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Deliberate Practice for Psychotherapists A Guide to
Improving Clinical Effectiveness 1st Edition Tony
Rousmaniere Digital Instant Download
Author(s): Tony Rousmaniere
ISBN(s): 9781138203204, 1138203203
Edition: 1
File Details: PDF, 4.06 MB
Year: 2016
Language: english
DELIBERATE PRACTICE
FOR PSYCHOTHERAPISTS
Tony Rousmaniere
First published 2017
by Routledge
711 Third Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2017 Taylor & Francis
The right of Tony Rousmaniere to be identified as author of this work
has been asserted by him in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
Library of Congress Cataloging in Publication Data
A catalog record for this book has been requested
Prologue ix
Acknowledgments xvi
vii
CONTENTS
Epilogue 193
Appendix: Videotaping Psychotherapy 195
References 198
Index 214
viii
PROLOGUE
Two weeks later my client1 died from a drug overdose. Her son was
shipped off to foster care.
This tragedy was the capstone of a long series of therapeutic
disappointments. I, like all therapists (whether they admit it or not), was
all too familiar with clients stalling, dropping out of therapy, and even
deteriorating. However, my client’s death and her son’s abandonment
brought painful clarity to the harsh consequences of clinical failure. I had
become a therapist because I wanted to help my clients, not watch them die.
This event sparked a crisis within me—one that I believe is shared by
therapists around the world, across all the treatment models: How do I
become a more effective therapist?
ix
PROLOGUE
The idea of deliberate practice has its origins in a classic study by K. Anders
Ericsson and colleagues (Ericsson, Krampe, & Tesch-Romer, 1993).
They were curious about what methods top-performing professional
musicians used to achieve expert performance. To examine this, they
went to a famous music conservatory in Germany and asked the students
to complete a survey regarding their training activities. Ericsson and
colleagues hoped to discover which training activities were associated
with the very best musicians.
When they compiled the data, only one variable reliably predicted
the skill level of the musicians: the amount of time the students had
spent practicing their instrument alone. Further investigation revealed
that the students were not just simply practicing their instruments but
were primarily working on goals to improve particular aspects of their
performance identified during the weekly meeting with their master
teachers. The students were engaging in a comprehensive series of
activities designed to maximize skill acquisition. According to Ericsson
(2006), these activities are:
They termed this process deliberate practice. Notably, all of the top
performers at the music conservatory had accumulated a minimum of
thousands of hours of solitary deliberate practice. This finding led to the
widely known “10,000 hour rule” popularized by Malcolm Gladwell in
his 2008 book Outliers, although the actual number of hours required for
expertise varies by field and by individual (Ericsson & Pool, 2016). The
widespread misunderstanding that 10,000 hours of work performance
leads to expertise is not accurate: 10,000 hours of solitary deliberate practice
was found to be the minimum for expertise. As I discuss in Chapter 4,
this misunderstanding holds considerable significance for the field
of psychotherapy, where hours of work experience with clients has
traditionally been used as a measure of proficiency.
Many professions rely on solitary deliberate practice to improve
performance. When a basketball player is told by his coach that he
needs to sharpen his 3-point shots and then arrives an hour early every
day to practice his shots until he improves, that’s solitary deliberate
practice. When a chess player loses a tournament, identifies a specific
opening sequence that would have helped him, and then spends hours
repetitively trying out that sequence against a computer chess training
program, that’s solitary deliberate practice. When a surgeon learning a
new laparoscopic procedure spends hours repetitively practicing on a
simulator that provides continuous feedback on his accuracy, that’s
solitary deliberate practice.
What about psychotherapists? While professional dancers, musicians,
athletes, orators, etc. would never expect to improve their performance
without investing many, many hours in solitary deliberate practice, most
psychotherapists will get through years of training, licensure, etc. without
having spent even a full hour in solitary deliberate practice. I sure didn’t,
and I had never met a therapist who did.
It’s not because we are lazy or don’t care. The vast majority of us care
deeply about helping our clients and are willing to invest substantial time
and money in becoming better therapists. However, unlike most other
professions, our field simply does not have a model for how to use solitary
deliberate practice to improve our work.
xi
PROLOGUE
xiv
PROLOGUE
substantial life-change improvements. But I have also had some who left
disappointed after a few sessions or, even worse, left after many sessions
with no positive change to show for their investment of time and money.
If this is disappointing to you—if you are looking for guidance or
clinical wisdom from a master psychotherapist—there are many other
books available for this purpose.2 However, while I am not a master
psychotherapist, I am passionate about becoming one, which has led
me on a never-ending quest to find more effective clinical training
methods. That is what this book is about: learning how to become an expert
psychotherapist. This process starts by acknowledging our clinical failures
(the “other 50%”), dropping our assumptions about what constitutes
effective psychotherapy training, and reexamining the whole endeavor of
psychotherapy skill acquisition from the ground up.
