Mastering the Inner Skills of Psychotherapy: A Deliberate Practice Manual

By Tony Rousmaniere, PsyD

Do you ever find that you are less effective with clients who are provocative, angry, shut down, or emotionally labile? Would you like to be more effective helping clients with challenging problems, including trauma, addictions, and comorbid conditions?
Clients can arouse strong emotional reactions in therapists, often termed experiential avoidance or countertransference. To be effective with these challenging cases, therapists must build their psychological capacity to stay self-aware, attuned, and clinically flexible while having strong reactions. This manual provides clear and practical deliberate practice exercises to help you master these inner skills so you can be a more effective therapist and enjoy your work more. This manual features a training plan that is based on the principles of deliberate practice, works with all major models of psychotherapy, aids all levels of therapist development, from beginning trainees to experienced clinicians, helps therapists be more effective with their most challenging clients, and protects the boundaries and privacy of trainees.
Louis G. Castonguay, Professor, at Penn State University, said the book "is an innovative addition to the movement of deliberate practice," and that "this book offers troves of ideas, tools, and resources for therapists of varied theoretical orientations and experience levels." Catherine Eubanks, president-elect of the society for the Exploration of Psychotherapy Integration, commented that "by practical techniques for increasing therapists’ capacity to be present and attuned in the therapy session, Rousmaniere draws attention to one of the most important ways to advance our field and improve our ability to help our patients."

• Language: English
• Publisher: Gold Lantern Books
• Release date: Jan 1, 2019
• ISBN: 9781732565715

Tony Rousmaniere, PsyD

Tony Rousmaniere, PsyD, is a faculty member at the University of Washington. He is a researcher with a focus on clinical training and supervision, deliberate practice, and supervision technology. Dr. Rousmaniere provides workshops, webinars, advanced clinical training, and supervision to therapists around the world. He also provides free clinical training resources through the website www.dpfortherapists.com.

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Author

Foreword

by Rodney Goodyear, PhD

I was intrigued to learn that the literal translation of the term kung fu does not concern martial arts but rather the condition of having attained exceptional skills through sustained, arduous practice. It is a term that acknowledges the results of having engaged in what we now describe as deliberate practice (DP; e.g., Ericsson, Krampe, & Tesch-Römer, 1993). But expertise is an ongoing and ever-evolving goal and the person who attains kung fu is not done. This point is captured in the story of the famous cellist Pablo Casals continuing to practice 5 hours to 6 hours a day well into his 80s because as he once stated: ‘I think I am making progress.’ (Lee, 2016, p. 895).

As this quote suggests, progress does not occur by simply engaging in the day-to-day practice of one’s craft. For example, despite what they tend to believe, psychotherapists with decades of experience tend to achieve no better results with their clients than their less experienced colleagues (Goldberg et al., 2016). To become more effective requires engaging in DP, which should occur as an activity separate from daily work. This type of DP approach typically will involve isolating and then focusing on specific skill subsets. That can be seen, for example, when basketball coaches have players work on dribbling, on shooting free throws, and so on as separate activities during their practice sessions.

In the one study that so far has examined the effectiveness of DP in the domain of psychotherapy (Chow et al., 2015), the therapists who achieved the best client outcomes reported having engaged in DP almost three times as often as other therapists in their sample. This is encouraging news, for it means that the field now has identified a pathway for improving therapists’ performance (see Rousmaniere, Goodyear, Miller, & Wampold, 2017). That establishes the foundation now for trainers to begin developing specific DP technologies.

Tony Rousmaniere is among the handful of people who have been working to develop those technologies. This manual reports some of his efforts and stands as a pioneering step. As is characteristic of most DP, this manual provides instruction on improving a specific subset of therapist competencies. In this case, those competencies are concerned with staying attuned to and engaged with clients when there is something about the client or the situation that causes the therapist discomfort. Depending on one’s theoretical framework, those discomforts could be described in terms of countertransference or perhaps reactivity, which the field has so far been able to address in inconsistent ways. When those therapist discomforts do get addressed, it usually is when a supervisor helps the supervisee, with varying degrees of effectiveness, to identify the situation and its causes and then to manage his or her reactions. In responding to these supervisee needs, the supervisor can sometimes veer into pathologizing the supervisees’ reactions or get pulled into the ethical trap of assuming the role of the supervisee’s therapist.

This manual not only normalizes those therapist experiences but also provides a mechanism for resolving them. As with most DP, it will involve hard work if it is to be effective. However, Rousmaniere has articulated the steps in a very clear and manageable way. As well, the process is inherently engaging. I have tried it in several workshops and the groups invariably have responded with excitement.

It helps as well that this manual is written in such a lively and engaging way. Rousmaniere’s stories of learning to rock climb, fly a plane, and drive a tour bus not only provide the reader with a sense of personal connection to him but effectively illustrate the points he is making.

In short, Tony Rousmaniere has written an innovative and important manual. Faculty and clinical students in graduate programs and internships will be glad for the tools it provides to teach something that has so far been hit-or-miss at best. Consultants will find it useful in helping experienced therapists. This manual also will be helpful to the therapist who wants to work alone to improve his or her psychological capacity. This is exciting stuff.

