Elevate Your CBT Skills with Deliberate Practice

Maor Katz, MD, Mike Christensen, MACP, RCC, and special guests Alexandre Vaz, PhD and Tony Rousmaniere, PsyD present this free 1 hour webinar to teach you how to identify barriers hindering excellence in therapy skills and apply the Deliberate Practice approach to achieve mastery in CBT.

In this free 1 CE webinar on deliberate practice, therapists are guided on effective CBT instructions and cognitive behavioral therapy exercises to enhance trainees' skills. The webinar is led by Maor Katz, MD and Mike Christensen, MACP, RCC, with special guests Alexandre Vaz, PhD and Tony Rousmaniere, PsyD. The focus is on providing two types of feedback: positive reinforcing and corrective feedback. 
Importantly, supervisors should highlight one specific corrective point to avoid overwhelming trainees. This approach aims to improve clarity, actionability, and focus on behavior.

A key part of the training involves role-playing exercises where supervisors practice giving concise, clear feedback. The webinar emphasizes the challenge of restraint, encouraging supervisors to identify and communicate the most crucial feedback succinctly.

Additionally, the webinar explores cognitive and behavioral practice within team CBT (Cognitive Behavioral Therapy), integrating skill training sessions and case consultations. The approach is compared to learning a musical instrument, highlighting the importance of practicing specific skills until they become intuitive. The overall goal is to enhance therapy effectiveness by adopting a structured, goal-oriented approach to skill development and feedback delivery, rooted in simply psychology and a cognitive approach.

IN THIS VIDEO:

Jill: Great! Welcome everyone to our first Wednesday of the month continuing education didactic series at the Feeling Good Institute. This month we're going to be presenting "Elevate Your CBT Skills with Deliberate Practice". I'm really excited to introduce the four presenters. I'll try to be brief but I'd love you to hear a little bit about who you're going to be learning from today.

Please join me in welcoming Dr. Maor Katz. Maor serves on the adjunct faculty at Stanford University in the Department of Psychiatry and Behavioral Sciences. He has many publications in the field of depression, anxiety, resilience and has won several teaching and research awards. In 2013, Maor founded the Feeling Good Institute, a treatment and training institute with a worldwide reach. We're dedicated to helping therapists become more effective through training and treatment in TEAM Therapy, which we'll tell you about more today.

I'd also like to welcome Mike Christensen, who's the Director of Professional Development at the Feeling Good Institute and also the co-founder of FGI Canada. He serves as its Clinical Director. Mike is a Level Five TEAM CBT Master Therapist and trainer and provides advanced level online and in-person training at workshops and webinars around the world. His diverse background in business leadership, theology, and as an elite level athlete has served to enhance his unique skill set as a therapist and trainer, especially in the deliberate practice model.

Our first featured guest, Dr. Alexander Vaz, is the co-founder and Chief Academic Officer at Sentio University and the Sentio Counseling Center. He provides workshops, webinars, and advanced clinical training and supervision to clinicians around the world. Alex is the author and co-editor of over a dozen books on deliberate practice and psychotherapy. He is the founder and host of Psychotherapy Expert Talks, an acclaimed interview series with distinguished psychotherapists and therapy researchers.

Last but not least, we have Dr. Tony Rousmaniere, who is the co-founder and Program Director of Sentio University and the Counseling Center there. Tony provides workshops and advanced clinical training and supervision to clinicians around the world. He's also the author and co-editor of over a dozen books on deliberate practice and psychotherapy. In 2017, he published the widely cited article in The Atlantic Monthly, "What Your Therapist Doesn't Know". Tony is the president-elect of Division 29 of the American Psychological Association.

We are really thrilled to have all four of you with us today. I know we're in for a treat. Let me tell you very briefly about who we are at the Feeling Good Institute. Our mission is to alleviate suffering by elevating the practice of therapy. We were started by a group of clinicians originally mentored by Dr. David Burns at Stanford University. We train and certify therapists in the processes of CBT, evidence-based CBT that are known to be the most effective. This includes focusing on the use of measurement, developing very strong empathy skills, helping therapists to reduce resistance and boost motivation in their patients, and the powerful cognitive and behavioral methods that many people think of when they think of CBT.