Let’s begin.
NOTES
1 All psychotherapy cases presented in this book have been modified to preserve
the confidentiality of the clients.
2 It is worth noting, however, that the claims of clinical expertise in these volumes
are usually not based on actual outcome data, but instead on the authors’ decades
of experience as therapists, or the quality of their writing. These claims are dubious.
Several large studies have recently suggested that years of clinical experience is not in
itself a reliable indicator of clinical expertise (Goldberg et al., 2016; Tracey et al., 2014).
I do not mean this as a criticism of these authors; not collecting or reporting outcome
data is the norm in our field. As I suggest in Chapter 5, this is a problem that needs to
be addressed if our field is to achieve substantial improvement in effectiveness.
xv
ACKNOWLEDGMENTS
alternate definitions is beyond the scope of this book; readers are referred
to Ericsson and Pool (2016) for an in-depth review of these topics.
William McGaghie also provided important assistance for this
project. As we will review in Chapter 5, Dr. McGaghie is one of the
leading proponents of using deliberate practice for the reform of medical
training. His pioneering work in medicine is a model of what we can
hopefully achieve in psychotherapy over the next few decades. I am also
indebted to Daryl Chow for inspiration and advice on this topic. Daryl
ran the first empirical study on deliberate practice and psychotherapy,
which was instrumental in opening my eyes to the potential in this area.
Additionally, I am thankful to Noa Kageyama for his generous assistance
and encouragement.
Allan Abbass, Patricia Coughlin, and Jon Frederickson helped this
project in many ways. First, they are case examples of psychotherapists
who strive tirelessly to improve their clinical skills and openly discuss
their outcomes. Additionally, all were willing to discuss their personal
training methods with me. Allan and Jon provide invaluable clinical
supervision that greatly benefits my clinical work. Just as important,
Patricia provided my first experience of truly top-notch psychotherapy.
Jon was the first psychotherapist to show me how to use the principles of
deliberate practice for psychotherapy supervision. I am deeply indebted
to all three.
This book is based on the intersection of two major domains of
research: psychotherapy outcomes and clinical supervision. I am very
fortunate to have benefited from encouragement and mentoring by
psychotherapy researchers in both domains. Jason Whipple, a researcher
in routine outcome monitoring, provided important advice on every
section of this book. Michael Ellis and Ed Watkins, who produced some
of the key clinical supervision literature that serve as the foundation for
this book, generously provided valuable guidance throughout my career,
as well as encouragement for this project.
I am also indebted to the therapists who experimented with the
exercises in this book, including the trainees I have supervised and the
licensed therapists who have attended my classes on deliberate practice.
Their curiosity and courage have been an inspiration. Much of the
information in Parts III and IV of this book was gleaned from their
experiences experimenting with deliberate practice.
xvii
ACKNOWLEDGMENTS
xviii
Part I
The wild cat ranges from the far north of Scotland, across Europe
and Northern Asia, to the northern slopes of the Himalaya. It has
always been known as one of the fiercest and wildest of the cats,
large or small. The continual ill-temper of these creatures is
remarkable. In the experience of the keepers of menageries there is
no other so intractably savage. One presented to the Zoological
Gardens by Lord Lilford some eight years ago still snarls and spits at
any one who comes near it, even the keeper.
The real wild cats differ in their markings on the body, some being
more clearly striped, while others are only brindled. But they are all
alike in the squareness and thickness of head and body, and in the
short tail, ringed with black, and growing larger at the tip, which
ends off like a shaving-brush.
In the Lynxes we seem to have a less specially cat-like form. They are
short-tailed, high in the leg, and broad-faced. Less active than the
leopards and tiger-cats, and able to live either in very hot or very
cold countries, they are found from the Persian deserts to the far
north of Siberia and Canada.
Of the lynxes the Caracals are perhaps the most interesting, from
their capacity for domestication. They are found in Africa in the open
desert country, whereas the Serval is found in the thick bush. In
Africa it is believed to be the most savage and untamable of the
Cats. That is probably because the Negro and the Kaffir never
possessed the art of training animals, from the elephant downwards.