Redlands, California

September 2018

Foreword

by Alexandre Vaz, MA

I have a single rule when composing my weirdo jazz-rock music. It goes like this: what would I love to hear, as a listener, that I haven’t heard before?

That might sound like a strange way to start off a psychotherapy manual. The thing is, while this question has always saved my artistic self, I was stumped for years when trying to apply it to my professional self. What do I wish I had learned in college? If I went back to graduate school, what would have made me feel more able to actually sit face-to-face with my first unsuspecting client? Or was it normal to resort to a therapeutic poker face throughout my entire internship?

Some usual candidates were off the table—most of my budget was already blown to pieces from all the psychotherapy books, videos, trainings, and personal therapy I’d done throughout the years. Maybe supervision? Sure, I’ve had some positive experiences with it. But, for reasons I think will become clear once you read this manual, supervision often focused on a heady, declarative type of knowledge that just made me feel smart. Often not even that!

There’s an old joke about a psychoanalyst boasting that the beauty of psychoanalysis is that even if the patient isn’t getting better, you know you’re doing everything right. Don’t worry, analysts: this applies to everyone. Every model and manual can be used rigidly, and we have good data showing that too much adherence can actually have negative effects in therapy (Owen & Hilsenroth, 2014). I think that’s why Tony, in his unusually clear, personal, and creative way, was so focused on writing a sort of antimanual—a book that doesn’t tell you it knows best but instead helps you develop according to your personal developmental threshold. In putting the person of the therapist squarely in center stage, deliberate practice has finally answered my single rule question. I just wish I had had this manual around during college. Fortunately, I can now make up for lost time.

I’m very lucky to have known Tony and will continue to collaborate with him. I truly hope that this wonderful manual helps spark the much-deserved research and practice that psychotherapy needs. Now, if you’ll excuse me, I should get back to my workout.

Lisbon, Portugal

October 2018

PART I

The Training Plan

In part I of this manual, we will review the rationale and research that are the basis for this deliberate practice training program:

•   Chapter 1: Introduction—This chapter explores the limits of psychotherapy training as it is currently practiced and introduces you to the rationale for using deliberate practice to master the inner skills of psychotherapy and develop psychological capacity.

•   Chapter 2: A Case Example—This chapter shows you the benefits of deliberate practice via an illustrative case example.

•   Chapter 3: Psychological Capacity—This chapter takes you deeper into the concept of psychological capacity with examples of how it can benefit or limit your clinical practice.

•   Chapter 4: Stimuli for Deliberate Practice—This chapter explores the importance of identifying appropriate stimuli for your deliberate practice of psychotherapy.

•   Chapter 5: Principles of Training—This chapter reviews principles and guidelines that guide this deliberate practice manual, including the importance of privacy and appropriate boundaries.

•   Chapter 6: Training Safely—This chapter gives you tools to ensure that your deliberate practice is safe and beneficial.

Please note that this manual focuses tightly on clinical training. For a broader discussion of deliberate practice and more in-depth review of the relevant empirical research basis, see Rousmaniere (2016) and Rousmaniere, Goodyear, Miller, & Wampold (2017).

CHAPTER 1

Introduction

This book proposes a new approach to psychotherapy training based on two findings from psychotherapy research:

1.   Some of the most important skills for therapists are interpersonal relational skills, including attunement, empathy, and responsiveness (Anderson, Ogles, Patterson, Lambert, & Vermeersch, 2009; Boswell & Castonguay, 2007; Hatcher, 2015; Norcross, 2011). Relational skills are necessary for all major models of therapy. Indeed, research suggests that therapists’ relational skills have more than ten times the impact on the outcome of therapy than their choice of a model or adherence to a model (Wampold & Imel, 2015).

2.   Therapists’ relational skills are limited by their intrapersonal (inner) skills and psychological capacity to stay attuned to clients while the therapist experiences discomfort. For example, a therapist may experience discomfort when clients are angry or suicidal or they describe trauma. This can cause the therapist to detach, change the subject, or even argue with clients. Termed experiential avoidance, this process has been identified as a major barrier to success across a wide range of therapy models, from cognitive behavior therapy to psychodynamic psychotherapy (e.g., Eubanks-Carter, Muran, & Safran, 2015; Greenberg, 2010; Hayes, Follette, & Linehan, 2004; Hembree, Rauch, & Foa, 2003).

Many excellent guides have been written on how therapists can improve their therapy-related interpersonal skills. However, precious little guidance has been provided on how therapists can build their intrapersonal (inner) skills and psychological capacity to use these skills, particularly when helping clients whom the therapist finds provocative or interpersonally challenging. The goal of this book is to fill this gap by providing a training program to improve therapists’ psychological performance. Before we review the training program, however, let’s explore what it looks like when a therapist doesn’t have sufficient psychological capacity to be effective. This is best illustrated by a case I had a few years into my training as a therapist.

I was working with a male African American client in his early twenties. (Details of clinical cases in this book have been modified to protect