Using deliberate practice to improve your therapy skills and confidence (with Aaron Frost)

[00:00:00] Bronwyn: Hey, mental workers, and welcome back to the Mental Work podcast, your companion to early career psychology. I'm your host, Dr Bronwyn Milkins. And today, we are talking about a special topic that I have wanted to do an episode on for quite some time. We are talking about deliberate practice and specifically how you can incorporate deliberate practice in the way that you develop yourself as a psychologist. Here to help us out with this topic is a wonderful guest, and their name is Dr Aaron Frost.

[00:00:34] Hi, Aaron.

[00:00:35] Aaron: Good day, Bronwyn

[00:00:36] Bronwyn: It's such a pleasure to have you on the podcast. Aaron, could you just tell listeners a bit about who you are and your non psychology passion, please?

[00:00:45] Aaron: Yeah. Look. I'm I'm a I've been a clinical psychologist for about 25 years. And when I'm not clinical psychology. I'm raising 2 children, raising a recently crippled dog who's just had some orthopedic surgery. I occasionally try and pick up a guitar or a pen to try and do some art.

[00:01:04] Bronwyn: Oh, that's wonderful. I'm very sorry about the doggo. I hope they recover soon.

[00:01:08] Aaron: Not Not as sorry as he is.

[00:01:11] Bronwyn: What did he do?

[00:01:12] Aaron: He tripped over and broke his leg, which when you're a little... when you're a little dog, it means being stuck in a crate for a very

[00:01:19] Bronwyn: Oh, no. Oh, that's a shame.

[00:01:21] Well, I'm really grateful for you to come on. So I'll tell listeners as well the background to this. So Aaron runs this psychology register endorsement program. Did I say that right?

[00:01:32] Aaron: That's correct.

[00:01:33] Bronwyn: Yep.

[00:01:33] So it's the prep program, And I saw a post on LinkedIn that was talking about the prep program. And I think the post was saying, like, we take a unique approach to training early career psychologists, and I think it mentioned deliberate practice. And I was like, oh, it really grabbed my attention. So great great LinkedIn marketing. And I was like I was like, I wanna learn more about this approach, um, because I've been interested in deliberate practice for some time, And and I've found it quite difficult to incorporate into my own practice, and so I was super interested in what you do in this area. Because being a certified trainer with the International Center for Clinical Excellence, which is a deliberate practice center, isn't it?

[00:02:15] Aaron: Very much so.

[00:02:16] Bronwyn: Yeah. And I thought that you would have some expertise.

[00:02:19] Aaron: That sounds great. I'm really looking forward to it. Should be fun. Let's chat.

[00:02:22] Bronwyn: Yeah, let's chat.

[00:02:24] So the first thing that we wanted to talk about was what is deliberate practice because it might be a listener's first time in hearing these two words. So could you just give us a bit of an overview of what it is?

[00:02:36] Aaron: Yeah. Fantastic. So I think the starting point is to recognize that deliberate practice is not the same as experience. Just being a psychologist for 10 years is not the same as practicing. And, actually, it's a relatively recent phenomena to think about deliberate practice in the context of psychology.

[00:02:54] Deliberate practice is much more familiar to anyone who's ever played tennis or played guitar or done art or tried writing something. Deliberate practice is the process of doing something and then striving for excellence by doing it over and over again and looking for smaller and smaller ways in which you can actually improve your performance at at its core.

[00:03:16] Bronwyn: Okay. So maybe this touches on something that I've heard in psychology is that We assume that the more experience you have, that you must be better at what you do. Could you just speak to that?

[00:03:30] Aaron: Yeah. Look. Um, a few years ago, Goldberg and colleagues pretty compellingly dispelled that. Uh, they did the largest ever study of exactly this question where they followed a whole bunch of psychologists over the course of their career, and some of their careers were up to 20 years long. They looked at the outcomes for clients, and what they found was People were no better after 10 years, 15 years, or even 20 years of being a psychologist than they were at the beginning of their career. In fact, They were statistically worse. Small effect, but worse.

[00:04:02] Bronwyn: That's a bit sad, isn't it?

[00:04:05] Aaron: Absolutely, and in fact, And I I apologize to some of my statistician friends because I'm going to sort of bastardize some numbers a little bit. But, effectively, without deliberate practice, it looks like we deteriorate by about 0.6 of a percent of performance every year,

[00:04:20] Bronwyn: Wow.

[00:04:20] Aaron: which isn't much but over a decade, that's 6 percent worse performance. There's certainly no evidence that we improve.

[00:04:27] Bronwyn: Wow. That's, um, very sobering because as a profession, we want to be delivering the best outcomes for our clients over time. I certainly don't wanna hear that I'm gonna get worse over time.

[00:04:38] Aaron: Sure. But I I'd also like to think that I'm a better driver after 30 years than I was when I started, but there's no evidence to support that either. In fact, the insurance actuaries know pretty clearly that I'm not. So so so when we go away from what we want and what we hope would happen and then we look at what the data says, we sometimes get some disappointing news. If I'd spent 20 years regularly going along to, you know, defensive driving classes, working on my driving, looking to improve my gear changes and my steering and my situational awareness, then I probably would be a better driver today than I was 30 or 20 years ago. Whereas if I just get in the car, turn off, put on a podcast, and drift into automaticity, there's no chance I'm gonna improve. Because in fact, automaticity is the enemy of progress. As soon as you do anything easily, it stop you stop improving.