In India the caracal's natural prey are the fawns of deer and
antelope, pea-fowl, hares, and floricans. The caracal is the quickest
with its feet of any of the Cats. One of its best-known feats is to
spring up and catch birds passing over on the wing at a height of six
or eight feet from the ground. A writer, in the Naturalist's Library,
notes that, besides being tamed to catch deer, pea-fowl, and cranes,
the caracal was used in "pigeon matches." Two caracals were backed
one against the other to kill pigeons. The birds were fed on the
ground, and the caracals suddenly let loose among them, to strike
down as many as each could before the birds escaped. Each would
sometimes strike down with its fore paws ten or a dozen pigeons.
"Caracal" means in Turkish "Black Ear," in allusion to the colour of
the animal's organ of hearing.
The Common Lynx is a thick-set animal, high in the leg, with a square
head and very strong paws and forearms. It is found across the
whole northern region of Europe and Asia. Although never known in
Britain in historic times, it is still occasionally seen in parts of the
Alps and in the Carpathians; it is also common in the Caucasus. It is
mainly a forest animal, and very largely nocturnal; therefore it is
seldom seen, and not often hunted. If any enemy approaches, the
lynx lies perfectly still on some branch or rock, and generally
succeeds in avoiding notice. The lynx is extremely active; it can leap
great distances, and makes its attack usually in that way. When
travelling, it trots or gallops in a very dog-like fashion. Where sheep
graze at large on mountains, as in the Balkans and in Greece, the
lynx is a great enemy of the flocks. In Norway, where the animal is
now very rare, there is a tradition that it is more mischievous than
the wolf, and a high price is set on its head.
Photo by A. S. Rudland & Sons.
EUROPEAN LYNX.
The largest of the cat tribe left in
Europe.
In Siberia and North Russia most of the lynx-skins taken are sold to
the Chinese. The lynx-skins brought to London are mainly those of
the Canadian species. The fur is dyed, and used for the busbies of
the officers in our hussar regiments. These skins vary much in
colour, and in length and quality of fur. The price varies
correspondingly. The Canadian lynx lives mainly on the wood-hares
and on the wood-grouse of the North American forests. The flesh of
the lynx is said to be good and tender.
Brehm says of the Siberian lynx: "It is a forest animal in the strictest
sense of the word. But in Siberia it occurs only singly, and is rarely
captured. Its true home is in the thickest parts in the interior of the
woods, and these it probably never leaves except when scarcity of
food or the calls of love tempt it to wander to the outskirts. Both
immigrants and natives hold the hunting of the lynx in high esteem.
This proud cat's activity, caution and agility, and powers of defence
arouse the enthusiasm of every sportsman, and both skin and flesh
are valued, the latter not only by the Mongolian tribes, but also by
the Russian hunters. The lynx is seldom captured in fall-traps; he
often renders them useless by walking along the beam and stepping
on the lever, and he usually leaps over the spring-traps in his path.
So only the rifle and dogs are left."
By permission of Mr. S. B. Gundy] [Toronto.
CANADIAN LYNX.
Great numbers of these are trapped every year
for the sake of their fur.
The Red Lynx is a small American variety, the coat of which turns
tawny in summer, when it much resembles a large cat. It is called in
some parts of the United States the Mountain-cat. This lynx is 30
inches long in the body, with a tail 6 inches long. It is found on the
eastern or Atlantic side of the continent, and by no means shuns the
neighbourhood of settlements.
THE CHEETA.
The cheeta is more dog-like than any other cat. It stands high on
the leg, and has a short, rounded head. Its fur is short and rather
woolly, its feet rounded, and its claws, instead of slipping back into
sheaths like a lion's, are only partly retractile.
Mr. Lockwood Kipling gives the following account of the cheeta and
its keepers: "The only point where real skill comes into play in
dealing with the hunting-leopard is in catching the adult animal
when it has already learnt the swift, bounding onset, its one
accomplishment. The young cheeta is not worth catching, for it has
not yet learnt its trade, nor can it be taught in captivity.... There are
certain trees where these great dog-cats (for they have some oddly
canine characteristics) come to play and whet their claws. The
hunters find such a tree, and arrange nooses of deer-sinew round it,
and wait the event. The animal comes and is caught by the leg, and
it is at this point that the trouble begins. It is no small achievement
for two or three naked, ill-fed men to secure so fierce a capture and
carry it home tied on a cart. Then his training begins. He is tied in all
directions, principally from a thick rope round his loins, while a hood
fitted over his head effectually blinds him. He is fastened on a strong
cot-bedstead, and the keepers and their wives and families reduce
him to submission by starving him and keeping him awake. His head
is made to face the village street, and for an hour at a time, several
times a day, his keepers make pretended rushes at him, and wave
clothes, staves, and other articles in his face. He is talked to
continually, and the women's tongues are believed to be the most
effective of things to keep him awake. No created being could
withstand the effects of hunger, want of sleep, and feminine
scolding; and the poor cheeta becomes piteously, abjectly tame. He
is taken out for a walk occasionally—if a slow crawl between four
attendants, all holding hard, can be called a walk—and his
promenades are always through the crowded streets and bazaars,
where the keepers' friends are to be found; but the people are
rather pleased than otherwise to see the raja's cheetas amongst
them." Later, when the creature is tamed, "the cheeta's bedstead is
like that of the keeper, and leopard and man are often curled up
under the same blanket! When his bedfellow is restless, the keeper
lazily stretches out an arm from his end of the cot and dangles a
tassel over the animal's head, which seems to soothe him. In the
early morning I have seen a cheeta sitting up on his couch, a red
blanket half covering him, and his tasselled red hood awry, looking
exactly like an elderly gentleman in a nightcap, as he yawns with the
irresolute air of one who is in doubt whether to rise or to turn in for
another nap."
