How Deliberate Practice is Transforming Therapist Training & Client Outcome with Dr. Tony Rousmaniere

Dan is joined by Dr. Tony Rousmaniere, President of Sentio University.

In this episode, Dr. Rousmaniere emphasizes the importance of accountability in therapy and introduces the concept of deliberate practice as a means to improve therapeutic skills. Then, Dan and Dr. Rousmaniere discuss the establishment of Sentio University, which focuses on rigorous training and feedback for therapists. The episode concludes with reflections on the impact of AI on the field of therapy and the need for therapists to adapt to this changing landscape.

Special Guest: Dr. Tony Rousmaniere

Useful Resources: 

Sentio University

Free Tools for Therapists

Research on Deliberate Practice

Practicing Deliberate Practice

ChatGPT my be largest mental health provider

Demonstration of Deliberate Practice

Supervision Using Deliberate Practice

Deliberate Practice Podcast

Deliberate Practice Exercises

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Chapters

• 0:00 Introduction to the Podcast and Guest
• 6:50 Shocking Realizations About Therapy Outcomes
• 11:27 Resistance to Outcome Monitoring in Training Programs
• 17:15 Therapist Accountability and the Role of Feedback
• 20:39 Understanding Deliberate Practice in Therapy
• 25:33 Translating Therapy Into Micro Skills
• 30:00 Structure and Application of Deliberate Practice
• 38:45 The Sentio Approach to Therapist Training
• 46:12 Tools and Resources for Deliberate Practice
• 49:33 The Rise of AI and Implications for Therapy

