Using Deliberate Practice to Improve Therapeutic Effectiveness
By Scott Miller, Mark Hubble and Daryl Chow
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About The Book
Deliberate practice is a systematic approach for improving psychotherapy outcomes one clinician at a time. This step-by-step guide to deliberate practice demonstrates how to collect and use client outcome data to create an individualized professional development plan to improve the quality of your service.
Your goal is to help more of your psychotherapy clients get better. For those who do realize gains, your goal is to help them experience a greater degree of improvement as a result of working with you.
In this book you will learn how to conduct routine outcome measurements to gather data from your own practice. Detailed instructions and examples walk you through the process of determining your baseline performance, identifying and addressing your strengths and deficits as a practitioner, and assessing your progress.
Richly-drawn case studies and stories from the business world and popular culture illustrate how research from the field of expert performance offers a different paradigm for professional development that departs from the field’s traditional emphasis on learning therapy models and techniques.
Improving treatment effectiveness: That’s the goal to which all clinicians aspire and to which Miller, Hubble, and Chow devote this extraordinarily stimulating and eminently practical book.
Learn how to leverage deliberate practice, in small actionable steps, to obtain better and better results.
A transformative read!
Many therapists are unsure about the effectiveness of their work.
In this fascinating and insightful book, Miller, Hubble, and Chow propose an empirically based program for how therapists can improve.
It is blunt and hard-hitting, but it may help therapists achieve what they really hoped for when they entered the profession.
– K. Anders Ericsson
Preface: Better Results Are Within Reach
I. The State of Our Art
1. What Therapists Will Say, Can’t Say, and Won’t Say
2. What Do We Really Know About Psychotherapy After All?
II. Expertise and Expert Performance: The Evidence Base
3. Learning From the Experts on Expertise
4. What Is (and Is Not) Deliberate Practice?
III. Getting Started: What to Do First to Achieve Better Results
5. Baseline Matters
6. How to Find Your Baseline
7. Making Sense of Your Baseline
IV. Moving Forward: Identifying What to Deliberately Practice
8. Mining Your Data for Better Results
9. How Average Leads to Better Results
10. How Being Bad Can Make You Better
11. What Matters Most for Better Results
12. A Study in Deliberate Practice
V. How to Deliberately Practice
13. “Yeah, But What Am I Supposed to Do?”
14. Designing a System of Deliberate Practice
Appendix A: Reliable and Clinically Significant Change Chart for the Outcome Rating Scale
Appendix B: Calculating a Standard Deviation
Appendix C: Taxonomy of Deliberate Practice Activities in Psychotherapy—Supervisor/Coach Version (Version 5.1)
Appendix D: Taxonomy of Deliberate Practice Activities in Psychotherapy—Therapist Version
Appendix E: Troubleshooting Tips
References - Index - About the Authors
Foreword by K. Anders Ericsson
Most of us want to be actively engaged in our work and lives. Psychotherapists are uniquely prepared to help when psychological difficulties and personal issues interfere with that objective. All such practitioners undergo extensive training and engage in continuous professional development to maximize their ability to deliver the requisite expertise. How psychotherapists develop andwhat can they do to improve are the subjects of this book. Although specific to psychotherapy, the research and training methods described apply across many helping professions—medicine, counseling, and teaching—enabling those who use them to achieve Better Results.
Some of the material presented in this volume is based on research my col- leagues and I conducted over the past 4 decades. We were particularly inter- ested in understanding how elite musicians, chess masters, and Olympic-level athletes did what they did, reaching world-class performance levels and managing to continuously improve. For me, interest in the subject of expertise and expert performance started early. In high school, I wanted to become a nuclear physicist to solve the energy problems of the future. To accomplish my objective, I studied the biographies of famous scientists, thinking that if I learned what they did, it might help me succeed.
From my extensive reading, I concluded a key to success was finding a Big Question—one the answer to which would make a big difference. I also decided that whatever subject I chose to pursue, it would have to be something I was genuinely interested in; otherwise, it would not be possible to sustain the deep interest necessary to last a lifetime. Motivation, I came to under- stand, was critical as many well-known scientists encountered challenges, roadblocks, and long periods of failure before achieving success. This latter
recognition ultimately caused me to abandon training as a nuclear physicist and pursue psychology instead.