BY LOUIS WAIN.
Photo by T. Fall]
WHITE [Baker Street.
SHORT-HAIRED.
Most white cats are not
albinoes—that is to say, they
have ordinarily coloured and
not red eyes.
Watch your own cat, and you will see that he will change his
sleeping-quarters periodically; and if he can find a newspaper
conveniently placed, he will prefer it to lie upon, before anything
perhaps, except a cane-bottomed chair, to which all cats are very
partial. If you keep a number of cats, as I do, you will find that they
are very imitative, and what one gets in the habit of doing they will
all do in time: for instance, one of my cats took to sitting with his
front paws inside my tall hat and his body outside, and this has
become a catty fashion in the family, whether the object be a hat,
cap, bonnet, small basket, box, or tin. If by chance one of the cats is
attacked by a dog, a peculiar cry from the aggrieved animal will
immediately awaken the others out of their lethargy or sleep, and
bring them fiercely to the rescue. They are, too, particularly kind and
nice to the old cat, and are tolerant only of strange baby kittens and
very old cats in the garden as long as they do not interfere with the
"catty" subject. The same quality obtains in Spain or Portugal, where
a race of scavenging cats exists, which go about in droves or
families, and are equal to climbing straight walls, big trees,
chimneys, and mountain-sides. Long, lanky, and thin, they are built
more on the lines of a greyhound than the ordinary cat, and are
more easily trained in tricks than home cats.
MACKEREL-MARKED
TABBY.
Tabbies are probably the
best known and the
commonest cats in
England.
Photo by L.
Medland, F.Z.S.,
North Finchley.
CAT CARRYING
KITTEN.
A unique
photograph,
showing the way in
which the cat carries
its young.
Photo by E. Landor,
Ealing.
BLUE LONG-
HAIRED, OR
PERSIAN.
Persian or long-
haired cats are of
various colours; this
is one of the least
common.
Photo by E. Landor,
Ealing.
LONG-HAIRED
TABBY.
A pretty pose.
Photo by E. Landor,
Ealing.
SILVER PERSIAN.
A handsome specimen.
Photo by E. Landor,
Ealing.
SMOKE LONG-
HAIRED, OR
PERSIAN.
A new breed.
The Tortoiseshell has long been looked upon as the national cat of
Spain, and in fact that country is overrun with the breed, ranging
from a dense black and brown to lighter shades of orange-brown
and white. The pure tortoiseshell might be called a black and tan,
with no white, streaked like a tortoiseshell comb if possible, and with
wonderful amber eyes. It is characteristic of their intelligence that
they will invariably find their way home, and will even bring that
mysterious instinct to bear which guides them back long distances to
the place of their birth; and, with regard to this cat, the stories of
almost impossible journeys made are not one bit exaggerated. The
tom-cats of this breed are very rare in England; I myself have only
known of the existence of six in fifteen years, and of these but three
are recorded in the catalogues of our cat shows.
SHORT-HAIRED BLUE.
This champion cat belongs to
Lady Alexander, by whose kind
permission it is here
reproduced.
The Black Cat has many of the characteristics of the tortoiseshell, but
is essentially a town cat, and is wont to dream his life away in shady
corners, in underground cellars, in theatres, and in all places where
he can, in fact, retire to monastic quiet. The black cat of St. Clement
Danes Church was one of the remarkable cats of London. It was his
wont to climb on to the top of the organ-pipes and enjoy an
occasional musical concert alone. A christening or a wedding was his
pride; and many people can vouch for a lucky wedding who had the
good-fortune to be patronised by the black cat of St. Clement Danes,
which walked solemnly down the aisle of the church in front of the
happy couples.