Transcript

0:00

[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way. If you find the show interesting, it would be much appreciated if you shared it with someone you know who might enjoy it too. It's a great way to spread the word and keep the conversation going. Today I couldn't be more excited to welcome one of the world's authorities on how to become a better therapist. This is a wonderful conversation that I really had a blast with, and my guest gave out a ton of resources that I think could be helpful for listeners, all of which are linked in the show notes. And part one of our conversation, we dig into my guest view on how to train therapists, which is radically different from how we've done things for the last 75 years. This episode starts with my guest talking about how we got into deliberate practice, so without further ado, it is my pleasure to welcome my very special guest, Dr. Tony Rumineer. You know, I started way back when I was a trainee 20 odd years ago. I, you know, when I joined the field, I was frankly in retrospect a little bit arrogant. I was like, okay, I'm going to be good at this. You know, my friends have told me, I'm good at, you know, giving them help, you know, yada yada yada. And I found to my shock and horror that, as I started seeing clients in my first few practicums that while I was helping some of them, their fair amount of them were not getting better. And I started tracking my outcome data using the methods that Scott Miller and Barry Duncan have, you know, talked about so eloquently. And I mean, I was just completely shocked that about half of my clients were not improving from therapy, which at first I just, I was horrified. I hit it. I didn't tell anyone. I didn't tell my super eyes until anyone because I was afraid that's going to be kicked out of the field. And then as I started to read the psychotherapy outcome research literature, you know, on my coursework, I found that that's actually quite average for the field, about half the clients improving give or take. And so I was a perfectly average trainee. Now, I wasn't satisfied with that. I wanted more of my clients to improve. So I got really focused on how could I become a better therapist? Because I was having the experience in grad school that I know, you know, many students have where my intellectual knowledge about therapy was increasing very quickly. I got very good at writing about therapy. I got very good at debating therapy. You know, I could sit there and debate what's better. So I go to an AMIC CDT and, you know, I could really sound like I knew what I was talking about. But if you watched a video of me trying to help a real client, particularly a client where it's kind of complex or, you know, I had, you know, my own kind of reactions, what you would see in the video is completely different than what I was writing in my papers for school. In other words, there was a break between my cognitive knowledge of therapy and my ability to perform or do therapy with my clients. And I got obsessed with how could I fix that break? How could I make my rate of performance ability and not performance, meaning I'm faking it, but like performance, meaning my ability to actually do therapy. Because therapy is something we do. Therapy is not just something we think about or write about. How could I make my rate of improvement better and more efficient? And that's how I found deliver practice. Okay. So I'm just curious. Did you, when you sort of got those data back and once you realized, okay, I'm normal, right? So sort of some of the stigma went away. Yes. Did you approach supervisors, professors, other people and say like, hey, I'm just sort of curious and what people, like how people responded to what you were saying? Yeah, I mean, there's kind of two layers to that. So when I would tell people that only half my clients were improving, they were, they were not happy about that. And it's, honestly, it's because many supervisors have not read the outcome literature. Right? And they don't collect their own outcome data. So they are living in this fantasy world that 95% of their clients are improving. And every model of therapy has these studies that show, whoa, you know, the vast majority of our clients improve and those studies get passed around. And people will remember those studies. And what they don't do is they don't, you know, look at the larger body of research that shows that, you know, largely most models of therapy are largely equivalent in outcome. And that, you know, roughly 50% of clients are improving. It's actually very rare to find licensed therapists or supervisors that track their own outcome data. And so everyone is just kind of living that it's like, imagine basketball teams where they never saw their own score. And they played for years and years and years, they could talk themselves into thinking that they had a perfect record because they're so good. You know, the same with musicians, if no one ever heard them play or an artist, if no one ever saw their art, you know, most fields, in fact, basically every other field has the benefit of some kind of public observation of the performance. And so they're going to continual feedback on where they need improvement. Our field, just because of the nature of the work is basically one of the most secret fields in the world. Where once you're licensed, you can go 60 years in a career and never get meaningful feedback on your work. Which I think serves as a real detriment to therapists. Yeah, I told this story only once when I had Scott Miller on, which was when I was in graduate school, I read his book, the, well, him and some of his colleagues. And sort of that's where they, I think, you know, because I'm old. So I think that was the first edition where they introduced the session rating, rating scale and the outcome rating scale, which are these super brief four items, right? And so me, so like, I read this book and then I passed along to some of my colleagues who were in like the same practicum that I was. And just, you know, we were third year graduate students. And we just started incorporating the scales in the sessions, because it's it's real. It's so benign, right? And so we just did it. And we didn't ask it. We just did. We didn't think anything of it. And then when our supervisor found out she's not happy. And it turned into a whole thing. But it read and and it always was just like, I mean, at the time, I'm still naive, but I was really naive then. And I was just like, I, it just did not make sense. Like, I don't understand why we wouldn't want to collect this. It takes 15 