Chow, D., Lu, S. H. X., Kwek, T., Miller, S. D., Jones, A., Hubble, M. A., & Tan, G. C. Y. (2025). Improving responses to challenging scenarios in therapy: A randomized controlled trial of a deliberate practice training program. Training and Education in Professional Psychology, 19(1), 1–13. https://doi.org/10.1037/tep0000493

Key Takeaways

Focus: This randomized controlled trial investigated the effects of a deliberate practice (DP) training program on therapists’ ability to manage challenging clinical encounters.
Aims: To examine if DP could enhance therapists’ skills in handling challenging therapeutic situations and if these skills could generalize to new scenarios.
Key Findings: Therapists in the DP group demonstrated significant improvements in their relational skills compared to the control group, and these gains were maintained over time and generalized to novel scenarios.
Implications: The findings suggest that DP training can effectively enhance therapists’ skills in navigating challenging therapeutic situations, which may ultimately improve the quality of mental health services.

Rationale

The study’s rationale stemmed from the observation that despite the proliferation of various therapeutic approaches, the overall effectiveness of psychotherapy has not seen substantial improvement in recent decades.

Research suggests that adherence to specific models or techniques, continuing education, supervision, and personal therapy have limited impact on client outcomes.

In this context, deliberate practice (DP) has emerged as a promising approach to enhance training and professional development in psychotherapy.

DP is a focused and structured approach to training that involves setting specific goals, actively seeking feedback, and repeatedly refining performance until mastery is achieved.

It’s about pushing beyond one’s comfort zone and engaging in activities that are slightly more challenging than the current skill level.

Previous research on DP in psychotherapy has yielded mixed results, with some studies showing positive relationships between DP engagement and client outcomes, while others failed to replicate these findings.

This study aimed to build upon previous research by incorporating all four key components of DP: individualized learning objectives, targeted feedback, successive refinement, and guidance from a coach.

Method

Procedure

The study employed a randomized controlled trial design. Participants were assigned to either a deliberate practice (DP) group or a control group.

Pre-study Questionnaire: All participants completed a pre-study questionnaire to gather demographic information and assess their clinical experience, therapeutic orientation, and self-perceived effectiveness.
Challenging Conversations Vignettes (CCVs): Participants were presented with eight brief video vignettes depicting challenging clinical encounters across four different themes.
Participant Responses: After viewing each CCV, participants were asked to write out in detail how they would respond to the client in that scenario.
Feedback (DP Group Only): In the DP group, two independent raters scored each participant’s response using the Facilitative Interpersonal Skills (FIS) measure. Discrepancies were discussed until a consensus was reached. Principle-based feedback was then provided to the participants based on their FIS scores.
Self-Reflection (Control Group Only): Participants in the control group watched the same CCVs and wrote out their responses but did not receive any feedback. They were instructed to reflect on their responses and consider how they might be improved.
Post-study Questionnaire: At the end of the study, all participants completed a post-study questionnaire to assess their perceived changes in skills and difficulty levels of the CCVs.

Sample

Sample Size: 72 participants (39 in the DP group, 33 in the control group)
Demographics:
- Gender: 55.2% female, 44.8% male
- Age: 50.7% between 26 and 40 years old, 26.9% between 41 and 55 years old, 10.4% between 56 and 60 years old, and 11.9% 61 years or older
- Experience: An average of 11.6 years in clinical practice
- Therapeutic Orientation: 34.3% “other” (e.g., analytic/psychodynamic, solution-focused, eclectic), 31.3% cognitive-behavioral therapy (CBT), 20.9% humanistic/person-centered, and 13.4% family/systemic
- Education: 19.4% doctorate, 59.7% master’s, 7.5% postgraduate diploma, and 13.4% bachelor’s degree

Measures

Pre- and Post-study Questionnaires: Gathered demographic information, assessed clinical experience, therapeutic orientation, self-perceived effectiveness, and perceived changes in skills and difficulty levels of the CCVs.
FIS Measure: An abbreviated version was used to assess six core therapeutic skills: persuasiveness, warmth, acceptance, and understanding, hope and positive expectations, empathy, alliance-bond capacity, and alliance-rupture-repair responsiveness.
Principle-Based Feedback: Developed based on evidence-based principles of therapeutic engagement, providing specific guidance for each FIS domain.
Participant Self-Rating: Participants rated the quality of their response and the perceived difficulty of each CCV on a scale from 0 to 10.