Not surprisingly, perhaps, my initial research focused on understanding how people think when solving problems. I developed a scientific protocol, a method known as think aloud, whereby, as the name implies, subjects shared their thoughts openly as they engaged in different tasks. While my colleagues and I started with college students, in time, we turned our attention to expert performers. We were especially interested in highly motivated individuals— those who wanted to go beyond their current level of performance in their domain of expertise. Along the way, there have been starts and stops, reviews and revisions. At the same time, our understanding of the development of expertise and achievement of expert performance has increased dramatically (Ericsson, Hoffman, Kozbelt, & Williams, 2018).
In 2010, I was contacted by Scott Miller, who was organizing an interna- tional conference for psychotherapists. He wondered if I’d be willing to talk about how our research on chess masters, elite athletes, and outstanding musicians might apply to the professional development of psychotherapists. I agreed, knowing at that point that no direct research, and only one article written by him (Miller, Hubble, & Duncan, 2007), had been published on the subject in his field. When we met at the conference, I was immediately struck by his and the attendees’ enthusiasm. This was a group that wanted to improve.I was also impressed by their willingness to do the hard work and research needed to translate our findings for psychotherapy.
Scott had already developed an empirically sound method for measuring therapists’ clinical work (Miller, Duncan, Sorrell, & Brown, 2005). As seen in the pages of this volume, having valid and reliable tools for assessing perfor- mance is a critical first step in improving performance. Together with Daryl Chow, Scott was beginning to study clinicians with superior outcomes essen- tial for understanding the specific variables associated with better results in any given performance domain. Everyone I met was deeply committed to helping students and experienced professionals alike improve their outcomes.
Ten years on, their work continues. Reading Better Results, I was amazed by the progress. You can feel the excitement in these pages. While reading, I was frequently reminded of the passion and sense of adventure I’ve experienced in my own research career.
One of the absolute high points, for example, occurred when I worked as a postdoctoral fellow with two famous cognitive psychologists, Herbert Simon and Bill Chase, at Carnegie Mellon University. The year was 1978. I was in San Antonio, Texas, with Bill for the annual meeting of the Psychonomic Society. He was at the front of the room, presenting findings of our research on training memory performance. At the time, the capacity of short-term memory was believed fixed. Presented with one digit at a time, it appeared most adults topped out at around seven random digits. The world record per- formance on this task was held by a mathematics professor who was able to repeat back 18 digits correctly.
Bill showed a graph of one of the participants in our research, a college student named Steve Faloon.1 In the first trial, Steve, or SF as he was known in our published article in the prestigious journal Science (Ericsson, Chase, & Faloon, 1980), performed like most adults, recalling seven digits. Over a series of testing sessions, however, his performance improved, surpassing not only the assumed limit but the world record. As recounted in my coauthored bookPeak: Secrets From the New Science of Expertise (Ericsson & Pool, 2016), with a few hundred hours of training, Steve was eventually able to recall sequences of more than 80 randomly presented digits! Other subjects followed, with one eventually managing to recall over 100 digits.
Most memorable to me were the surprise and excitement in the audience. To be sure, some doubted the findings. Others suggested we’d merely lucked out, recruiting a naturally “gifted” person. A few accepted the results but questioned their significance. I remember one well-known cognitive scientist asking, “Who cares about improving one’s memory for random digits?”
Still, many were and have remained interested, in particular, about the changes in SF’s thought processes that accompanied his progress. The most general insight emerging from this research was that ability could be signifi- cantly extended by presenting tasks just beyond an individual’s performance level, giving immediate feedback, and then allowing time to reflect and prob- lem solve before proceeding with further attempts to improve. In time, we would call this process purposeful practice. When a teacher and coach agreed to monitor and guide each individual trainee to engage in particular training tasks, the improvements were greater and more predictable. This type of train- ing we termed deliberate practice.
Over the years, I’ve met people who think our research shows anyone can achieve anything. Even some researchers appear to believe this is our per- spective (cf. Macnamara, Hambrick, & Oswald, 2014). Nothing could be fur- ther from the truth. What we actually found is scientific evidence about howsome achieve amazing results: a map, so to speak, of the types of training activities and encoding (memory) methods that others can follow to obtain similar, specific exceptional performances. Of note is the word specific in the previous sentence: One critical finding from our studies is that expertise is domain specific. Participants in our digit span studies, for example, did not exhibit superior memories on other, seemingly related tasks, such as recalling letters and geometric symbols. Nonetheless, the general principle remains true: To improve, memory processes, mental representations, and expanded working memory have to be developed for each particular skill domain.