seconds. So it's not like, it's like, I don't understand what's happening. But, but I think it speaks though, it speaks though to what you're saying and how that's not ubiquitous. It's not everybody. But it is common where people see that as like, you know, I think people interpret it differently, but that there is certain folks are just very resistant to it. Yeah, Scott Miller is one of my greatest mentors. Everything we do at Centio is on his shoulders. You know, he really paved the groundwork and was out, you know, just beating the pavement on this when a lot of people didn't want to hear about it. And I think history has proven him right in many, many ways. When I started tracking outcome data at my practicum, which was a, a, a, a, a, community mental health center run by the government, my supervisor, my supervisor was very supportive, but she said she had to run it by the director and the director ran it by the lawyer and the lawyer said, no. And I was like, what do you mean? Why? And he is like, well, what if someone does poorly? We don't want a written record of that. And I'm like, what do you mean? Like, that's what we want the most is to find out. And so what I did is I probably shouldn't say this on podcast. But what I did is I got one of those whiteboards and I copied the outcome rating scale onto the whiteboard so I could collect the data and put it in my own private day and then erase it each time. So if, you know, if that lawyer found it, it would have been erased. And so I had my own, it was basically black market clinical outcome data. But it was helping me identify which of my clients were not improving. And we all know that, you know, our field has about a 5 to 10% rated deterioration, meaning someone symptoms get worse during therapy. And those are really the clients we should be most concerned about. And unfortunately, the clients won't always tell us that, like directly, they'll be like, oh, you're great. You're doing so well. You know, they often want to make us happy and they blame themselves for there being not going well. So it's important that we try to, you know, collect the outcome data to try to identify. I think that's an amazing story. That beats my story because I think we just put our tails between our legs and stop doing it. But I think that like it is, it is one of those interesting like you're trying to do the right thing. And so you sort of have to skirt what your, what authority, what you should be deferential to in a way, is telling you to do to help your clients as best you can and to help you become a better therapist. It's an amazing story. I mean, it speaks to what we're facing is really a culture change in our field. Where our field has basically gotten away without having accountability because we work in secret and because no one really understands what we do. And talking about what we do makes most people uncomfortable that we've, we've kind of gotten away without accountability. And our whole thing at Centito is increasing therapist accountability through outcome. And I know we're going to maybe, maybe touch on this later on. I actually think the error of non accountability is coming to a close because of AI. I think AI is going to provide an alternative to human therapy. And for the first time in a hundred years, we're going to have a real competitor. And so the more we can focus on internal accountability within our field and the better we can get the higher a chance we have of thriving in this new world that's coming. So we've talked about in a way routine outcome monitoring or whatever however you want to call it. So we're getting data back. The one of the reasons I wanted, the primary reason I wanted to have you on was to talk about deliberate practice. Now obviously these in a way, preparing for this, I was trying to separate these two things and sort of like, well, can you really, but so why don't we start with to just sort of frame 30,000 foot view what is deliberate practice? Yeah. So most listeners will have actually engaged in deliberate practice whether they realize it or not. So let me, let me, let me, here's a good way to go through it. Let me ask you, did you ever play a sport or a musical instrument growing up? Uh-huh. Yeah. So what sport? Baseball. Baseball. Okay. So, uh, and you have a coach and a team and, uh, I, how many hours of practice do you think baseball practice? You, as a ratio to the number of hours in playing baseball games? Oh, I mean, practice is way more. I mean, you know, playing in school during the season, which was even preseason, whatever. I mean, it's, yeah, preseason. It's just two hours a day. Yeah. Right? So it's two hours a day for a few months. Okay. Right. Now imagine, here's a thought experiment. Imagine you went to your coach, your baseball coach, and you said, you know, coach, I love baseball. I think I'm pretty good at it. I think I'm pretty gifted. In fact, I think I want to play professionally, you know, college and then professionally, but I want to be honest with you. I don't have time for practice. I just can't do it. You know, I, I got homework, I got a club, you know, when I'm older, I'm going to have, you know, a family and kids and work. So how about instead of practice, I just, I do two or three thousand hours of baseball games. No practice. Just the games. I'll write notes after every game. We can meet once a week for an hour and talk about my notes. You can give me feedback based on my notes. And over three thousand hours of that, do you think that'll get me to a professional baseball ability? What would your coach say? Oh, it's, I mean, silly. Right. It's laughable. It's inconceivable. Right? It's a completely inconceivable. Now, that is our model for therapist training. There is, we have trainees study therapy and then do therapy with clients. We call it practicing therapy, but it's not actually practice because they're performing therapy with real clients. It's like a real baseball game. You have an opposing team there. The difference between deliver practice and performance is in practice, you can pick micro skills. So let's say, you know, hitting the ball. And you can have a pitcher throw 50 or 100 pitches at you. And you take a swing each time. And you have a coach standing right there and says, oh, you know, lift your elbows a little bit or lift the bat a little higher or look, you know, this way when you're hitting the ball, in over time you can refine your performance of the micro skill with feedback. Now, that is in contrast to performing baseball with an opposing team where you do not get 50 or 100 tries at bat, you have