Statistical Measures

Mixed-design ANOVA: Used to compare FIS scores between the DP and control groups across all trials.
Huynh-Feldt correction: Applied to account for the violation of sphericity assumption.
Bivariate correlations: Examined the relationship between FIS scores and self-ratings of performance and difficulty.
Independent sample t-tests: Compared self-rated difficulty and performance between the DP and control groups.

Results

Hypothesis 1: Participants in the , deliberate practice (DP) group would show more improvement in their facilitative interpersonal skills than those in the control condition.

Result: Supported. The DP group demonstrated significantly greater improvement in FIS scores over the eight trials compared to the control group.

Hypothesis 2: Skills gained from engagement in DP would generalize to novel clients and clinical scenarios.

Result: Partially supported. The DP group maintained their gains when introduced to new clients with the same clinical theme and when presented with a new theme and client. However, the improvement did not generalize to a new client with the same theme in the final trial.

Hypothesis 3: Given the historically weak relationship between therapist ratings and measures of both clinical performance and effectiveness, participant ratings of the quality of their responses and difficulty level of the challenging clinical vignettes would not correlate with actual measured performance.

Result: Supported. No significant correlations were found between FIS scores and self-ratings of performance and difficulty.

Hypothesis 4: Control group participants would rate their performance more positively over the course of the study than those engaging in DP.

Result: Supported. Participants in the control group rated their performance significantly more positively than those in the DP group across all trials.

Insight

The study’s key findings highlight the effectiveness of deliberate practice in improving therapists’ relational skills.

The DP group’s consistent improvement and ability to maintain gains over time suggest that DP can lead to lasting changes in clinical skills.

This is particularly informative as it provides evidence for a structured training approach that can enhance therapist effectiveness, addressing the limitations of traditional training methods.

The study extends previous research by incorporating all four key components of DP, providing a more comprehensive and rigorous test of its effectiveness in psychotherapy training.

The findings also shed light on the limitations of self-reflection as a primary means of professional development, emphasizing the need for structured training programs with feedback and guidance.

Future research could explore the long-term impact of DP training on client outcomes and investigate the effectiveness of DP in different therapeutic settings and populations.

Additionally, research could examine the specific mechanisms through which DP leads to skill development and generalization.

Clinical Implications

The findings of this study have several implications for practitioners and policymakers:

Training Programs: DP should be integrated into training programs to equip therapists with the skills to navigate challenging clinical encounters effectively. This could involve incorporating individualized learning objectives, targeted feedback, opportunities for successive refinement, and guidance from a coach or supervisor.
Continuing Professional Development: DP could be incorporated into continuing education activities to promote ongoing skill development and enhance the effectiveness of practicing therapists.
Supervision: Supervisors can utilize DP principles to provide more structured and targeted feedback to their supervisees, facilitating skill development and generalization.
Policy: Policymakers could consider incentivizing or mandating DP training for mental health professionals to improve the overall quality of mental health services.

Implementing DP training may present challenges such as time constraints and the need for additional resources.

However, the potential benefits in enhancing therapist skills and improving client outcomes could outweigh these challenges.

Strengths

Randomized Controlled Trial: The use of a randomized controlled trial design strengthens the internal validity of the study, allowing for causal inferences to be made about the effects of DP training.
Comprehensive DP Framework: The study incorporated all four key components of DP, providing a more rigorous test of its effectiveness compared to previous research.
Principle-Based Feedback: The use of principle-based feedback promotes the development of transferable skills rather than rote imitation.
Ecological Validity: The use of challenging clinical vignettes enhances the ecological validity of the study, as the scenarios reflect real-world therapeutic encounters.

Limitations

Attrition: The high attrition rate (48.71% in the DP group and 33.33% in the control group) may have introduced bias and limited the generalizability of the findings.
Small Sample Size: The relatively small sample size, especially after attrition, may have reduced the statistical power of the study.
Limited Generalization: The study’s findings may not generalize to all therapeutic settings and populations, as the participants were primarily psychologists from Singapore.
Self-Report Measures: The reliance on self-report measures for some variables may have introduced bias.

Reference