[00:05:26] Bronwyn: this is what I was thinking as you were speaking because I was like, but surely if I see, like you know, if I have 300 more client sessions over the next year, Surely, I would see some improvement just by nature of doing that, but what I'm hearing is that, no.

[00:05:40] If you get into the automaticity of those sessions and you're just doing the same thing over and over again, then there's no there's no evidence that that would lead to improved outcomes.

[00:05:51] Aaron: No. In in fact, there's evidence to the contrary. I, um, one of my early career psychs a few years ago said something to me which totally told me that she'd got it, but it was such a such a neat little moment. We were heading towards the end of her registrar program, and she said to me, you know what, Aaron? I can sort of feel that it's gotten easier to do my work. You know, I don't have to work so hard before each client. I don't have to think so hard afterwards. I could go into a session and my heart rate's not up. And I'm I'm a little bit relaxed, and it's so much easier than it was. And on the one hand, that feels like I'm progressing. But on the other hand, that feels like beginning of the slippery slope where I slide into mediocrity, and I'm like, yep. You get it. That's the beginning of the slippery slope.

[00:06:31] Bronwyn: So are you saying that, like, to not stagnate, we always need to have our heart rate up a little bit?

[00:06:37] Aaron: Hopefully not. Hopefully, it doesn't have to be attached to poor heart rate variability and increased heart rate. But But in interestingly, deliberate practice is hard work. When when you actually do something that is deliberate practice, you can only do it for half an hour, hour or so. You you you find it mentally fatiguing.

[00:06:52] Bronwyn: Yeah. I mean, like, I I do guitar as well. And when I practice guitar, if I want to improve how I'm playing a piece of music, I will start with usually, I start with trying to play the whole way whole song through, and I usually find that I can't get very far. So what I do is I break down, and then I will literally select out, like, phrases that I am not doing smoothly or up to the speed that I want to. And then I will put the metronome onto, like, 40 beats a minute, which is quite slow, and then I will make sure that I can get that phrase, 40 beats a minute, then I'll speed up to 45 beats a minute.

[00:07:28] And that could take me half an hour to do just to get this phrase, and then I'll do the few notes beforehand so I can smooth out the phrase. And then I'll do the few notes afterwards so I can get it into the next thing.

[00:07:38] But it is quite intensive work, and I'm like, good job, Bronwyn. You did a phrase today, like a few a collection of notes. But so it's slow, but but it means that the next time that I try and pack play that piece of music through, It's definitely smoother than it was before.

[00:07:53] Aaron: Absolutely. And and what you're talking about there is deliberate practice. You're taking something that's that's a stretch goal. It's something that's beyond what you're capable of doing right now, And then you're putting a whole scaffolding and a whole system of, um, practice in place to actually improve it. And and I guess to to follow your metaphor, The opposite of that would be picking a Beatles song that, you know, has, you know, 3 relatively simple chords that we can play comfortably. And when we practice guitar, we just do that song over and over again. Because it doesn't matter how many years you play Eleanor Rigby, you're not going to get better at playing Eleanor Rigby. Whereas if you Take something that is outside of your comfort zone and you push yourself, your your playing improves.

[00:08:35] so To me, deliberate practice makes sense in that context. It's like I I understand how to do it because I've being trained to do it in music. I understand what it would look like in sport maybe. Like, if I'm trying to learn a new swing in tennis, I would break that down. But I think I struggle to understand what how that would translate to therapy.

[00:08:55] Aaron: Fantastic. And that's such a good question. And I think, for me, this is why Freud called psychology, the impossible profession. Uh, and the reason is if you are playing golf and you hit a ball and it goes left, you can adjust your swing and try again.

[00:09:13] And then if it goes right you can adjust your swing or you can adjust your stance or you can adjust your hand position And eventually over a few different iterations, you'll get to the point where the ball is going straight. It might take you 10 years to get to the point where it's consistently going and consistently going along and going where you want to, but you can continually iterate. Our problem is that, first off, a ball and a golf club is like 1 variable. Each client that we see might have 20, 30, a hundred variables attached to them. And secondly, a golf swing takes Half a second, and how long it takes for the ball to land is 2 or 3 seconds. A client takes 3 weeks, 3 months, 3 years.

[00:09:56] So before we actually know whether our approach or our swing has been successful or not, it takes us a long time. Actually, it's only been in more recent years. So we can sort of turn to the data and look at how we're going overall, and then what are the aggregate areas of poor performance, and then we can work on those aggregate areas of poor performance. And then we start putting deliberate practice processes around those areas of poor poor performance, which will hopefully improve us over time.

[00:10:24] Bronwyn: Yeah. What you're saying, uh, it speaks well to something that I noticed when, uh, in the first few years that I was practicing, which is Sometimes I would say something in sessions, and it would land so well. And I would get a great response from the client, and I'd be like, That was the best thing I've ever said. I'm gonna say that to everyone. And then when I said it to everybody, it flopped. And I was like, that sucked.

[00:10:48] Yeah. And and I think and I think it speaks to that. It's like but every other client comes with 50 unique variables. So the thing that I said to this client in that moment, in that specific context. That worked really well, but it it didn't work for those other clients.

[00:11:02] So maybe my question then is is, like, okay. If you're looking at these aggregate areas of poor performers. How do I get better when everyone's so different?

[00:11:11] Aaron: This is a fantastic question.

