Psychotherapy has been consistently shown to be effective. Results of numerous studies reveal that those treated with psychotherapy report better outcomes compared to those untreated or on waitlists. In the current climate of cost containment, limited resources, and increased accountability, therapists are being increasingly tasked with demonstrating effectiveness – to clients and payors. This shift has resulted in an increased emphasis on continuous quality improvement efforts and a review of current methods of skill development and professional growth. Despite long-held beliefs that experience is related to effectiveness (i.e., the longer the amount of time in the field, the more effective the therapist), recent studies suggest that this is not the case. This finding has implications for continuing education models in that they may not be effective in improving therapist performance. Thus, new models are needed to ensure continued therapist growth and development which focus specifically on individual growth edges or areas in need of improvement. Deliberate practice is an emerging continuous improvement approach in which therapists challenge themselves to identify the edge of their ability by examining inconsistencies in performance and through consultation, reflection, and practice, refine skills to improve performance. This commentary briefly describes the deliberate practice approach and argues for its use in psychotherapy continuous quality improvement efforts and continuing education programming.

Klostermann K, Mignone T (2017) Improving Therapist Effectiveness: The Case for Deliberate Practice. J Addict Med Ther 5(2): 1034.

In most studies of psychotherapy conducted over the past 40 years, results consistent find that the average treated person is better off than 80% of untreated samples [1,2 ]. In fact, the outcomes related to behavioral health services equals, and in most cases, exceed outcomes related to medical conditions (coronary heart disease [1]. On average, mental health professionals achieve outcomes on par with success rates obtained in randomized controlled trials (with and without co-morbidity [3].

However, when therapist effectiveness is examined over time, rather than cross-sectionally, the results of aggregate therapist data seem to suggest that therapists are not improving over time; regardless of model or technique employed [4]. Moreover, the effectiveness of the average helper seems to plateau early in a practitioner’s career [5-8]. Contrary to popular belief, therapists do not seem to get better with time and experience. While many practitioners perceive themselves as naturally improving with time and experience, available evidence suggests no difference in effectiveness between beginners and experienced clinicians [9]. More specifically, in a study on the effect of experience on outcome, results indicated that on average, outcomes declined over time [10]. This finding suggests that while collecting and examining outcomes is important, it is not enough to improve therapist effectiveness [9]. Although examining session-to-session outcomes has become increasingly popular and may be helpful during a therapy episode [11], it does not provide specific areas for therapist improvement across clients. To be clear, outcome data are important in that they can reveal if a client is getting better or worse, but are limited in that they do not reveal what you should do or how to do it; by itself, the data provide an incomplete picture of overall therapist effectiveness across clients. In other words, outcome data do not tell a clinician what to do when things go wrong, only that the particular approach is not working. Consequently, clinicians must make a conscious and intentional effort to refine their craft; they must engage in continuous deliberate practice activities in which performance and outcomes are examined over time to determine overall efficacy levels [9].

According to Ericsson, for therapists to improve effectiveness and continue developing they must challenge themselves to push the edge of their ability by examining inconsistencies in performance, performance errors, etc. [3]. This type of reflection cannot be done in the therapy room and requires a plan to identify appropriate growth areas and strategies for improvement. From a deliberate practice perspective, the goal is for therapists to create a context of supportive, growth-oriented feedback and engage in the practice of “failure facing” in a self-compassionate way to specifically target consistent areas of struggles and mistakes; this is often an iterative process in which therapists regularly practice to improve skill level in low-performing areas. To be clear, there is no short-cut to a deliberate practice culture; it requires time and on-going commitment to engage in clinically focused learning activities including honest self-reflection to identify weaknesses. Thus, on-going support is necessary and critical to success in this endeavor.

Deliberate practice begins with therapist self-reflection and identifying three important practice domains: 1) comfort zone, 2) learning zone, and 3) panic zone [3]. The comfort zone refers to the things the therapist does well, the learning zone refers to achievable growth areas, and the panic zone refers to those areas that the therapist perceives are beyond his or her ability or willingness to pursue. The goal for therapists is to identify learning zone activities that are outside the comfort zone, but not so as ambitious as to put the person into the panic zone (i.e., the growth edge).