My old pet Peter was a black-and-white cat, and, like most of his
kind, was one of the most remarkable cats for intelligence I have
ever known. A recital of his accomplishments would, however, have
very few believers—a fact I find existing in regard to all really
intelligent cats. There are so many cats of an opposite character, and
people will rarely take more than a momentary trouble to win the
finer nature of an animal into existence. Suffice it to say, that Peter
would lie and die, sit up with spectacles on his nose and with a post-
card between his paws—a trick I have taught many people's cats to
do. He would also mew silent meows when bid, and wait at the door
for my home-coming. For a long time, too, it was customary to hear
weird footfalls at night outside the bedroom doors, and visitors to
the house were a little more superstitious as to their cause than we
were ourselves. We set a watch upon the supposed ghost, but
sudden opening of the doors discovered only the mystic form of
Peter sitting purring on the stairs. He was, however, ultimately
caught in the act of lifting the corner of the door-rug and letting it
fall back in its place, and he had grown quite expert in his method of
raising and dropping it at regular intervals until he heard that his
signals had produced the required effect, and the door was opened
to admit him.
One man told me that upon one occasion he sold eight cats at an
isolated mining township in Colorado, and some six days' journey
farther on he was caught up by a man on horseback from the
township, who had ridden hard to overtake the menagerie caravan,
with the news that one of the cats had climbed a monster pine-tree,
and that all the other cats had followed in his wake; food and drink
had been placed in plenty at the foot of the tree, but that the cats
had been starving, frightened out of their senses, for three days,
and despite all attempts to reach them they had only climbed higher
and higher out of reach into the uppermost and most dangerous
branches of the pine. The showman hastened with his guide across
country to the township, only to find that in the interval one bright
specimen of a man belonging to the village had suggested felling the
tree, and so rescuing the cats from the pangs of absolute starvation,
should they survive the ordeal. A dynamite cartridge had been used
to blast the roots of the pine, and a rope attached to its trunk had
done the rest and brought the monster tree to earth, only, however,
at the expense of all the cats, for not one survived the tremendous
fall and shaking. A sad and tearful procession followed the remains
of the cats to their hastily dug grave, and thereafter a bull mastiff
took the place of the cats in the township, an animal more in
character with the lives of its inhabitants.
Photo by E. Landor]
[Ealing.
LONG-
HAIRED ORANGE.
A good specimen of this
variety is always large and
finely furred.
SILVER PERSIANS.
Three of Mrs. Champion's celebrated
cats.
Siam sends us a regal animal in the Siamese Royal Cat; it has a brown
face, legs, and tail, a cream-coloured body, and mauve or blue eyes.
The Siamese take great care of their cats, for it is believed that the
souls of the departed are transmitted into the bodies of animals, and
the cat is a favourite of their creed; consequently the cats are highly
cultivated and intelligent, and can think out ways and means to
attain an end.
I have tried for years to trace the origin of the Long-haired or Persian
Cats, but I cannot find that they were known to antiquity, and even
the records of later times only mention the Short-haired. European
literature does not give us an insight into the subject; and unless
Chinese history holds some hidden lights in its records, we are
thrown back upon the myths of Persia to account for the wonderful
modern distribution of the long-haired cat, which is gradually
breeding out into as many varieties as the short-haired, with this
difference—that greater care and trouble are taken over the long-
haired, and they will, as a breed, probably soon surpass the short-
haired for intelligence and culture.
THE FOSSA.
The Civets are the first marked deviation from the Cat Family. Their
bodies are elongated, their legs short, their claws only partially
retractile. Some of them have glands holding a strong scent, much
esteemed in old days in Europe, when "The Civet Cat" was a
common inn-sign even in England. The civets are generally
beautifully marked with black stripes and bands on grey. But none of
them grow to any large size, and the family has never had the
importance of those which contain the large carnivora, like the true
cats or bears. Many of the tribe and its connections are
domesticated. Some scholars have maintained that the cat of the
ancient Greeks was one of them—the common genet. The fact is
that both this and the domestic cat were kept by the ancients; and
the genet is still used as a cat by the peasants of Greece and
Southern Italy.
The African Civet and Indian Civet are large species. The former is
common almost throughout Africa. Neither of them seems to climb
trees, but they find abundance of food by catching small ground-
dwelling animals and birds. They are good swimmers. The Indian
civet has a handsome skin, of a beautiful grey ground-colour, with
black collar and markings. It is from these civets that the civet-scent
is obtained. They are kept in cages for this purpose, and the
secretion is scooped from the glands with a wooden spoon. They
produce three or four kittens in May or June. Several other species
very little differing from these are known as the Malabar, Javan, and
Burmese Civets.
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