The Cycle of Excellence (Rousmaniere, Goodyear, Miller, Wampold)

The Science of Expertise

Anders Ericsson and others have studied individuals in different professions (e.g., musicians, chess players, athletes, surgeons), have found that merely "accumulating work experience does not itself lead to expert performance." Researchers have identified "three components critical for superior performance," aka the cycle of excellence.

Step 1: Determining Baseline

Two scales for assessing outcome, both on the SAMHSA list of evidence-based programs and practices: Partners for Change Outcome Management Systems (PCOMS) and the Outcome Questionnaire Psychotherapy Quality Management System (OQ-Analyst). PCOMS includes a scale for assessing the therapeutic relationship. 

Lag Measures = distal outcomes. Lead measures = predict or impact lag measure. Example: the pounds lost is the lag measure, while caloric intake and time spent exercise are lead measures. To help identify lead measures, see Chow and Miller's Taxonomy of Deliberate Practice Activities Worksheets (TDPA). (Chow 1, Chow 2.) 

Step 2: Feedback

Feedback comes from two main sources: empirical outcome measures and coaching/supervision. Example: A basketball player receives the former feedback when he shoots the ball and sees whether it goes it; he receives the latter feedback when before and after the game, "the coach reviews video recordings and works with the player to identify small errors and develop specific skills." Therapy example: We receive empirical feedback through the PCOMS or OQ-Analyst; we receive supervision when we review audio or video recordings with a supervisor and receive feedback. 

Step 3: Deliberate Practice

This involves "identifying where one's performance falls short, seeking guidance from recognized experts, setting aside time for reflecting on feedback received, and then developing, rehearsing, executing, and evaluating a plan for improvement." Deliberate practice "involves a tight focus on repetitively practicing specific skills until they become routine." Deliberate practice requires "sustained concentration and continuous corrective feedback outside [one's] comfort zone" and usually "is not enjoyable or immediately rewarding." (Thus, deliberate practice requires grit.) Maintenance of expert performance requires "continued deliberate practice throughout the career span." Thousands of hours of deliberate practice required for expert performance. For most therapists "a serious focus on skill acquisition" ends after grad school. 

Deliberate Practice in Supervision. Supervisors can (a) explain and demonstrate "models for effective practice," (b) determine the supervisee's areas of improvement, (c) provide corrective feedback, (d) offer "emotional encouragement to boost the learner's morale and buffer against the emotional challenges inherent in deliberate practice."

Deliberate Practice in Independent Practice. Therapists can (a) receive advanced training from experts, (b) receive "skill assessment and case consultation with experts or peers," and (c) undertake solo study (e.g., watching videotapes of oneself work).

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Supervision

Introduction

Supervisors work with trainees, while consultants work with credentialed therapists.

Carroll (2010): "The acid test of how effective supervision is is simple: What are you (the supervisee) doing differently now that you were not doing before supervision?"

Research does not show that supervision leads to better outcomes for clients.

Competence is a necessary for insufficient condition for developing therapeutic expertise; it's insufficient because competence does not lead to improved client outcomes.

John Wooden coach article (p. 74).

Supervisor has three roles: teacher, consultant, and counselor (to support/encourage).

Elite performers are initially coached by "local teachers, people who can give generously of their time and praise. Later on, however, it is essential that performers seek out more advanced teachers to keep improving their skills. Eventually, all top performers work closely with teachers who have themselves reached international levels of achievement."

Begin by learning one specific model, which can mean initially being guided by treatment manuals.

Necessary Relationship Conditions for Supervisors

Effective supervisors must:

1. Have obtained competence through formal training and practice. 
2. Establish "clear expectations about performance goals and about the responsibilities of each party in that relationship." 
3. Remain "committed to resolving conflicts when they occur." 
4. Provide "clear and ongoing feedback and evaluation." 
5. Demonstrate multicultural competence. 

The Expertise-Development Model of Supervision

The supervisor has five functions. 

Function 1: Obtain Information about Therapist Performance. The supervisor must first determine the therapist's current levels of performance. This information comes from three sources: 

1. Direct observation of the therapist. Their therapist recalling what happened is insufficient: e.g., memory is limited, verbal descriptions limited, therapist might leave out salient parts of client interaction, therapist might withhold or distort information to appear more competent. Audio and video recordings are best because certain parts of therapy to be reviewed.  \
2. Routine outcome monitoring (ROM).
3. Simulations of therapy. Simulations with actors who have been trained to act as clients. Anderson's measure of facilitative interpersonal skills offers a tested simulation. 

Function 2: Identifying Gaps between Observed and Desired Performance. The therapist must have a goal, which might begin "with ROM data on a set of that therapist's clients who deteriorated in treatment...and might proceed to examining other data (video recordings, data on alliance quality, qualitative information) to identify some aspect of the therapist's work that is contributing to these results." 

Function 3: Providing Feedback. Supervisor must:

1. Provide timely feedback. 
2. Provide incremental feedback. That is, "feedback in digestible units that focus on performance goals that are just slightly beyond the learner's current level of functioning." E.g., the supervisor might first teach behavioral skills (eye contact) and then verbal skills (careful listening). To ensure that therapist understands feedback, it might be helpful to ask them to summarize feedback and its implications for their work. 
3. Provide constructive feedback. Feedback must not "elicit defensiveness or other forms of affective arousal that will interfere with how therapists hear and use it." A "feedback sandwich" can come across as "vague or even patronizing." Instead use this seven-step sequence, making sure that feedback is "delivered in descriptive rather than evaluative language" (quoted verbatim):
1. Ensuring the learners are aware of the purpose of the feedback. 
2. Learners commenting about the goals they were trying to achieve during their task. 
3. Learners stating what features of the task they thought they'd done well. 
4. Supervisors stating what features were done well. 
5. Learners stating what should be improved. 
6. Supervisors stating what should be improved. 
7. Agreeing on action plans for improvement. 
4. Providing specific feedback linked to benchmarks. Feedback must be precise. Don't give global goals (e.g., "Try to build a stronger alliance with the client"). Supervisors tend to feel uncomfortable giving corrective feedback. 

Function 4: Facilitating Critical Reflection about Feedback. Once feedback is giving, supervisor and therapist must link new knowledge to action. Therapist can mentally review past sessions and mentally run through future sessions. See sports psychology literature on mental rehearsal as a form of deliberate practice (p. 82). 

Function 5: Facilitating Successive Skill Refinement. Skill acquisition and refinement come through behavioral repetition, not talking about theory. This can occur through simulation-based behavioral rehearsal. See John Wooden example. More examples: watch video of session together; supervisor demonstrates the skill in question; supervisor and therapist then switch roles; supervisor assigns homework (e.g., "Spend an hour watching other videos of sessions with this client. Notice when this particular sequence we identified as challenging occurs. At that moment pause the video and practice responding to the client in the ways we have been rehearsing here"). Solitary practice: therapist watches video of session and practice "making assessments, saying interventions to the client in the video, and tuning in to their own experience while the video is playing (in real time)." 

Ericsson on practice: elite performers "have been found to practice, on the average, roughly the same amount every day, including weekends, and the amount of practice never consistently exceeds five hours per day." It's important for therapists to develop a routine "that would occur at roughly the same time every day." During this practice, the therapist "should be engaged in the same way they would with work performance and should be undisturbed (e.g., turn off phones, internet access, etc.)."