Deliberate practice: getting started

Given the emphasis on examining data over time, at the outset therapists might begin keeping a log of sessions that went well and those that did not. This process may last 2-3 months in order to develop a robust enough list of items. Gathering solid baseline performance data is critical and cannot be understated. Minimally, details about presenting concern, progress toward goals, and any relationship issues are necessary to track over time. Therapists might also consider adding their thoughts or commentary about the process in each session and their reactions to the client and the session. This information will be helpful in identifying potential areas for growth. Following this phase, the aggregate data should be examined to identify the themes or patterns that emerge from the data. Simply stated, identify what is being done well and what’s not being done well. By identifying patterns of shortcomings over time, the therapist can begin to identify possible growth edges (i.e., areas for improvement). The rational for examining aggregate data is that therapist tend to overestimate effectiveness (i.e., self-assessment bias [4,12]. Moreover, there tends to be tremendous variability in therapist performance from session to session. Complicating matters further, therapists frequently fail to identify failing cases; in fact, it’s estimated 1 out of every 10 clients accounts for 60-70% of expenditures - these are the clients that fill up caseloads with no improvement and drain resources.

Developing a deliberate practice plan

Given the time commitment and clinical and self-exploration required in this process, a carefully constructed and well-thought out deliberate practice plan is critical to success in this journey. A deliberate practice model and mindset requires a paradigm shift away from more traditional practice improvement models in which attending seminar, workshops, conferences was viewed as sufficient for professional growth and clinical skill building. By way of contrast, deliberate practice plans are individualized to the particular therapist and specifically tailored to areas identified as in need of growth or improvement based on data collected from clients over time. This process challenges (and relies on) the therapist to honestly examine skills, be receptive to feedback, and be willing to incorporate this feedback into practice to improve effectiveness [3]. Thus, it is important to have a comprehensive practice plan, with small, realistic and achievable goals, and identify appropriate support persons to assist in this process.

Deliberate practice components

A deliberate practice plan typically includes the following components: 1) a concrete and specific plan, 2) baseline or reference data to determine strengths and possible areas of growth, 3) willingness to step out of comfort zone and try new skills, and 4) supportive consultants and mentors that share a growth mindset and willing to challenge you to push past current levels of functioning [3]. Concrete, realistic, and specific plans involve carving out specific days and times each week for self-reflection and to work on skill development. In order to identify areas for improvement, a clinician must have an accurate understanding of current abilities, including what he or she is doing well and what might be improved. Identifying a baseline level of functioning is important as it serves as a reference point in measuring future growth and progress toward goal attainment. Developing a deliberate practice mindset requires a commitment to follow-through– both in the short- and long-term. Clinicians may be well-intentioned in developing clear and robust training plans, but without the continued desire to grow and improve, even the best plans fail. Moreover, a deliberate practice plan that is too ambitious will also lead to burnout or failure over time; thus, creating a realistic and feasible plan is a critical part of the process. Finally, given the purpose of the deliberate practice is to identify areas for improvement, it is essential that therapists identify a supportive supervisor who is familiar with this approach and also willing to gently challenge the individual to step out of the comfort zone. To be clear, a therapist new to a deliberate practice mindset may feel vulnerable or exposed and be concerned this information may be used against him or her or inform; this type of suspicion is likely typical in the beginning as the supervisory process may not have always been a safe environment. Thus, the supervisor should be a partner in the growth process and encourage self-reflection and creativity. Compared to more traditional types of supervision, the supervisor serves as a consultant and focuses specifically on the areas identified by the therapist as growth edges. Thus, the supervisory process does not involve supervisees ‘sitting at the knee of the master,’ but rather the supervisor tailoring the process to the individual with focus on how to improve specific skills.

The shift toward more professional and deliberate practice as way to improve therapist effectiveness is not merely an academic exercise. As noted by Watkins, there is no evidence to support the conclusion that current models of clinical supervision are related to outcome. This finding, coupled with the fact that therapists do not seem to be become more effective based on experience, underscores the need for new performance improvement models to ensure continued growth and development and by extension, clinical quality. The movements toward more intentional efforts to improve performance are in their infancy and further study is needed (For a more comprehensive review [13]. The challenge for both researchers and clinicians alike is twofold: 1) how best to transform a firmly entrenched performance improvement and supervisory culture and 2) how to encourage therapists (early, mid, late career) to engage in this practice. Given the amount of work required, coupled with the needs to honestly examine skill limitations, many therapists may decide that this is too much work and despite the research, decide to continue in the current professional development/continuing education model. Thus, the task for deliberate practice researchers is to identify dissemination and implementation opportunities at every professional level. Perhaps incorporating deliberate practice into mental health training program curricula (e.g., supervision, internship, practical) may be one avenue to indoctrinating students in a lifelong deliberate practice mindset.

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