June 6, 2019
Deliberate Practice for Psychologists, Psychotherapists, Psychiatrists.Part 1: No videos?!
Most of the deliberate practice I have done has involved watching videos of my clinical work. I've been watching videos of expert therapists since I was a research assistant twenty years ago and my own videos consistently since preparing for core training in EDT 12 years ago. So much of what I teach, think, and write about DP is using video footage. However, it isn't the only way to do DP and this came into sharp focus when I was asked last week for advice for a supervisee who was having no luck getting agreement from clients to video their sessions.
So, with this common problem, shared by a new supervisee about to start core training with me; I automatically turned to deliberate practice to support my answer. Why? The key goal as a trainer and supervisor is to enable the 'trainee' to learn and to self supervise more effectively, and in my experience, nothing seems to support self supervision quite like the concept of deliberate practice (see my previous article for the description of DP).
"Dear all, Four out of four patients so far have refused to let me video record the sessions! Bit concerned all other patients on my caseload will refuse too! Help!"
So here's my response:
"What a great question! Thanks for sharing these difficulties, I'm sure you won't be the only one to experience difficulties in asking about videoing. This is a perfect opportunity for some deliberate practice! The idea with deliberate practice is to purposely set out to practice one element of the therapeutic work you do with a client at a time. It is hard to dissect, but really important to try. Separating out what is going on n our work, can be really supportive of the therapeutic process, especially when it is possible to play and to practice. This way - when we put the elements back together, the process is less mysterious and slightly, just slightly, more straightforward!
The most recent way we have divided up domains within DP are:
1) focusing on the internal experience of the therapist
2) focusing on what you are doing with the client
(There are plenty of other ways of separating the domains but these two are proving to be both simple and helpful to Tony Rousmaniere, author of Deliberate Practice forPsychotherapists, myself and a group of psychotherapists who are workingtogether to use DP in our clinical, training and supervisory lives.) I will share with you some specific ideas about the problem you are having but for all aspects that I mention and that you look at you might want to consider:
Domain 1) what is my experience as I talk about videoing with the client?
- How do I feel?
- Where do I feel it within my body? What does it feel like?
- What anxiety am I experiencing?
- What internal or external behavioural responses are coming up for me (i.e. pulling away, justification, minimising, shutting down, etc)?
Domain 2) What am I doing? What response does the client have to the different aspects of my doing?
- As I put pressure on, I notice that they back off.
- As I focus on what they get out of it, I think that they get more interested.
- As I break it down into a smaller chunks ('We could video for just ten minutes, just one session.'), they seem more able to consider it.
Now specifically, I would share that from my experience the timing and the way that we ‘sell’ the idea of videoing is something we all need to learn and it's very common to get no’s before the yes’s! I’ve put some ideas down here to help you consider how to move forwards, but it might be that you take your foot off the accelerator and practice for a while first, or use these ideas to try again next week.
Formulation and timing
- How are you approaching the timing of this topic? Have you built a therapeutic alliance first or are you approaching it in the first session?
- Have you given prior warning and time to consider before asking for an answer?
- Have you got a consent form as well as a service leaflet or policies which describe issues about video recording, that deal with the practical issues (storage, encryption, etc)?
- Have you considered their current difficulties and the impact on the question of videoing? Paranoia, poor self image, and high levels of intrusive thoughts are the most likely blocks in my experience, and in some cases it might be unethical asking at all due to the level of disruption or difficulties it might bring for the client.
I am not going to get into the details regarding these practicalities, no doubt they give you some food for thought. Also because you've had 4/4 decline the opportunity so I suggest it is better to assume there is something you can change about how you are approaching this issue practically or personally rather than assuming it's about the client's difficulties. In addition, apart from the suggestions above regarding clients, it is hard to tell early on who will say yes. And finally, the person it is easier to change is you!
So maybe you have considered all the questions above and got all the practicalities dealt with; in this case, I'd really pay attention to the way it feels for you when you are talking about this topic.