to, it has to work. Right? So deliver practice is when you take us a whole field, like say baseball or therapy or maybe if you play piano or if you're learning to fly a plane or you're playing chess or any number of the scuba diving you name it, these fields are typically taught by breaking down work performance into micro skills and repeated rehearsal of those micro skills with feedback. So how have you come to think about that in terms of in preparing for this and thinking a lot and thinking about the and thinking, man, how do you even begin to cut that? How do you even begin to slice psychotherapy in terms of the micro skills in a because there's so many variables, right? And so many things happening simultaneously. So I'm curious, where, where, how, where have you come down on that? Well, here I can give you an example. I'm going to pull this up one second. So I'm going to put a link in a chat and you can share this with your audience. This is a page of specific therapy micro skills from a variety of models and corresponding slides and exercises to do deliver practice to practice those skills. And the way we have approached this is we have worked with leading teachers of many major models of therapy. So we have a book series through the American Psychological Association and we've published at 15, 18 something like that books on different models of therapy. So a motion focus therapy, cognitive behavioral therapy, motivational interviewing, DBT, so on and so forth. And we asked the leaders of those models of therapy to identify a dozen or so key crucial micro skills that students should learn. And then from each of those skills we develop a deliver practice exercise so students can drill down on it. Now, you know, every model of therapy has potentially hundreds of skills. So these are not comprehensive. But this would be like in baseball what are their crucial key skills? Swinging the ball, catching the ball, maybe throwing the ball like really basic skills that we think students should practice. Now, so that's one approach to it. The other approach we also take is have you probably heard of the common factor of therapy? So common factors, researchers, Bruce Wampold, Scott Miller, involved with research and others have identified skills or factors that are most important for therapy outcomes that are trans-model. So they apply it basically every therapy model. And we also have deliver practice exercises for those skills. And so here I will put a link for we've actually got a a podcast series for that. Hold on one second. I'll put that in the chat as well. And let me see you know, I've never done this before. Let me see if I can actually share if I lose you. We'll figure this out. Let's see if I can do it. Let's see if I can click on that and then click on share and see what happens. Oh, look at that. Okay. So for the folks who are watching on YouTube. And so there will be a certain percentage that are watching on YouTube. So we should describe what's here. But so what I've shared is a list of on a like a Google spreadsheet. A whole bunch of deliberate practice exercises are in one column. Then there's slides and then there's recommended resources. And so each deliberate practice exercise has a hyperlink. So as I'm reading going down here. So there's one on a listening change talks. That sounds like a motivational interview kind of a thing exploring conflicting parts of self presenting outcome monitoring, providing rationales for focusing on emotion. And so for each one of these, I'm guessing I click here and then it'll pull up the exercise that corresponds to that. Yeah. Now these are great to use in graduate coursework. They also we've heard been used by undergraduate professors who are teaching classes and you know, introduction to therapy, you know, kind of a clinical skills course. And then they can also just be used by therapists who are in independent practice for their own professional development. Right. Okay. So so this is the first link. Now there's a second link which is a YouTube podcast series, which is also available on Spotify and the other podcast apps, I believe, which is a series of six episodes that focus on common fact, deliberate practice, a common factor skills. Okay. And for listeners of this podcast, I really encourage you to to try one of these yourself. It delivers practices, the kind of thing that makes a lot more sense, even if you just spend five minutes trying it yourself. Right. And so I just clicked on I didn't pull it up and I'll link all these in the show notes. So they'll be there. But like so I'm looking in so the on the YouTube, the podcast, you know, episode one and pathic understanding, episode two collaborative goal setting, you know, later on soliciting client feedback, therapist self disclosure. These are some of the topics that are covered. And this is, you know, I said, you know, Scott Miller is one of our my greatest mentors. Everything we do is built on these shoulders. This is one of the areas where we slightly disagree, which is he is really into common factors and he wants everyone to focus on skills in the common factors. I am my team are we're more open. We think a lot of trainees benefit from learning a model because the model kind of provides a whole map for structured therapy. And so we have exercises for specific models of therapy as well. That's all right. I want to get I want to take a little bit of a detour here because I want your opinion on this. So this is something that sort of I think programs generally some there's different opinions, right? So I think that most people would, let me say this, in my world, I'll say many folks would agree that there isn't one approach that is empirically better than you know, another, right? So we can sort of just generally say that we can generally more or less agree on that. But approaches provide structure. Yes. And especially for early trainees, they crave structure. I did. Yes. So, not just that. Keep going please. It also one of the common factors is the therapist ability to provide a coherent rationale for how and why therapy works. And you know what does that mount? And clients appreciate that. Now, he doesn't mean that they have to say this is the best model of therapy is the only model blood that it up. But having a coherent rationale, which the therapist feels comfortable with. Now the research shows that across models we're not seeing differences in client outcome. However, I have found that different therapists feel more comfortable with different models of therapy. And so why not let them use that? So, do you lean on the side of