[00:11:13] So I I think there's a couple of things that I wanna pick up on there. The first thing is In terms of aggregate areas of poor performance actually, can I just give a a neat little example of what this might look like? And this this is a registrar, um, recently. So this is one of the registrars in our practice who I was working with, and we looked at her data. Uh, we calculate dropout rate based on The percentage of people who don't make it to the third session. Industry standard is less than 30 percent. We aim for about 20 percent dropout rate In our practice, so dropout is one of those key performance indicators that you can sort of look at and identify whether you're doing a good job as a therapist or not.

[00:11:53] This particular registrar had a dropout rate sitting in the early sixties. So her dropout rate is 60 percent, which kinda means you think about that. Two thirds of her clients are walking in, and after 1 session or after 2 sessions, they're deciding I don't wanna see this person anymore.

[00:12:09] And I I guess I always have a bit of a humanist thing about that in that that's a huge lost opportunity because behind every client, there's a mom or a brother or a kid or a best friend or a wife or somebody who is hoping that this interaction is going to make the person that they love's life better. So the idea that two thirds of the people are just not going to get that opportunity, that's that's a that's a critical issue to deal with. So we've recognized okay. So on aggregate, this person's dropout rate is problematic. So then we have to ask the question, why is your dropout rate so high? And if your dropout rate is high, then we need to actually figure that out. So the the next step is we start watching videos together.

[00:12:54] Bronwyn: I was gonna ask about because I was like, well, how? Because they they'd just be like, oh, I don't know. So the videos is really crucial.

[00:13:00] Aaron: Absolutely. And in in this instance, we're very lucky. The The issue was actually fairly self evident. What was happening in the first couple of minutes, she'd kinda start with, hi.

[00:13:11] How are you going? What are you here for? Then she'd rapidly and abruptly end that conversation and give a lengthy spiel about ethics. And then in the middle of the spiel about ethics, she'd start start talking about presenting problem again. And then at the end of the spiel about ethics, then she'd finally launch into getting to know you.

[00:13:28] And you could just see that over the course of that 10 minutes, I've kinda continued starting to tell my story, but kinda being frustrated telling my story. You could just see the client's eyes were glazing over. And before she'd even started therapy, she'd kind of lost them. So in her case, what deliberate practice looked like was, You know what? Let's script you an efficient 3 minute introduction to ethics and then a good way to transition or pivot from ethics into presenting problem and do that, and then keep practicing that.

[00:14:01] And over the course of, I think, 3 months, her dropout rate went down to the mid twenties, which I'm super happy about, she's super happy about, uh, and hopefully her clients are happier about.

[00:14:12] Bronwyn: That's an amazing example. And one thing that I'm picking up in deliberate practice, Is it the case that you would want to change one thing and then see the effect of that? So you wouldn't have wanted to change multiple things about that practitioner the way that They were doing things, or or would you?

[00:14:29] Aaron: I would always think one thing at a time, Yep. because, again, it's it's a you've got to be a little bit scientific and a little bit rigorous about this. Again, if we go back to our golf analogy, if we change our hand position and then change our leg position and then change the direction of our swing. If it works, how do we know what you need to keep doing?

[00:14:47] Bronwyn: Exactly.

[00:14:48] Aaron: in in that case, if we did the thing with her for a couple of months and her dropout rate didn't improve, then we can say, okay. So your ethics thing isn't the problem. Let's try another thing. And we can iteratively finally hone in on what is the issue.

[00:15:01] In interestingly, we had another registrar in parallel who was having the same problem, who actually, it wasn't an ethics field. It was something that she was doing at the end of the session.

[00:15:11] So what she needed to do to solve the aggregate problem was not the same as what the first person needed to do.

[00:15:17] Bronwyn: It's a very oh, yeah. That's okay. So it's a very, uh, logical, like, scientific approach where you have a hypothesis about what could be occurring here. You You test out the hypothesis by changing a thing, and then you see, uh, the outcomes, and you're measuring that the whole way through.

[00:15:33] Aaron: Absolutely. Yeah. But but I I certainly think about it as being a very logical and mathematical thing.

[00:15:38] Bronwyn: Yeah. I think one thing that early career psychs suffer from. And I'm gonna say suffer deliberately because I think it is, um, suffering in a lot of shame about how they are performing. And so I can imagine maybe that somebody whose videos are being watched, they might feel very judged, and they might feel like, oh god. I'm a crap clinician, and and have those global thoughts about it. And I'm just curious, how do you approach this when you're giving feedback to the clinician about about what's happening for them.

[00:16:12] Aaron: This is such a great point. Um, we the the language that I use, and we use it all the time here at Benchmark, It's the idea of developing a culture of feedback, and a culture of feedback really views feedback as a gift. Like, I'm I'm a psychologist. I've been a psychologist for 25 years. I really value being a psychologist. I really care about the work that I do, which means that if you tell me something that I'm doing wrong that could make me better, you've given me a gift. That's an opportunity for me to improve.

[00:16:41] Um, and and we view it in the other direction. I I view that helping the person get their dropout rate from 60 percent down to 25 percent, that's a gift. And I don't mean to I'm certainly come from no place of criticism of them if, you know, if I've got a problem in my data or if I've got a problem as a manager or if I've got a problem as a supervisor.

[00:17:01] If someone tells me that, that's a learning opportunity, and I'm excited for that. And I think if if I can model that As a as a supervisor and as a senior psychologist, uh, I hope that that creates a culture for people where we're all learning, And the thing that you might need to be learning on is different from the thing that I might be, um, needing to learn, and that's fine. But we're all working on improving something.

