with my supervisor. I had to fight strong urges to avoid it. I scheduled practice in the morning but put it off until the afternoon. When I sat down to practice in the afternoon, I felt tired and decided to do it the following morning. The next morning, I was tempted to put it off yet again. However, I summoned the willpower and did the exercise.

When I started the video, I noticed a general tension throughout my body and fogginess in my mind. I kept losing track of time, so I set my phone to count down in twenty second intervals. I found it hard to say the anxiety regulation words out loud to the video. I felt awkward and had strong thoughts of shame and self-doubt. When I stopped after about twenty minutes, I felt discouraged by how much harder it had felt doing the exercise on my own rather than with my supervisor.

Two days later I did the exercise for a second time. Like my first practice session, this took considerable willpower. However, this time I had less fogginess and noticed more distinct internal experiences, including dry mouth, sweaty palms, and ringing in my ears. I felt clearer when saying the anxiety regulation words out loud. My shame and self-doubt were less pronounced. I ended the practice after about twenty minutes feeling more optimistic.

Three days later I did the exercise again. This time felt very different. As I watched the video, I noticed strong waves of tension rising from my stomach through my chest to my throat. I almost choked as I said the anxiety regulation words. The waves increased in intensity as I repeated the exercise. With surprise, I noticed tears forming in my eyes.
I felt a sharp spike in my shame and self-doubt and a strong urge to end the exercise
I felt a sharp spike in my shame and self-doubt and a strong urge to end the exercise. However, I gathered my willpower and persisted. As I watched the video, I realized my client reminded me of times as a teenage boy when I had felt anxious and disassociated. I remembered the pain of those days, along with the social isolation and confusion. As I spoke the words of anxiety regulation to the video, I pictured saying them to myself as a teenager. I started crying out of sadness for my younger self as my shame melted into self-compassion. Resisting the temptation to stop the video, I continued with the exercise. I cried throughout the last ten minutes of the practice session.

Deliberate Practice Helped

This experience helped in multiple ways. First, my effectiveness as a therapist improved dramatically. I felt less tense and foggy sitting with the depressed young client whom I had videotaped. I was better able to help him see his own disassociation and use anxiety regulation techniques to reduce his anxiety. Over time, his mood improved, and he became more socially engaged. My effectiveness with other clients improved similarly.

Second, my morale and confidence as a therapist improved. I experienced less shame and self-doubt in my work. I felt optimistic about resolving other clinical impasses I was encountering and enthusiastic to practice more.

Third, the effects of the practice carried over to my personal life. I grew more open and engaged with my friends and family. I felt like I had further healed an old wound.

The impact of deliberate practice on my personal life has been surprising
The impact of deliberate practice on my personal life has been surprising. I had previously done years of my own therapy, in which I had talked extensively about my teenage years. I assumed I had finished processing these old wounds. However, empathizing with this client stirred up painful memories that I had not recalled in my own therapy. Deliberate practice with my session videos helped me process those memories. After having many similar experiences myself and hearing of many from my trainees, I have come to see that deliberate practice with session videos can be a valuable tool for therapists' personal growth. Deliberate practice helped me build my psychological capacity to be more effective with this client—and with my other clients.  

Mastering the Inner Skills of Psychotherapy, Gold Lantern Books © 2018
Bios
Tony Rousmaniere Tony Rousmaniere, PsyD is Clinical Faculty at the University of Washington and has a private practice in Seattle. He hosts the clinical training website www.dpfortherapists.com, and is the author/editor of four books on clinical training: Deliberate Practice for Psychotherapists, The Cycle of Excellence: Using Deliberate Practice to Improve Supervision and Training, Using Technology to Enhance Counseling Training and Supervision: A Practical Handbook, and the forthcoming Mastering the Inner Skills of Psychotherapy: A Deliberate Practice Handbook. In 2017 Dr. Rousmaniere published an article in The Atlantic Monthly, “What your therapist doesn’t know”. Dr. Rousmaniere provides workshops, webinars, and advanced clinical training and supervision to clinicians in the United States, the United Kingdom, Europe, Asia, and Australia. He was previously Associate Director of Counseling and Director of Training at the University of Alaska Fairbanks Student Health and Counseling Association. More about Dr. Rousmaniere can be found at www.drtonyr.com