training programs do well to sort of to start students in an approach and sort of start narrower and then broaden as they move along? Yeah, I think when you when you learn any skill, you typically start with a model. And you're working within a model and then as you gain proficiency and expertise, you learn additional models and you eventually develop your own personal model. And I think most therapists end up with their own personal, you know, Dan's N of one model of doing therapy, right? Which is going to be very unique to you. And we'll likely include a bit of a bunch of different models you've learned. And so that's where we want you to end up, but to expect you to be there in your first three months of therapy is crazy. So what we do at Centrios, we teach a number of different models of therapy that we think are accessible and appropriate for beginners. And we are using deliberate practice to help those trainees internalize those skills and then personalize the skills. And if it's okay if I expand upon that a little bit. Absolutely. So one of the most common concerns I hear about deliberate practice is that it's going to turn therapy to reductionist approach to therapy. It's like, oh, therapy is as hard. It's nuanced. It's ultimately kind of ineffable. And if you break it down into micro skills, you're really just, you know, reducing it to, you know, to pieces. And you could turn therapists into a cog in a machine or robot. And there we don't want therapists just memorizing lines. You know, when I was in training, I tried reading the transcripts of the great therapist and memorizing their lines and saying those lines to my clients. Can you guess how well that worked? Yeah. Yeah. That's right. Actually, I clients tell me, Tony, it sounds like you memorized that line. That's super vision we get from our clients. And so I learned, unfortunately, that was, I was going to have to come up with my own life. And so, and so what you do, it's actually deliberate practice is quite the opposite. There's a famous musician, I forget his name, who said something to the effect of without thousands of hours of practice, I would not know how I sound. That musicians learn chords and memorize pieces to then discover their own personal style. Right? It's the same with art students. They learn models of art to discover their own style. Right? Jazz, jazz is improvised, but jazz musicians start by memorizing and practicing the same body of skills. And deeply internalizing those skills then lets them improvise. And so that's what we focus on with our students is we are having them practice micro skills that are defined from the models, but the goal is for them to stretch experiment because in deliberate practice, you're rehearsing in a role play. And so, you're allowed to make mistakes. You're allowed to try things. You're allowed to stretch. When you're with a real client, it's a little different. You know, like it's higher stakes. So, yeah, when you're talking about the musician, like what I was thinking about is like finding your voice. Yes, thing. And that like, I mean, I certainly, I was thinking about you, I like stand-up comedy a lot. And listening to stand-up comedians talk, they talk about how they need to do it for years before they can just to learn how to craft a joke and do all that sort of stuff. Before and then at some point, they start to figure out what they actually care about and they can find their voice. And they keep practicing. They don't, in fact, from what I've heard, the higher in the field they get, the more they practice. It's the same with basketball players. When someone gets into the NBA, they don't stop practicing. If anything, they practice more than anyone else. And our field is completely opposite. Once we get our license, it's like, okay, good, that's done. I think so, you've mentioned sentio several times. I think it would make sense for you to just tell us about sentio. Yeah, so, you know, I spent a number of years writing about deliver practice and then teaching, doing workshops and consultations and my colleague, Alexandra Vaz joined me in a lot of that. And we went around the world, ex-stalling the use of deliver practice and we're encouraging faculty to do it in their courses and so on and so forth. And what we kept hearing is that people were excited about the idea, you know, not everyone, but many people were excited about the idea. But then when they went to do it, they would face institutional inertia and they're like, well, you know, my school has these requirements, you know, for a certain amount of lecture or a certain amount of this or a certain amount of that and everyone had good intentions. It's not like anyone was saying, no, you can't do that. But it's just that the field has so much institutional legacy inertia that they were just not able to really make these changes or very few people were. And so just starting to erupt, but we're going through our rear accreditation stuff right now. Right there. It's all comes from good motivations and there's value in it and all that sort of stuff, but you're, but we're dealing with, okay, we have to meet this competency for this specific thing. What class does that go in? And so, I didn't mean to interrupt, but I just, I was just feeling what you were saying. Well, hold on. This is important. So when the accreditation committee is assessing whether you're helping students achieve competency, are they looking at their clinical outcome data? Absolutely not. Are they looking at videos of them performing skills? No. They're looking at paperwork. Yeah. That's the difference. Is our field in an intention to improve quality has gotten super focused on paperwork. And research shows, unfortunately, that the more years you are in graduate school does not improve your clinical outcomes. And I think this is part of the reason why we have to break the cord from paperwork. Right. I think graduate school for therapists should look more like a music conservatory than philosophy school. Right now we look like philosophy school. It should be like a music conservatory or even athletic training program. What does a music conservatory look like? Where most of your time is spent rehearsing and getting feedback on rehearsal. Now there's definitely some theory. You know, there's definitely some performance, but the vast majority of the time is spent rehearsing with feedback. And so to go back to the Centio, what we realized in 2020 is we just have to do it ourselves. It's not fair for us to ask everyone else to make this big change. So we're starting our own graduate school from scratch, not