How Deliberate Practice can Improve Your Therapeutic Effectiveness

October 14, 2016 By scottdm Leave a Comment

In 2015, colleagues and I released the largest, longitudinal study of therapist effectiveness ever published. The study examined outcomes of 6500 clients treated by 170 practitioners whose results had been tracked an average of 5 years—some as long as 17 years!

The result? Clinician outcomes, on average, not only did not improve, but actually slowly and inexorably worsened with time and experience—and this, despite the fact that practitioners involved in the study routinely measured and had access to ongoing feedback about their results. As I’ve blogged about previously, despite the many claims, measurement and feedback are not enough to improve therapist outcomes.

So, what does work?

For the last several years, I’ve been advocating deliberate practice (DP)—conscious and purposeful effort aimed at improving specific aspects of an individual’s performance. DP contains four essential ingredients:

In short, those wishing to improve must: (1) identify objectives just beyond their current ability and then (2), together with a coach, develop and execute a plan complete with steps and strategies for reaching those performance objectives; (3) throughout, attention must be paid to small errors and mistakes and immediate, corrective feedback provided; finally, (4) with time and repetition, slow but steady improvement results.

To date, research shows time spent in deliberate practice is associated with top performance across a variety of domains, including music, medicine, sports, mathematics, and chess.

With regard to psychotherapy, Chow, Miller et al. (2015) found the most effective clinicians spend more than twice as much time in activities specifically designed to improve their outcomes than their more average counterparts (see Figure 1). The impact of making small but consistent investments of time to deliberate practice is especially dramatic, compounding like interest in a savings account, when results are plotted over time (see Figure 2).

Most important, however, is that the benefit of engaging in deliberate practice extends far beyond mere “statistical significance.” Clients of top performing clinicians, for example, experience 50% more improvement and 50% less deterioration and drop out.

However, as Mark Hubble and I wrote in the “Road to Mastery,” back in 2011, “knowing the facts and putting them into practice are two altogether different matters.” It turns out there’s a reason why most do not devote much time to deliberate practice: it’s hard. Damn hard. Not only is it labor intensive, the rather glacial progress one makes along the way can be pretty discouraging. The key to long term success, it turns out, is community–a complex, interlocking network of people, places, resources, and circumstances working “behind the scenes” to nurture and support ongoing efforts to improve.

And now the data: a study involving more than 150 clinicians and 5500 clients documents what’s possible when agencies work purposefully to create a climate for therapist improvement–specifically, putting systems in place that support deliberate practice in the workplace.

The results? Instead of worsening over time, therapists improved in effectiveness year after year over a seven year period. No, the change in outcome wasn’t dramatic. Rather, consistent with findings in other performance domains, it was slow and stead,y ultimately leading to a large cumulative effect.

What’s it take to get started? The first step is establishing your baseline level of effectiveness. All you need to do to get started is download two, brief measurement tools. Next, get inspired by watching the interview below. Iain Caldwell, the director of an award-winning mental health agency in the U.K, discusses how to develop and sustain a practice committed to superior outcomes and documented professional development. Along the way, we discuss recently published research on the results of a massive government investment in mental health services as well as reports that as many as half of practitioners working within the National Health Service are depressed. Provocative and interesting stuff.

“Mind the Gap”: A Strategy for Insuring you get the Feedback you need to Improve your Game (whatever that is)

September 23, 2016 By scottdm 3 Comments

Join me in a brief “thought experiment.” Suppose you were a gifted painter or photographer and had the chance to provide an image of yourself that would endure–and perhaps be the only one people would know you by–for hundreds of years after your death. How would you proceed? What criteria would guide your work, be used to deem it a success?

Seriously, take a moment to picture yourself in your mind’s eye…

Now, consider the painting below.

It’s a self-portrait painted by Rembrandt van Rijn.

Why, you might wonder, would a painter widely considered one, if not, “the greatest . . .in European art” leave the world such an unflattering portrait? His face is puffy and pale, his hair thin and receding, and his cloak and cap plain and undistinguished. And lest one assume this particular image is an exception to otherwise beautiful renditions of himself, think again. The self-portraits he painted throughout his life share the same, homely quality.

Clearly, the skills Rembrandt possessed ensure he could have made himself look any way he wanted and the world would have been none the wiser. Why such brutal honesty? More to the point, given the choice, would you paint yourself as you truly are or as others generally see you?

