#3. Clinical Practice vs. Deliberate Practice

In times of change, learners inherit the Earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists. – American moral and social philosopher, Eric Hoffer (1973, p. 22)


Question: Would you hire this guy? Imagine an NBA basketball player decides that he doesn’t need training outside of competitions, because he has gotten so good at his game, and all he needs to do is continue play more game. If you own an NBA team and it’s drafting day, would you invest in this guy? Probably not. You won’t bet your money on the “Learned”, but you would do so for the “Learners”.

Many mental health professionals, counsellors, psychologists, psychiatrists, nurses, social workers, and marriage and family therapists alike, spend hundreds of hours clocking in our practicum years in order to be accredited and/or licensed to practice. Not to be confused, the word “practice” here means, well, work. It is not practice per say. It is the real deal. We end up falsely believing that since we have spend all that time in practice during our educational years, we are well equipped for the real work, that is, clinical practice. Thank goodness not everyone falls into this “Learned” group. Others whole heartedly believe that learning is lifelong. These are the “Learners”. But both “Learned” and “Learners” group have to deal with the same professional development issue: What keeps me at sharp at my skills in helping people?

It is crucial to make a distinction between work, and work that targets at getting us better at what we do. Therapists often confused that they worked hard to improve at their craft when they find themselves experiencing “flow” states during sessions. Clearly, when we are engaged in the therapeutic encounter, we strive to be fully present, attuning and relating to the emerging emotions and unfolding lived experience of this person who is in front of me seeking help and counsel. We get taken by this process, sharing a specific aim to ameliorate the person’s suffering.

Professionals who values their craft are more likely to have the notion that you need to continuously hone in on your skills. Besides acquiring new skills, skills maintenance is critical, if not, more important. This applies not just for athletes, musicians, and other pros, but also for psychotherapists. In fact, going back to elementary knowledge from time to time has a profound impact. Often, in times of complexity or so-called “difficult cases”, the rule of thumb would be to return the basics. (This will be discussed at length in a future article).

In a study of psychotherapist practice activities, we were able to demonstrate that the among of time therapists devote to serious engagement in specifically improvement at their work was a significant predictor to their client outcomes (Chow, 2014; Chow et al., in press). The highly effective therapists (playfully termed as Supershrinks) spends more “alone time” working at their craft.

DP Graph Top Quartile vs Rest (5Sept14)
Note. Error bars = standard error of the mean (SE); due to small sample size at some of the data points, the error bars are not so visible in the graph for the 2nd and 3rd Quartile
Figure above: Therapists grouped into quartiles based on their adjusted client outcomes, as a function of their accumulative time spent on “deliberate practice alone” in the first eight years of clinical practice.

Based on the current engagement in deliberate practice, if we divide the group of therapists into four parts based on their effectiveness levels, the supershrinks (i.e., top quartile therapists) spent almost twice as more personal time than the second quartile, and 3.7 times more than the third quartile group. (We weren’t able to reliably compare with the least effective group, simply because we only had one therapist in that group who responded to the questionnaire. But just so you are curious, take a look at the table below).

DP Quartiles Table

Although new to the field of psychotherapy research, the mediating impact of deliberate practice has also been replicated in a variety of other studies conducted in different professional domains such as music, chess, sports, and medicine (e.g., Cote, Ericsson, & Law, 2005; Ericsson, 2007b; Ericsson et al., 1993; Gobet & Charness, 2006; Krampe & Ericsson, 1996; Mamede, Schmidt, Rikers, Penaforte, & Coelho-Filho, 2007; Norman, Eva, Brooks, & Hamstra, 2006; Schmidt & Rikers, 2007).

What’s intriguing about this study of psychotherapists is that the among of time their reported on deliberate practice was a current estimate of the last typical work week. What this means is that these supershrinks were still engaging in deliberate practice, even though they already are, well, Supershrinks! It’s like Michael Jordan. He was already frighteningly good at his game, but he still spent time on his own working at his jumpshots, even after the rest of the Chicago Bulls have gone home.

In case you are wondering, did the among of time spent in clinical practice predict outcomes? The answer is no. Years of clinical experience, alongside with other demographic variables such as age, gender, profession, highest qualification (that’s right) did not impact outcomes.

How do we discriminate between clinical practice and deliberate practice?

DP vs CP

Clinical Practice:
It is not a practice per se. It’s the cumulation of all our efforts to be helpful to our clients. It’s the performance part of the equation. It’s the music performance of all that deep practice.

Deliberate Practice:
Deliberate practice is aimed at improving your skills in a defined manner. It takes a lot of focused and deep work, but it’s designed to help you get better at your clinical practice. Here are four elements that promote deeper learning (Lehman and Ericsson, 1996):

1. Design an individualised learning plan;
2. A coach/clinical supervisor to assist you in your professional development, thus providing you an “auxiliary mind”;
3. An environment of immediate feedback, &
4. Repetition/successive refinement.
I will be talking about each of these in future posts.

Here’s How:
Do not get confused when you work hard at your clinical practice as a short-hand for working hard at deliberate practice. I do subscribe to Donald Schon’s seminal idea of of reflection-in-action during clinical practice. But the differentiating factor is what you do outside of the game. Said in another way, clinical practice is what you do in-sessions; deliberate practice is what you do before-and-after sessions.
This is the cycle of clinical practice and deliberate practice. You learn all that you can, and when you enter into the therapeutic realm, you let go all of that. Let you and your client get entranced by the meeting of minds.

Make no mistake about it. Compared to being a “Learned” person, it’s a tough road being a “learner”.

Stick-It:
Clinical Practice vs. Deliberate Practice.

See Other Related Articles:

The “MMI” Meetings

Why Our Self-Assessment Might be a Delusion of Reality?

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