affiliated with any other school. It's called Centio University is based in Los Angeles and we're starting with a Merit and Family Therapist program. Our first cohort is in their third semester now. Very courageous first cohort. The website is a centio.org. And it's different than other schools. It's really focused on deliberate practice. We're collecting outcome data from all the clinical work with all the clients. The students present videos of their clients in every class. So five days a week they are presenting videos of their clients and getting feedback on those clients and then going through skill rehearsal to improve their work with those clients. It's very rigorous. It's very vulnerable to be frank. I mean look writing about therapy is not very vulnerable. Showing your work of your mistakes with the client who's deteriorating is very vulnerable. But that's where we learn the most. Is when you bring a video to your professor, supervisor and you're like, I try doing what I learned in it completely blew up. The client hated it. I have no idea. What do I do next? I have no idea. That is the best opportunity for learning. And so we want to maximize opportunities for that in the program. And that's what we're doing. So when they start the program, are they starting clinical work immediately? No. So we have I wanted that. But they have to take a course in ethics and law. And basically they have to do a semester first. And so they have one semester of traditional coursework except there's a ton of deliberate practice added in. By in fact, we have a disclaimer on our website that says this this program is probably not for you because it's way harder than you need to normally get a degree. So but there's deliberate practice throughout the whole first semester and then starting the second semester they start seeing real clients. So what does deliberate practice look like in semester one? So add whatever they are learning in class. So like for example, they start off learning common factor therapy skills. Every skill they learn they also rehearse. Not just skills they learn ethics they rehearse challenging ethical scenarios. For example, an important one they rehearse is if you have a client who is dangerously suicidal and you have to call the emergency providers you have to call the police or get them to the hospital. We have them repress that. Because what we found and what the research on learning suggests and people have known this for decades is people can students can memorize all kinds of material. But when they have to perform it it just is gone. Especially if they have to perform it under stress. And you may many of our listeners may have noticed that we perform under stress, you know, not in frequent. So we need those skills in our bones. It's called muscle memory. And you only get that by reverseing it. So this is just sort of the expectation is that basically every class either in class or outside for homework, people are going to get into groups, you know, one, two, three. What I haven't read in people and practice these skills and then record it. They so they start by learning the skill and they visit in class. They do it as a group. So they so there's like a demonstration with with feedback. Everyone in the group tries it. And then they move into diads and they practice it in diads. And then they do it again as homework. In diads. Yes, and record it. Yes. Yeah. And they're getting feedback throughout the whole process from the professor. And then they do that in supervision as well. In supervision? Yeah. So in supervision. So traditional supervision, a trainee will bring their notes or if they're lucky, they'll have a video of the client and they'll show the video or their notes and the supervisor will be like, well, you know, I think you client could benefit more from this or that or the other thing. And they kind of talk about it for an hour. Our supervision is very different. We use what's called the Centio's Supervision Model. Here, let me put the link in the notes here. We actually have a year-long training for supervisors on how to do deliver practice supervision. And here is the link for that. And what we train our supervisors to do is to look at the look at the Alchem data, first of all. Look at the video, second of all, but then come up with a practical skill that the trainee can use to improve their work and then rehearse that skill. They don't rehearse it. Let me ask you this. When you're playing baseball, let's say your coach taught you a new way of throwing. How many times would you want to rehearse that before you would feel confident using it in a game? Well, I mean, in if I can't remember my younger self, but I would tell you now it would be a lot. I mean, to do anything like that because like if it's a new way of throwing, right, you're not just, it's not just you're learning a new skill. It's you have to your body's going to keep wanting to do the thing it used to do. Bingo. Yeah. So typically in tradition, so a lot of therapy faculty and supervisors use role plays, but it's an extended role play. It might go for 10 or 15 minutes where you're just kind of doing therapy and that's great and all, but you're only getting to do once each skill once. You're not going to internalize it. Typically trainees need to rehearse a skill at least 10, 20, 30, 50 times to really internalize it. And so that's what we are focusing on. Now this is not fun. You may have remember that baseball practice was not always fun. You know, this is hard. It can it's grueling. It's effortful. It can get boring. It can feel monotonous. But this is how we get really good at challenging skills that we need to perform under stress. Right. So then so that so this in the in the classroom, this not just this approach, but you you articulated a pretty specific first you do a then you do B then you do C then you do D, right. You sort of had you laid out the sequence. Yeah. So is it that more or less that same sequence that persists in every class? Well, the structure of deliver practice is is is usually the same. There are some edge cases where things are a little different. What's the what's the structure? So the structure is you describe the skill. You make sure everyone understands the skill. So a basic skill would be empathic reflection. So in fact, let me let me show you a put a video in the link here for everyone. Hold on one second. Alex Vaz made a great demonstration of deliver practice and I'm putting the link right here. This is a YouTube video. It's eight minutes and so you could really see what it's like. But what he does is he describes