[00:17:25] Bronwyn: That makes a lot of sense to me, actually, when I put it back to the the music and the sport, actually because when I think of my own guitar lessons, I would hate it if I was playing a song and my guitar and and there was something I could improve about the song, And my guitar teacher was just like, yep. All good. Okay. Bye. Like, I I want him to be invested in in my progression in in this, and I want it to sound musical, and I want it to be lovely to listen to. And so it sounds like when we transport that into the therapy space. It's like, yeah, it's it's your supervisor wanting for you to Be great at what you do, but also give good outcomes to your clients. Does that sound about right?

[00:18:09] Aaron: Absolutely. Feedback is not the same as criticism. If if I go to to your guitar analogy, I've I've got a phrase that I've been trying to work on for 20 years, and I still can't play it fast enough. Um, but the guitar teacher who gave me 2 tips that, uh, got me closer to being able to play it at the the the the right metronome. I appreciate that gift incredibly.

[00:18:30] Bronwyn: Yes. Yeah. Absolutely. Yeah. I love that. I love the thinking of it as a gift. I think that's really lovely in a way to alleviate this shame that I think early career psychs are prone to coming in. It's like it is a gift to be able to work on your craft in a way that that helps you deliver better outcomes.

[00:18:48] Aaron: And and if I I I really think about it in in the other direction as well because I think about when I started clinically, For me, the shame was in not knowing. I didn't know how effective I was. I just had a bunch of clients who came in, and my books were always full. And some of them liked me, and some of them didn't like me. And I had a, you know, a bunch of laughs and a bunch of tears and a bunch of emotionally intense experiences, but no idea whether I was actually doing a good job or not.

[00:19:18] So for me, that really kicked it off of How effective am I, and then how do I benchmark that against other people? Because sitting there with that neurotic anxiety that maybe I'm a really lousy therapist and just nobody's bothered to tell me, that is way worse the knowing. You know what? I'm on the fiftieth percentile of therapists, which, you know, there are people who are better than me, but actually on the whole, I'm doing a pretty decent job. Having having the number is so much more real than living in a world of neurosis.

[00:19:48] Or on the flip side, a world of narcissism where, you know, A client but a a client buys you some chocolates, and you feel like you're the best therapist in the Totally. Yeah. That's a really excellent point.

[00:19:59] Bronwyn: And, yeah, I think that would resonate with a lot of listeners that the uncertainty about what's happening I'm thinking of a very common situation that can happen, and it's like You might have the experience of a client comes in once and then they never come back, and you have no idea what that happened. And then you can be drawn into that neurotic anxiety about having such a bad therapist. But it sounds like when you've got, uh, when you're integrating deliberate practice into how you do things, like, you might be like, I wonder what what happened there. Can I review what what happened with that situation?

[00:20:29] Aaron: Absolutely. And and you put it into the context. If one client ghosts you and disappears. And then you look at your data and you go, well, overall, that only happens with 10 percent of my clients. Industry average is 30 percent. I'm doing okay.

[00:20:43] Bronwyn: Wow. That's nice. I like that.

[00:20:45] Aaron: So, again, I I think that the data can be looked at in a really scary, You know, working in the Googleplex and people monitoring your every movement kind of way, or you can view it in a it's just numbers. It gives you some information that helps you benchmark your effectiveness and know where you can go about improving.

[00:21:03] Bronwyn: I really like that. It's objective and impartial. So it sounds like wondering about own outcomes is what led you down the journey of exploring deliberate practice yourself. Is that right?

[00:21:14] Aaron: Yeah. So for me, after well, while I was doing my PhD because, you know, while I was doing my PhD, I discovered that I also like to pay rent. So, you know, I had to go and get a real job. Um, so so my my first job was as a research psychologist, and I worked in a large tertiary hospital, partially managing larger research projects, but doing a lot of quality assurance and key performance indicators and outcome monitoring at at that much kinda larger global level. And then when I went out into private practice after a few years of that and started going back to, you know, my first love of clinical work, I'm like, there's no accountability here. No one's keeping an eye on this, and that just created a real insecurity for me. So It it was timely.

[00:21:57] I I attended a workshop from Scott Miller at about that period in time when, you know, he he was just starting to talk about, routine outcome measurement or fit as he called it feedback informed treatment at about the time that I was having my own crisis of confidence in how effective am I? And that that really kicked off, you know, what, I guess, has become the next 2 decades of my career.

[00:22:19] Bronwyn: Yeah. So I might be jumping ahead here, but, now you run the preparation program for registrars. And can you tell us a bit about What prompted you to adopt the deliberate practice approach for PrEP?

[00:22:34] Aaron: Yeah. Sure. So that there's a again, like like many things, there's a few different threads that converge. One is, I guess, I had been training registrars for for a long time, like, 15 years or so now. I know, you know, like many people, I've got my own opinions as to what works and and what doesn't.

[00:22:52] Um, and when when my wife and I started, um, benchmark psychology, like most practices, a lot of the new people who came to us were people who I was training. And, um, we we got to a point that we thought we were doing quite a good job of bringing on new psychologists and developing early career psychs and I remember Rebecca saying to me, wouldn't it be great if you could have, like, a finishing school in psychology where you could go and learn all of the things that you missed out on in your your university training.

[00:23:20] Bronwyn: What a genius idea.

[00:23:21] Aaron: And yeah. So so Rebecca's idea of a a finishing school in psychology. That really opened up the idea of what what could we do and what what would that actually look like. In terms of the deliberate practice thing, I think that that really comes down to, I go to that data that I said earlier that if you don't do deliberate practice, you deteriorate by about 0.6 of a percent. If you do do deliberate practice, it looks like you improve by about 5 percent a year. And I just think if I was gonna spend the 30000 dollars that it's gonna cost me to get a whole bunch of supervision over the first 3 to 5 years of my career. I'd like to be 20 percent better than I was at the beginning rather than 2 percent worse.