The answer, according to some to very interesting and recent research, is, “No.” The gap between how we view ourselves on the one hand and, on the other, look, think, and act in life is often quite wide. And, it turns out, we fill that space with people who agree with us, who see us as we want to see ourselves.

Actually, according to Paul Green of the University of North Carolina at Chapel Hill, people actively, “move away from those who provide feedback that is more negative than their view of themselves. They do not listen to their advice and prefer to stop interacting with them altogether . . . tend[ing] to strengthen their bonds with people who only see their positive qualities.”

Surrounding ourselves with people who shore up our self-image is both understandable and needed. Life is hard. Support is a must. The problem is that this largely unconscious behavior undermines performance. In a variety of work contexts, for example, the researchers have documented that, “dropping relationships that provide disconfirming reviews [leads] to decreases in performance in the succeeding year.”

The importance of being able to see ourselves as we are is something Rembrandt appeared to understand quite well. Indeed, it likely accounted for a significant portion of his artistic mastery. img_20160922_1024365

Bottom line? Whatever our particular craft, if the goal is to improve, to get better at what we do, it’s essential to “mind the self-assessment gap.” First, we have to be aware it exists. Next, we have to actively work to solicit views other than our own.

In the therapy world, our team has pioneered a simple set of tools clinicians can use to solicit feedback about the quality and effectiveness of their work. Multiple clinical trials document improved results. Read this free article to learn how to get started.

Does practice make perfect?

August 30, 2016 By scottdm 1 Comment

“Practice does not make perfect,” my friend, and award-winning magician, Michael Ammar, is fond of saying. “Rather,” he observes, “practice makes permanent.”

Thus, if we are not getting better as we work, our work will simply insure our current performance stays the same.

Now, before reading any further, watch a bit of the video below. It features Diana Damrau singing one of the most recognizable arias from Mozart’s, “The Magic Flute.” Trust me, even if you don’t like opera, this performance will make the hair on your neck stand on end.

All right, now click on the video below (and listen for as long as you can stand it).

No, the latter recording is not a joke. Neither is it a reject from one of the “GOT TALENT” shows so popular on TV at present. It’s none other than Florence Jenkins—an American socialite and heiress who was, according to Wikipedia, “a prominent musical cult figure…during the 1920’s, ‘30’s, and 40’s.”

How could that be, you may well wonder? Her pitch is off, and there are so many mistakes in terms of rhythm, tempo, and phrasing in the first 30 seconds, one quickly loses count.

The problem? In a word, feedback—more specifically, the lack of critical feedback extending over many years.

For most of her career, Lady Florence, as she liked to be called, performed to “select audiences” in her home or small clubs. Attendance was invitation-only–and Jenkins controlled the list. Her guests did their best not to let on what they tought of her abilities. Instead, they smiled approvingly and applauded–loudly as it turns out, in an attempt to cover the laughter that invariably accompanied her singing!

Everything changed in 1944 when Jenkins booked Carnegie Hall for a public performance. This time, the applause was not sufficient to cover the laughter. If anything, it followed, treating the performance as a comedy act, and encouraging the singer to continue the frivolity.

The reviews were scathing. The next morning, the critic for the New York Sun, wrote, Lady Florence, “…can sing everything…except notes…”

The moral of the story? Practice is not enough. To improve, feedback is required. Honest feedback–and the earlier in the process, the better. Research indicates the keys to success are: (1) identifying performance objectives that lie just beyond an individuals current level of reliable achievement; (2) immediate feedback; and (3) continuous effort aimed at gradually refining and improving one’s performance.

Here’s the parallel with psychotherapy: the evidence shows therapist self-appraisal is not a reliable measure of either the quality or effectiveness of their work. Indeed, a number of studies have found that, when asked, the least effective clinicians rate themselves on par with the most effective–a finding that could well be labelled, “Jenkin’s Paradox.”

Evidence-based measures exists which can help therapists avoid the bias inherent in self-assessment as well as aid in the identification of small, achievable performance improvement objectives. Studies document, for example, how therapists can use such tools, in combination with immediate feedback and practice, to gradually yet significantly improve the quality and effectiveness of their therapeutic relationships–arguably, the most important contributor to treatment outcome.

Let me leave you with one last video. It’s an interview I did with Danish psychologist Susanne Bargmann. Over the last 5 years, she’s applied the principles described here in an attempt to not only improve her effectiveness as a clinician, but also in music. Recently, her efforts came to the attention of the folks at Freakonomics radio. As was the case when you listened to Diana Damrau, you’ll come away inspired!