How will they benefit? The sales pitch!
The first thing to get clear in your mind is what is in it for them! Not you.
I know that in your current situation you want to videotape for a training course and supervision, but the whole purpose of videotaping is to support your professional development and to improve your outcomes. This may have become disconnected from the direct benefits that your client will receive but you need to get re-connected to this and to work out ways to ensure that this is the case. Planning to do deliberate practice with your videos will support this. When you do have videos of your clinical work, watching sections where a session went off track, identifying alternative ways of responding and practicing these, will enable you to make sure that this particular client will receive meaningful benefits for the process and outcomes of their therapy, when they say yes to a video recorder joining you both in the room.
We seem to benefit most from deliberate practice when we get some guidance from an expert who can help you identify what type of practice will benefit you most, so clients who say yes to sharing the video with your supervisor will be likely to gain more.
I've called this section 'The sales pitch' because to be honest, this is how it can feel when we ask at the beginning. Every great sales pitch is about a win win - we all get something out of it! In this case, used appropriately, a client who allows video recordings might get better more quickly in a potentially more attuned and respectful relationship (because we can watch afterwards if we are going 'wrong'), and the therapist can feel more effective, with more routes to improvement and help in difficult situations. Of course, this win win situation is hard to hold onto, especially when:
- you are more in touch with your benefits than theirs,
- you aren't sure that there will be any benefits for anyone,
- you are planning to use the videos (even unconsciously) to beat yourself up with (i.e. I bet I'll look / sound stupid, say ridiculous things) or with the expectation that others will do this when / if you share them (i.e. when people see my work, it'll be obvious to everyone that I'm incompetent)
- you are ambivalent - "I don't want to video but I need to for my training".
If this is the case take it to supervision, peer supervision or give yourself some time before you ask again to think. If you are not videoing for the benefit of the client, it's best to consider the ethics of asking to do so in a clinical setting when research isn't involved. In addition, are you being open with the client that it won't benefit them?
Video yourself asking a peer pretending to be a client about this and then watch it back. Watch the whole thing to get an overview first to consider the practical issues around making this request:
- Do my words, body language and tone reflect effectively that this could be meaningful for their progress as well as support my learning?
- Would I say yes if I were the client? Why? Why not?
- What concerns would I have that I would want clarifying?
Deliberate practice can help you connect with your internal process (domain 1). Watch your video again paying close attention to your internal responses - what do you notice? Ask yourself:
- How do I feel? Where do I feel it within my body? What does it feel like?
- What secondary emotions - anxiety, shame, compassion or pride am I experiencing?
- What internal or external responses are coming up in me, what urges do I have? What do I do?
So I haven't specifically had to use deliberate practice purposefully for this issue, but within my research and clinical work, I have practiced asking clients about videoing them for 20 years. I had significant ambivalence at the beginning about the whole process in my clinical work but I was deeply aware of the potential benefits it could bring us both. This awareness was connected to the long term benefits I trusted implicitly would come from watching my work and learning from what I did rather than what I remembered. The ambivalence I felt was connected to my uncertainty about how to ensure that it would be helpful for this particularly client over the x sessions I would see them for.Over the years, I have learnt to use the video to the benefit of all my clients irrespective of whether I have a supervision session using them or not; in fact, the presence of the camcorder recording in itself can support more effective sessions.
The development of using Deliberate Practice within our field, learning from other professions and learning more about what works best for us, will revolutionise the way that we can make use of videos of our clinical work. Clearly my intense enthusiasm 15 years ago that the video would hugely benefit each client was without specific research evidence... however, with the addition of DeliberatePractice, we can be calmly enthusiastic that it could benefit each client now.
I hope that helps, I know you are keen to get started but we purposely do not look at videos of your work in the first session of core training so that we can talk about any issues that are coming up together. So bear in mind that we will work together as a group on this, and that someone will eventually say yes - it will happen with time and practice, and especially with deliberate practice!!"