[00:24:02] So for me, deliberate practice really offers the only empirically demonstrated epistemology or kind of teaching methodology that is associated with better outcomes for people. So the the choice to go down a deliberate practice Pathway just seemed like a really obvious one once once we'd had that initial thought of the finishing school idea.

[00:24:23] Bronwyn: I mean, when you put it like that it it does sound quite obvious, but the the pressure I feel for early career psychologists, as an early career psychologist, is quite the opposite. It's I remember reading biographies of therapists, and it was like so and so is trained in list 10 different acronyms for therapy modalities. And I very much acutely felt that pressure to get trained in as many different modalities as I could. And in my first year or 2, I signed up I signed up for CBT training, ACT training, EMDR, schema therapy, and a few other bits and pieces because I felt very inadequate just having CBT, on my profile. And so that was a huge pressure for me.

[00:25:03] So it it seems like an obvious approach, but I think it's very unique. And I'm wondering could you just speak to maybe that pressure that that is placed on therapists to learn the different modalities and have a hundred of them under their belts?

[00:25:16] Aaron: Yeah. Look. I and and whether that pressure comes from an internal, you know, perfectionism and and wanting to be help helpful or or whether it comes externally. But, honestly, that thing of learning 20 different methodologies, that's good for the trainers. That's not good for you. It's not good for your wallet, and it's not good for your clients.

[00:25:38] If if we go back to the thing that we We all know, and it's not controversial, there's the dodo bird effect. Right? EMDR is not better than CBT. CBT is not better than ACT. ACT is not better than IPT. IPT is not better than EMDR. All of these things are roughly equivalent. There's There's a little bit of a shiny new thing that happens. Um, there's this interesting research cycle where when a new methodology comes onto, onto the scene, it always looks about twice as effective as everything else.

[00:26:09] Um, and the reason for that is there's a correlation between quality of study design and then effect size. The poorer the study, the bigger the effect size. So when I come up with the brilliant new Frost School of Therapy, I'm not gonna have any money to study it. So I'm gonna do a really dodgy study, And I'll find that I'm 2 times more effective than everything else out there. Then it'll get the world's attention, and I'll go off and deliver the training workshops about how amazing my new methodology is. And other people will start replicating it, and they'll introduce active control conditions, and they'll introduce blinding, and they'll introduce treatment fidelity. And suddenly, it'll take us 10 years, but at the end of that one more run around the, um, the rat wheel, we'll find that my therapy is exactly the same as every other therapy it's back to the dodo bird effect.

[00:26:56] The difference is the difference is not between therapies. The difference is between therapists.

[00:27:03] Bronwyn: That, like, just blew my mind because it's like one of the things I remember seeing a few years ago was lots of headlines saying that t CBT has declined in effectiveness. And so when I hear you say that, I'm like, oh, CBT has a million studies on it. They're quite rigorous. Like, it's one of the only therapeutic modalities where you can Train people in it specifically, follow a manual, follow it in this controlled setting, and then see if there are any differences between that and a wait list or or psychoeducation or something. Whereas perhaps newer therapies, they may not have those rigorous studies, so they're producing better effects with, uh, with less It's rigorous am I understanding that correctly?

[00:27:41] Aaron: You you're absolutely correct.

[00:27:43] When when we when we come up with a new innovative idea and and I was reading this. I I won't name the therapy, but it's it's sitting on my pin board just behind there. And they're they're claiming a Cohen's d of something like 3.5. So they're they're about 7 times more effective than every other therapy. The paper is called a preliminary pilot study of and I won't name the therapy.

[00:28:06] It's got an n of 22 people. It doesn't have a wait list. It doesn't have an active treatment control. It's just it's I'm sure it's a good idea, and I've people who've been trained in this model of therapy, and, you know, I'm sure they've got something out of it, and I'm sure it's got some ideas to talk about. However, I can guarantee what the results are gonna look like in 10 years' time when other people come along and they actually do the study properly.

[00:28:29] Bronwyn: Wow. God. It makes me think that psychologists are such magpies, and we just want the shiny new thing.

[00:28:36] Aaron: Well, we again, we we come to psychology, You know, wanting to help. And, you know, we we we come in with pretty high expectations on ourselves, and, you know, we are the kind of people who got the GPA of 6 and a half or whatever got the first class on and got all of those shiny certificates on our wall. And we kinda get led down the path of thinking that what's gonna take us further is going off and getting these extra credentials where it's actually what we should be working on is ourselves. How do we get better at doing the thing rather than just learning more things to

[00:29:08] Bronwyn: Yeah. And that comes back to what you just said beforehand. It's not Therapies, it's therapists. So it sounds like prep really is that a focus for prep, like focusing on the therapist's personal development?

[00:29:21] Aaron: Yeah.

[00:29:21] So so prep prep has a bit of There's a few different streams that that come together. The the one is there's a big deliberate practice thing. So measure your data, identify your data, talk to your supervisor, watch videos. Another part is we do teach specific methodologies, but we try and the the language that I use is taking a wide enough angle lens that you kinda see how all the methodologies are the same. I I could absolutely tell you how in my mind psychoanalytic therapy and behaviorism are the same thing because I can see the overlaps, and I can see the theoretical, uh, discrepancy.