the skill. I think it's empathic reflection. This is a skill from a motion focused therapy, but frankly, it's used in every model therapy. Right. So we would consider this a you know, a common factor skill. And he describes the skill and makes sure the trainees understand it. And he then demonstrates the skill in a role play. And then he asks the trainees to perform the skill. So he will role play a client and he will say something. He'll say something to the effective like I feel sad because I lost my pet dog the other day. And the trainee will try to perform in a pathic reflection. And he will then provide feedback. And then they'll try to get it. And then he'll perform as a client a different statement like, oh, it's winter and it's dark all the time. So I'm feeling down and then she'll try that. And you'll just keep doing it again and again and again and again and again. And what we want to see is we want to do it enough time so that the trainees demonstrating competence across a broad range of client presentations. So then so can you take us to for the I'm a clinical supervisor working with a student. That's a bit that's a rather uncontrolled environment, not supervision, but the real world psychotherapy that the student's doing. Yes. How does that? How do they work to figure to bring this? How do they put structure on? How do they make decisions, I assume, with a student to work on? Yeah, it's collaborative with the student. Right. Because when we don't want to fall into as a student just pretending to, you know, like pretending doesn't work. If you're just going through the motions, you're not learning. So what what happens is that the student in our program, we have videos of every client session. And the supervisor watches the section of the video that the the training marks bookmarks, sections of the video where they're like, this is where I need help. The supervisor watches those sections. They might watch more of the video if they want. And the supervisor using their experience determines, okay, what can help the trainee in this situation? What specific skill? It might be the skill that the trainee is trying to use, but sometimes trainees are very confused about what's going on with the client and it might be another skill they haven't even considered. So for example, I can go back to my own training. I've had clients where I thought what I needed to do was help them with skills to move forward in life. My supervisor after watching the video saw, wait a minute, Tony, this client actually has dysregulated anxiety and is kind of frozen with you in session. And so while you're trying to help them learn skills, they're not internalizing any of this, which you have to do first is help them with their anxiety. And so I had to kind of back up and learn the host skill and rehearse those skills and then do that. And then we could move on to what I was previously trying to do. And so that's that's fairly common in supervision. The important part is that we want our supervisors to spend at least half the supervision session rehearsing those skills. As far as we're concerned, when the supervisor says the solution, that is not worth anything. It goes in one, the supervisor can write it down, they can go study it, but when they go sit down and try to use it with their clients, it often disappears. It's kind of like in baseball, if your coach describes a new way to throw the ball, you can write that down, you can read books about it, but until you rehearse doing it, forget it, there's no way you know how to do it. And so the rehearsal is the primary teacher in supervision. The supervisor's job is to guide the rehearsal. That is a major difference from traditional supervision where the supervisor's wisdom is seen as somehow providing the benefit to the training. When you're talking, one of the things, so I teach some basic counseling, helping skills to class. And I'm very much on the same page of we need to do it, we need to do it. And I always think if there's this line from this '90s movie and it was something like talking about love is like dancing about architecture. And that's what always plays in my head. I love it. Yeah, that's exactly it. Yeah, because it's like, you know, and you'll notice that students, and maybe not in your program, you know, because they, if they enrolled in your program, we can assume they came there for you over. But students, particularly new ones, they will do like they like talking about it. Because it's not scary. It's not vulnerable. It's not vulnerable. Yeah. That's right. And so like, and it's very easy, easy as an instructor to sort of be like, well, I like talking. And I like being the center of attention. We've got we've got a lot of great things to say, very important things. Absolutely. So I learned like in my, in my early on in teaching like, oh, this is a trap I'm falling into. Yeah. And like when they, they can ask some clarifying questions, but not many, we need to jump into it. And then we need to ask clarifying questions about the experience and then get that feed back and then jump into it again. Yeah. Great. I mean, you're already a step ahead of the game. Yeah. We say gravity is always pulling us away from rehearsal. Oh, beautiful. Everyone wants to do anything but rehearsals. The students, the professor, the supervisor, everything else, they, they, anything but rehearsal. And so we've built this whole structure to try to maximize the amount of time in rehearsal. Right. Yeah. And it does have to be pretty overt because I love that gravity because that's what it is. It is. There is a gravitational pull away from rehearsal. They're absolutely is. Look, if you go to the, look, when I go to the gym and I'm working with a fitness coach, I much rather talk about anatomy and the science of fitness, then sit down and do another 20 sit-ups. And his job is to make sure I sit down and do another 20 sit-ups. Right. Exactly. Totally. So one, one of the things as you were talking, so everything you're saying is making a lot of sense, one of the challenges is rehearsal as we're describing it requires at least two people. Yeah. I mean, there's tools like the podcast I put in the chat is designed to do solo. Yeah. John Fretrickson, one of my favorite supervisors, has these great deliver practice exercises. I think you can get through his website that you can do solo. And the books we produced have example responses from the author, so you could do those solo as well. Now that said, therapy is not on solo. So it's not the best way to do it, but sure, you could start that way. Okay. Okay. And I'm curious, are