Author: Lou Lasprugato, MFT
My graduate school training at Lesley University was rooted in the philosophy of “self-as-instrument” with regards to the process of therapeutic change; that is to deeply know and effectively make use of oneself in evoking behavioral changes through the therapeutic relationship. Many years later, I continue to embrace and find this orientation helpful, albeit it has evolved to become an open, aware, and engaged self that is aiming to shape psychological flexibility within therapeutic encounters.
Psychological flexibility, or “the ability to contact the present moment more fully as a conscious human being, and to change or persist in behavior when it serves valued ends,” (Biglan, Hayes, & Pistorello, 2008) is the overarching aim of acceptance and commitment therapy (ACT).
While textbooks, workshops, webinars, and other training resources abound, the actual implementation of ACT in the clinical context can remain elusive for many practitioners. Just as a musician is not expected to skillfully play an instrument at performance time without having spent dozens, if not hundreds, of hours strategically practicing with the instrument beforehand, it would make sense that therapists aspiring to become skillful clinicians would benefit from strategic practice opportunities outside of therapy to increase their competency; and this is exactly what preliminary research is suggesting (Goldberg et al., 2016; Chow et al., 2015; Westra et al., 2020).
In fact, a longitudinal study (4.73 years) examining the clinical outcomes of 6591 patients for 170 therapists found that years of experience alone did not predict better outcomes, and on the whole, effectiveness actually decreased slightly over time (Goldberg et al., 2016). That is, without purposeful practice, our skill level is inclined to worsen over the years! So, if we value providing effective care for our clients (and patients), how might we go about developing a practice regimen that can support such ongoing aspirations?
We can turn to the work of the late K. Anders Ericsson, author of Peak: Secrets from the New Science of Expertise, who coined and defined the term “deliberate practice” as “engagement in structured activities created specifically to improve performance in a domain” (Ericsson, Krampe, & Tesche-Romer, 1993).
In his lifelong study of human performance, skill mastery and expertise across different professional domains (e.g. music, chess, sports, surgery), he discovered core behavioral patterns common to expert performers, which can be summarized by the following functional definition: focusing intently on practice activities designed to improve specific skills that are just beyond one’s comfort zone while receiving and incorporating timely feedback from a coach.
The new, and innovative live online course/workshop, Feedback-Enhanced ACT: Shaping Psychological Flexibility On-The-Fly, is designed to provide such a personalized training experience for participants. Clinicians will have opportunities to practice, from various perspectives, targeting the improvement of clinical ACT skills that lie just outside of their existing competence level, or within their “growth edge”, as measured through self-assessment. A functional feedback loop, based upon operant conditioning principles, will be established to promote in-the-moment learning and shaping of behavior for both client and clinician. To this end, attunement to ACT processes will allow for tuning up self-as-instrument.
Before diving into specific skill enhancements, the course will focus on what I refer to as the “ACT Foundational Trilogy”: approach, analysis, and interventions.
Imagine that we’re building a house of psychological flexibility in therapy. To construct this house, we’ll need a plan or design, materials, and tools. The therapeutic approach can be viewed as the house design.
ACT resides within a much larger context that includes a philosophy of science and a theory of language and cognition that was operationalized as a therapeutic approach in the landmark book, Mastering the Clinical Conversation (Villatte, Villatte, & Hayes 2015). We can derive four behavioral principles from the approach presented in this book: experiential, pragmatic, integrative, contextual.
These four interdependent processes function to create an approach that promotes agency, efficacy, acceptance, and transformation of self.
The materials we are working with in building our house of flexibility are antecedents, behaviors, and consequences; that is, we are interested in and focused on collaboratively understanding and manipulating the contextual variables or contingencies that give rise to and/or maintain behaviors over time.
Such analysis, or more precisely, functional analysis, is an ongoing therapeutic process that aims to undermine or extinguish ineffective behavior while promoting more workable behavior with respect to living a meaningful and fulfilling life as defined by the client.
And, our primary tools for helping clients with this overarching goal are behavioral interventions, notably the modeling, evoking, and reinforcement of mindful, values-based choices and behavioral patterns. In other words, we aim to embody the core processes of ACT as clinicians; create a context for flexible responding to emerge in the client; and draw attention to the meaningful and workable functions of such responses.
This foundational trilogy – design/approach, materials/analysis, and tools/interventions – will serve to strengthen participants’ ability to shape psychological flexibility on-the-fly during deliberate practice sessions in the Feedback-Enhanced ACT course.
Biglan, A., Hayes, S. C., & Pistorello, J. (2008). Acceptance and commitment: Implications for prevention science. Prevention science, 9(3), 139-152.
Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337.
Goldberg, S. B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W. T., Whipple, J. L., … & Wampold, B. E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy, 53(3), 367.
Westra, H. A., Norouzian, N., Poulin, L., Coyne, A., Constantino, M. J., Hara, K., … & Antony, M. M. (2020). Testing a deliberate practice workshop for developing appropriate responsivity to resistance markers. Psychotherapy (Chicago, Ill.).
Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of counseling psychology, 63(1), 1.
Ericsson, A., & Pool, R. (2016). Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt.
Ericsson, K. A., Krampe, R. T., & Tesch-Römer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological review, 100(3), 363.
Villatte, M., Villatte, J. L., & Hayes, S. C. (2015). Mastering the clinical conversation: Language as intervention. Guilford Publications.