[00:29:58] So so the goal is that people have that wide angle lens that they can really see where the therapy is just, what are the commonalities, where are we just talking about the same phenomena with different language, and then we take a really narrow micro lens. We spend an entire week working on the first sentence And the difference between, did you get parking okay today? How are you feeling about being here today? Uh, have you seen a therapist before? Those 3 conversations, and we role play them, and we look at what works, and we look at how clients respond to them. Each of those 3 different ways of opening a session leads to a completely different way of you and the client interacting with each other, setting a therapeutic frame, gathAarong information and building relationship. And no none of those 3 is correct. Um, but the goal is that you as a therapist play around with each of those different ideas and figure out what's your way of opening a session so we get right right down into the weeds of the nitty gritty.

[00:30:59] Bronwyn: It's so funny that you said that none of them are correct because, literally, there was a question in my head. I was like, which one's the best? And it's such a such a different approach.

[00:31:09] Aaron: And and the answer is the one that works best for your clients.

[00:31:12] Bronwyn: Amazing. That's so cool. So it and and, you know, that's not like that's not something I'd read in a textbook. Like, there's no, like, Opening sentence. I've never seen opening sentence practice on a on a textbook page. It's like but these are the fundamental building blocks that lead to retention, that lead to a good assessment, that lead to a good outcome, a good therapeutic relationship, which is, you know, one of the huge factors that determine whether therapy is gonna get a good outcome right.

[00:31:38] Aaron: No. It took 25 years ago, I I was just told by a supervisor, you know, ask if the person, you know, had difficulty with the traffic today. And it's just, you know, make light conversation. And, again, it's not that that's wrong, But maybe the person's been sitting there the whole time desperate to wanna get their story out in there. You know, the idea of having light conversation seems completely anathema to them. And then another person really doesn't wanna tell their story and is quite happy to spend 5 minutes easing into the weather.

[00:32:07] Bronwyn: Yeah. Totally. Wow. That's so interesting. I find that really fascinating, and I think that's such an interesting approach.

[00:32:14] Aaron: Anecdotally, and I'll depart from the evidence here a little bit, but anecdotally, the best therapists have more options available to them at any point in therapy. So if you're just kinda reactively, they said this and now I'm gonna say that, That's kind of what we see with, you know, quite junior and, in some cases, um, more more mediocre therapists.

[00:32:37] Bronwyn: I wonder if this connects to the automaticity as well. Because let's say that I've got a script in my head, which is like, I always go into talking about the weather. Um, and I don't modify that for the client in front of me. And What I've missed is that the client in front of me, they're, like, bursting at the seams to tell their story, and here I am chit chatting about the weather. And if I don't pick up on those body cues or or those, those, um, tone of voice in their responses, maybe they're giving short responses and if I wasn't on autopilot, I would pick that up, then I would be like, oh, you just you wanna get straight into this. Let's dive into it, um, and that that would make a better session.

[00:33:12] Aaron: that's exactly right. And and if you had just 2 or 3 openings that are comfortable and that you're well practiced in, and as you walk from the waiting room down the hallway, you make a decision as to how you're gonna open the session. It is more likely that with time and also reflection of did it work, was I right, was the data that I was gathering from the person in the waiting room leading me to make a sensible decision, you'll gradually become more expert in the choices that you make.

[00:33:40] Bronwyn: So cool. And being a practitioner yourself who has employed this deliberate practice approach, have you seen improvements in your, uh, outcomes that you measure, or could you just tell us a bit about the literature? Like, you know, if I invest in this approach, is it is it going to help me, like, on average?

[00:33:57] Aaron: Yeah. And and that goes back to so so the data tells us about 5 percent a year. If you're if you're actually consistent about it, collecting data and then being deliberate in your your practice, yeah, you will be looking at around a 5 percent improvement. For me, disappointingly, my my numbers are improving very incrementally.

[00:34:17] Bronwyn: Is that okay, though? Like, that sounds good to me.

[00:34:19] Aaron: Yeah. I'm I'm a just over mediocre therapist in terms of my outcomes, and and I'm okay with that. For for 20 odd years and, you know, for 20 odd years ahead of me. Uh, I will continue to be a just above mediocre therapist. But the big thing in terms of the neurosis and in terms of the narcissism is knowing that I'm not superb, but also I'm not terrible.

[00:34:41] Bronwyn: Uh, I love that. I think that would be hugely alleviating for a lot of people.

[00:34:45] Aaron: I hope so.

[00:34:48] Bronwyn: So jumping a bit, Aaron, but What does a deliberate practice focused supervision session look like?

[00:34:55] Aaron: Yeah. Fantastic. That's a how long is a piece of string question in some ways in that it really depends on what is the thing you need to work on. If the thing that you need to work on is dropout, then what it typically looks like is let's identify the problem. Let's generate some hypotheses as to how we solve the problem. Let's gather data that supports our hypothesis as well as data that refutes our hypothesis, and then now let's set that up as a goal.

[00:35:22] Often what we find is that there's kinda 2 levels of deliberate practice going on. There's kind of the... the bigger picture deliberate practice, you can't work on 20 things at once. But you also can't work on a dropout rate dropout problem between 2 sessions, between supervision with me this Monday and next Monday. So a dropout rate thing might be one of those bigger macro issues, and that might be something that we come back to in 3 months to see what does the new data say about that thing that we put in place.