Decades later, numerous studies conducted by different researchers docu- ment that engagement in extended practice tailored to the specific task and individual learner can lead to improvement across a wide range of human activities, including music, ballet, gymnastics, chess, the word game Scrabble®, radiology, and education (Ericsson et al., 2018). To be sure, some remain skep- tical. I’ve met experienced professionals from a variety of performance domains, for instance, who seriously doubt their ability to improve meaning- fully beyond their present level. When asked, many say they have reached a limit determined by their unique inheritance of genes. It’s a compelling notion, despite an overall lack of empirical support for such constraints on increases in expert performance (Ericsson, 2014). Indeed, recent studies of middle-aged identical twins provide compelling evidence of the diverse outcomes that can be achieved with an identical set of genes when the twins pursued dissimilar developmental paths and engaged in different amounts of practice (Bathgate et al., 2018).
Rather than engage in abstract arguments about the role genetics may or may not play in the development of expertise, what I’ve found most helpful in addressing skepticism is showing what the best performers in the same domain actually do to improve and excel. That’s precisely the approach taken in Better Results. Its publication at this time heralds, I believe, a major change in the con- ception and implementation of training of beginning therapists, and, perhaps even more impactful, change in the methods used to ensure continued refine- ment of experienced therapists’ performance throughout their entire careers. It clearly shows that a given clinician’s performance is not the result of some inherent, immutable limit on their ability to succeed but is a function of the methods they use to train and develop. Most important of all, it provides ther- apists with the means for delivering more effective care.
—K. Anders Ericsson, PhD Conradi Eminent Scholar and Professor of Psychology Department of Psychology, Florida State University, Tallahassee
- The first evidence-based work to describe how to apply deliberate practice to psychotherapy
- Provides detailed, step-by-step instructions for developing an individualized, data-driven, professional development plan
- Describes a transtheoretical approach to professional development—applies to all theories and modalities of therapy
- Written in an engaging narrative style using accessible, everyday language that motivates readers to apply the ideas
- Includes hand-drawn graphics to illustrate and simplify data analytics concepts and to add humor
This book has the potential to change the field of psychotherapy in remarkable ways.
The authors give us the tools needed to take the guesswork out of the complexity of mind care by providing a path to professional excellence that is both orderly and governed by a clear set of principles.
[Better Results] clearly shows that a given clinician’s performance is not the result of some inherent, immutable limit on their ability to succeed but is a function of the methods they use to train and develop.
Most important of all, it provides therapists with the means for delivering more effective care.
In this empirically sound and remarkably engaging work, Miller, Hubble, and Chow remind us that psychotherapy is a co-creative process that is more effective when corrective feedback, individualized treatment strategies, and continuous refinement are applied.
This work gives hope … beyond outdated clinical orthodoxies.
I highly recommend this book to all who practice the art and science of psychotherapy.
Better Results provides clinicians practice-based guidance to help clients achieve the results they are hoping for in counseling and therapy.
It also provides tangible strategies for improving one’s own practice.
Scott D. Miller, PhD,
is the founder of the International Center for Clinical Excellence (ICCE)—a consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavioral health services.
He conducts workshops and training, helping hundreds of organizations worldwide to achieve superior results. He writes and edits books and professional articles on the curative factors of psychotherapy and the development of expert performance.
Scott’s work on routine outcome management led to the development of Feedback Informed Treatment, now listed on SAMHSA’s National Registry of Evidence-based Programs and Practice.
He lives in Chicago, Illinois. Visit scottdmiller.com and follow @TheICCE.
Mark A. Hubble, PhD,
is a founding member and senior advisor at the International Center for Clinical Excellence. He is the co-author and co-editor of many professional papers and several books—including the award winning first edition of The Heart and Soul of Change: What Works in Therapy.
A graduate of the prestigious postdoctoral fellowship in clinical psychology at Menninger, he also served on the editorial review board for the Journal of Systemic Therapies. His most recent work has focused on expert performance, deliberate practice, and the history and role of “magick” in psychotherapy.
Mark is also a professional bass player. He lives in Danbury, Connecticut.
Daryl Chow, PhD,
is a senior associate of the International Center for Clinical Excellence. He conducts research and workshops on the development of expertise and highly effective psychotherapists, and ways practitioners can accelerate learning.
He is the co-author of many articles and co-editor and contributing author of The Write to Recovery: Personal Stories & Lessons about Recovery from Mental Health Concerns, and the author of The First Kiss: Undoing the Intake Model and Igniting First Sessions in Psychotherapy.
Daryl’s blog and podcast, Frontiers of Psychotherapist Development is aimed at inspiring and sustaining practitioner’s individualised professional development.
Daryl maintains a private practice in Perth, Western Australia.
Scott Miller, Mark Hubble, & Daryl Chow.