there other ways that you found in your training program? Obviously, it makes a lot of sense, but even still, right? I mean, this is a challenge that we have, which is, hell, even if you had a small class with 10 students, right? Like there's only one instructor, sort of the expert, right? So it's still, it's, so is there, are there other work rounds or other ways that you've found to help people engage in deliberate practice without needing another person? I mean, it's kind of like how could you train for baseball without another person? You know, there's some things you can do, but no, typically, typically we need other people. And that's the nature of our work is it's a deeply interpersonal work. And you can practice painting without another person. You can practice music without another person. You can fly without another person. Therapy is an interpersonal gig. And so you know, I mean, I have done, you know, I've done a deliberate practice. I think there's a video on YouTube where I would watch videos of my own work and I would just try to scan how it's feeling in turn. And I was trying to build my inner awareness skills in my inner ability, my inner capacity to feel sad or empathic with someone. Because I found that I was veering away. I don't know if you've ever had this experience, but I would have certain clients when they would get super sad, I would almost back off like I'd get scared, basically, you know, and so I was trying to build my capacity to sit with people who are in extreme distress. So you're rewatching to sort of like re-experience those feelings so you can sort of whether it's habituator, have new learning to sort of so that when you're in that moment again, you are able to recognize what you're feeling, do something with that. Yeah, exactly. And so I was able to do that so low and that was, you know, helpful to some degree. But no, ultimately, I think it's an interpersonal skill and we need to practice it, uh, interpersonally, uh, mostly. Right. So this I brought this up when I was talking to broad good year because we, one of my colleagues and I we developed sort of this prototype for this for to use chat GPT. I don't know if you ever use their voice function. Yeah. If you just have a conversation and it sounds very human. But we created a custom GPT to practice specific skills. So the idea is that the GPT or the chat GPT is the client practicing different things. And then we also programmed it to on the back end. It actually gives the person some feedback on what they did, how many times they did it, where were places in the conversation they could have done something differently. Because I think that this was something, I'll say when I was in graduate school, I think maybe in your program it wouldn't be the same because I wouldn't feel as embarrassed. But when I was in graduate school, I was like, I was reading, you know, I read one of the things I remember reading, you know, Judith Beck's CT for Beginner's book, which I think is a great book. And it was like, but I didn't have anybody to practice with. And I was too embarrassed to ask any of my, you know, cohort mates, hey, would you practice this with me? Yeah. So what you designed sounds like a great tool. I mean, it sounds, you know, students would be very lucky to have that. And so absolutely, I'd have two comments on that. First of all, when a student is sitting with chat GBT, it's a relatively neutral kind of low intensity, a low emotional intensity, right? And you can ask it to maybe simulate high intensity, but there's only so much that the student's going to feel it. And with deliver practice, we want to aim for what's called state dependent learning, which means that people are practicing in somewhat the same conditions that they're going to perform. And for therapists, that means emotional conditions. And so rehearsing with a real human being, we think will help because it'll just raise their anxiety just a little bit, which is how they're going to need to perform. So that's one. That's what you're talking about. So it sounds great, especially it's like homework or something like that. However, we are now entering the world where chat GBT might be like, well, wait a minute, why do we need these human therapists? You know, we recently did a survey of just 500 random US residents on the internet who said they used AI and they have at least one lifetime incidence of a mental health condition. And half of them said they were going to LLM's for emotional support. Half. That's just a random, I mean, it wasn't it wasn't chat GBT users. It was just random sample. So that here's the link to the right. It's in peer review right now. And we just got positive reviews from the first round. So we, I would expect it should be published within a few months. And see if that link works. So I, half of them are using it for emotional support. Two thirds of them find it very effective. Of those, a significant portion find it more effective than their human therapist. Now there might be a sample bias in the sample because we're surveying people who are using AI already. And so they might just feel very comfortable with AI. So this does not represent all Americans. But it's a heads up. That this is coming for our field. That people, and I've heard the Santa Cdodoli, I'll talk to friends. If you go to Reddit, you'll see many, many, many examples of this. Of people getting real meaningful therapy like support from chat GBT or the other LLM's. Chat GBT doesn't want to talk about this. None of the LLM's want to talk about this because they're not registered licensed mental providers. But I personally, I can't prove this, but I personally think that chat GBT is currently the largest provider of mental health support in the country. Oh, yeah, if you said a single provider. Yeah. Then I think that that, I think that'd be hard to just, I've been trying to think of what would compete with it. And not many people want it. I mean, you're willing to acknowledge this, but many therapists I talk to are like, no, no, no, no, no, it's a robot. You can, you know. So I think this is something we should take very seriously. And I think about every day in terms of my trainings, how are we going to help them stay competitive in a future world with robot therapists? Right. Yeah. And so where have you gotten with that? I, you know, I am staying optimistic. There's something, have you heard of Jem? That's a wrap on the first part of our conversation. As I noted at the top, it'd be much appreciated if you spread the word to anyone else who you think might enjoy the show. Until next time.[Music][Music]