[00:35:53] But then in a micro session, it might be the supervisee coming in and saying, I'd like to show you a video of something that went horribly wrong, and we have a look at the moment where, you know, there was an empathic fail or, You know, the the session broke down in some way or simply that the the supervisee didn't know how to respond to the client. And then we generate some hypotheses. How would you have liked to respond it? Now let's let's think about that. Are there any other ways you could have responded? Is that authentic for you? How about we roleplay one. How about we role play where I do one and you you're the client, and we try it out, and the person goes away now having gone through that experience of getting into the real micro of that.

[00:36:33] Bronwyn: That's really cool. You said the magic word just before. Um, it's role play because I know that I was I just I just have a curious question. Why do so many psychologists hate role plays, and why are they better in deliberate practice sessions?

[00:36:46] Aaron: Yeah. Uh, because we do them wrong.

[00:36:48] Bronwyn: Okay. Alright. Cool.

[00:36:49] Aaron: Yeah. Typically and and I I say this this is my experience as a trainer rather than as a supervisor. So often role plays in training look like you go off and do a training. Right? You go off and do your schema therapy or your EMDR or whatever.

[00:37:02] And then at about 3 o'clock, the trainer has run out of his or her A material and says, now can you go go into a role play? And then they go out and smoke a cigarette or, You know, have a coffee or, uh, you know, answer their emails, and you do this hour long exercise in Theatresport confabulation. And then at the end, you give each other feedback, and the person says you've got a really nice manner, and I found it really easy to talk to you. And I think you're you're a really nice person, and, you know, I enjoyed the session, and you've got nothing out of it. To do role play well, it's gotta have a couple of preconditions. One is that it's gotta be small and focused on something small. Any role play that goes for longer than 3 minutes is a waste of time.

[00:37:45] Bronwyn: Really? Oh my gosh. Okay. Go on.

[00:37:48] Aaron: You you shouldn't you shouldn't be working on your ability to, You know, be a character actor. You should be working on your ability to open a session. You should be working on your ability to ask about suicide. You should be working on your ability to do a psychoeducation thing. So break it down to something small.

[00:38:03] Bronwyn: That's nuts. Yep.

[00:38:05] Aaron: secondly, the feedback should be actionable. It should be, When you said this, I felt uncomfortable because it made me think you were being judgmental. 3, it needs the person to be given an opportunity to have a think about that feedback and whether they agree with it, whether they need to modify. And then 4, it needs an opportunity for them to do a do over. So, actually, when we do role plays, it's always a double role play. It's a 3 minute role play, 2 minute role play, bit of feedback, bit of thinking time. Now let's do the role play again.

[00:38:40] Bronwyn: Wow. That sounds amazing. Like, literally, I have never experienced anything like that. In in all the role plays I've done in trainings, It's been at least 15 minutes. I've never had a 3 minute role play.

[00:38:51] And you're right. It's always been like it towards the end of the day. And then both of us, It's like if we are in a group, we're like, oh, man. We're so tired. And then we and I'm like and then we're always like, what are we doing? And then we don't know what we're doing, and then we try and do something. And we're like, yeah. That was nice. It was literally all the things that you just said.

[00:39:09] Aaron: And and it and it goes back to that point that I was saying before that deliberate practice is actually mentally exhausting. If you do that 3 minute role play, the feedback, and then 3 minute role play, I can guarantee you will be mentally fatigued at the end of that. That's hard. Whereas the 15 minute role play, I I can fake 15 minutes of a therapy session with anyone at any time without without having any kind of mental work happening there.

[00:39:31] Bronwyn: Wow. That is so cool. Thank you so much for sharing that with us. I think It's really it's really good to know that. Mind is blown.

[00:39:37] I already loved deliberate practice before, but hearing you speak about this with I think you're quite passionate about it, by the way, that you speak about it. It it really is quite convincing that this is, uh, could be a beneficial way for a lot of early career psychs to proceed. And so if listeners want to apply deliberate practice to, uh, like, include it in their professional development plan. How can they go about this?

[00:40:01] Aaron: I think the really key thing is to find a supervisor. You you've got to find a supervisor who is is keeping up with that literature, but it's also that you feel comfortable being uncomfortable with. So you have to be in a relationship, a supervisory relationship, where you can step out of your comfort zone, and I use the word permission to fail. You have to be willing to do role plays, show videos where it didn't go well, and that you and your supervisor, you might have a laugh about it, you might have a cry about it, but that it's not a judgmental, belittling, criticising, uh, kind of experience. It's, uh, you know what? I'm gonna show you my worst, and we're gonna work on it together.

[00:40:43] So I'd say actually interviewing supervisors rather than the other way around is a really critical part of the process. You should look for the supervisor who can create that comfort with you and who's willing to give you that tough feedback. Obviously, the supervisors who work with us at Prep are all um, working within that model and, you know, we've got our CPD and whatever, but, You know, I don't just wanna shill, um, my stuff. There are a lot of supervisors out there who are, um, really keen and really capable in in doing that, but I'd say that the Key part is in interviewing and contracting with your supervisor that you say this is kinda what I want.

[00:41:18] Bronwyn: So if listeners wanna find a supervisor, What are the questions that they can ask them to see if they use a deliberate practice approach? Is it like, do you use a feedback informed treatment or deliberate practice approach? Like, what are they trying to, Well, how do they find this out?

[00:41:32] Aaron: Yeah. I I think the starting point is to ask about data. Uh, so so feedback informed therapy is that's that's Coke that's Coke. Right? It's Coke or Pepsi. So feedback informed therapy, that is the Scott Miller school of doing that. It can also be, um, the outcome informed approach. It can also be measurement based care. There's a whole bunch of different client directed outcome informed are all different methodologies that are kind of, um, outcome directed. So I think the starting point is to ask supervisors, are they interested in data? Are they interested in effect size? Are they interested in dropout rate? If you go in and say, I wanna work on I wanna establish what my dropout rate is, and I wanna establish what my effect size is, and I'd like to improve them... if the supervisor says, well, actually, I'd like to make sure that you master psychoanalysis, there's probably not gonna be a great fit there if you'll pardon the pun.

[00:42:24] Bronwyn: That makes a lot of sense. No. That's really helpful. Thank you.

[00:42:27] And If listeners have listened to this and other than finding a supervisor and it sounds like prep has a lot of, uh, great supervisors who use that approach, Is there anything else, like, practical and realistic that listeners can do as a next step if they're interested in deliberate practice?

[00:42:44] Aaron: Look. If if they'd like to contact us at, um, at prep, You can dig us up at, um, prep.clinic.

[00:42:50] Uh, I'd also, um, probably look at some of the more, I guess, psychologist focused books. I think you mentioned better outcomes...

[00:42:58] Bronwyn: yeah.

[00:42:59] Aaron: ...recently, Daryl Chow's book, The First Kiss, um, is excellent. So, yeah, I'd I'd probably jump on Scott Miller's website, and I think there's a bunch of quite good, um, books there. Some people learn much better, um, you know, working their way through a a well written text.

[00:43:16] Bronwyn: Yeah. I really enjoyed the Better Outcomes and they're quite, um, I really like them as well because they're actually quite slow going books. Uh, and I say that deliberately because you have to you have to do the activities. So it's like, go do this, collect the data, come back, set up your plan, go do this, come back. And so I really enjoyed that approach. Were you a coauthor on the Better Outcomes, or I feel like you have a different book?

[00:43:38] Aaron: No. Um, myself and Kaye Frankom, Daryl Chow, Nathan Castle and Raylene Alvarez, uh, wrote a book called Creating Impact, which came out last year, I think. Creating impact has the deliberate practice stuff in there, but it is more taking a deliberate practice approach at that next level up when you're kinda starting your first clinic.

[00:43:58] so so there is stuff in there about supervision. There's stuff in there about clinical governance. There's stuff in there about financial management and kind of doing the more business management leadership side of things, um, really well.

[00:44:10] So, yeah, creating impact is a good resource, but not specifically targeted at early career who are just working at, um, mastering their clinical chops.

[00:44:20] Bronwyn: Thank you for clarifying because I did download Creating Impact last year. I'm sorry to say that I haven't read it yet. It's on my list. But I do I was like, no. I'm sure you've been on a book. Yeah.

[00:44:30] Aaron: No. No.

[00:44:31] That's totally fine. And and, again, I'll I'll I'll take the 50 bucks if people want the book. But, uh, the the target audience is certainly

[00:44:38] Bronwyn: Yeah.

[00:44:39] Aaron: It's it's it's just that next next career stage.

[00:44:42] Bronwyn: Yep. Um, well, Aaron, what's the biggest takeaway you hope listeners will learn from our conversation today?

[00:44:49] Aaron: The the big thing for me is I I'm really passionate about early career people, and I'm really passionate about the potential rip offs of people who are early career. And I don't think that training in psychotherapy is a rip off.

[00:45:07] However, I think you can be ripped off by feeling that You aren't a good enough therapist unless you've got an entire, um, scrabble box full of letters after your name of all of the different therapies that you've learned.

[00:45:20] So I guess the big thing that I'd I'd suggest to people is it we're not anti model. We're not anti therapy technique, but work on yourself first. And then as you get to know yourself better, you'll know what your weaknesses are. And if you need to be able to do cognitive therapy and you can't do cognitive therapy, it's totally worth you going investing in some cognitive therapy training. If you need to be able to do EMDR and you can't do EMDR, it is Totally worth you going and doing that. Whereas just collecting it, you know, like like some sort of stamp collection is not necessarily a pathway to becoming better at what you're doing.

[00:45:59] Bronwyn: I think listeners just breathed out a collective exhale of relief. Um, so thank you for saying that. That's really good to hear. Aaron, if listeners wanna learn more about you, I know you already mentioned the prep website or get in touch.

[00:46:13] Are there any other links, or could you remind us of the link?

[00:46:17] Aaron: Yeah. So it's prep.clinic. If you're interested in supervision, uh, so I obviously, uh, train supervisors as well at stap, stap.org.au.

[00:46:29] you'd like to work with us, um, benchmarkpsychology.com.au, or if you just like to LinkedIn stalk me like, um, you obviously did a few months ago, You can just hunt me down on LinkedIn and keep up with, um, what whatever whatever musings I'm putting out on any given day.

[00:46:45] Bronwyn: Thank you so much. I'll pop all those links in the show notes. And, listeners, I'm really passionate about this approach as well, and I think I think it's really wonderful that we can we can adopt it and that we've got something that is really evidence based in leading to improved outcomes. I think that's really cool.

[00:46:59] Aaron: Fantastic. Thank you so much,

[00:47:00] Bronwyn: No worries. Thank you so much, Aaron, for your time. I know you're such a busy person, so we really appreciate your and expertise.

[00:47:06] And listeners, thank you so much for listening. And if you're loving the show, you don't wanna miss an episode, be sure to press follow on your podcast listening app. And if you've got a mate who would love listening to this episode, do feel free to share it. It'd be so great, and word-of-mouth is really the best way to get these episodes out. So, listeners, that's a wrap. Thanks for listening to Mental Work. Have a good one, and catch you next time.