We have a group of therapists that are affiliated with the Feeling Good Institute that are all highly skilled and vetted. At the Feeling Good Institute, we engage in a weekly system of continuous improvement using the deliberate practice model to help our therapists learn, grow, and advance their skills week over week. We also offer flexible services to meet clients' needs. We have video-based therapy across the US and Canada, and in-person treatment centers in New York, Silicon Valley, Canada, and Israel. We focus on both traditional weekly therapy sessions as well as an intense therapy program where people come in from out of town and do therapy multiple hours a day, many days over the week to make therapy that much more efficient. Finally, we have fee options that range from lower fee options to the whole gamut.

You'll get CE credit for being here today as long as you're here till the end of the presentation. We will drop the link in the chat box. You must be here and you have to complete the survey on time today, by the end of the hour, in order to get your CE credit. You'll get it via email. You don't need to send an email letting us know. As long as you complete the survey, then within a week you'll get your CE certificate delivered to you via email.

Now, I'll turn it over to Mike. 

Alexander: Did we introduce Jill? I don't know that we let people know who you are here in this group.

Jill: I will very briefly then just say I'm Jill Levit and I'm a clinical psychologist and I'm the Director of Training at the Feeling Good Institute.

Mike: When you ask that question, when you have somebody that's really famous, they don't need an introduction. As we all know, Jill is one of our lead trainers and is so graciously hosting for us today. If you have an opportunity to take any courses from Jill, I highly recommend it because she's phenomenal.

Today, our agenda is to have a look at what is deliberate practice. We'll spend a little bit of time looking at that and then how do deliberate practice and the TEAM CBT model kind of mesh together. Maor is going to give us some examples in a demo of deliberate practice in TEAM CBT. Then we're going to look at what are some of the barriers that get in the way that pull us away from doing deliberate practice. Then we'll have a little bit of time for Q&A. If you do have questions that come up during the presentation, please send them directly to Jill.

She's our host. You can chat with her, and she'll be moderating the Q&A at the end. Our hope is that today you'll learn a couple of things. The first is to identify some barriers that hinder excellence in therapy skills. Tony's going to talk a bit about his passion for deliberate practice and what brought him to that. He'll also discuss the key elements in getting there and what gets in the way. Secondly, we'll learn a bit about the deliberate practice process of obtaining mastery in our skills with CBT and team CBT.

I'm thrilled today that we have two of the world's leading experts in deliberate practice, Dr. Tony Rousmaniere. Tony, maybe you could start us off by telling us a bit about what it was in your research that motivated you to pour your life and passion into deliberate practice.

Tony: Before the research, what motivated me was my own caseload. When I started training, I thought I was going to be a pretty good therapist. I was frankly a bit overconfident. As I went through training and started to collect my own outcome data, I was very humbled and quite shocked to realize that I was not as effective as I thought I was. While some of my clients were improving, roughly half or more were not improving. A fair amount of them were dropping out, and most horrifying to me, some of them were deteriorating, meaning getting worse during therapy. This is despite my best efforts. I was studying as hard as I could, going to supervision, and doing all the things you're supposed to do.

So, I got quite focused on how I could improve my skills personally. Long story short, that's how I found deliberate practice, which is a method of training that is used in most professions. It's a term coined by K. Anders Erikson, a psychologist in the science of expertise, to describe a process of skill rehearsal focusing on key skills with expert feedback. This process gets a trainee up to a certain level of skill but then crucially continues throughout a career.

For example, when a basketball player joins the NBA, they don't stop practicing. If anything, they practice more than anyone else because that's how they maintain their expertise.

Alex, do you want to jump in with anything here?

Alexander: My story is pretty much close to Tony's. I come from a music background. I was originally trained as a musician. I started playing piano when I was 5 years old. So, imagine my shock when I got to graduate school and realized that there was zero skills training at my college when I was studying to become a clinical psychologist. I learned through books and we discussed theory. I loved theory, but from my musical training, something felt off. How am I actually supposed to help people having no training in performance-based skills?

But I was kind of shy to ask that after a while because everyone kind of assumed that's how psychologists are trained. So, I thought it was my problem, and I shut up after a while. Only then to realize that most people were kind of freaking out inside and actually most people did not feel confident seeing their first clients for say the first five to ten years of their clinical practice, maybe longer.

So, long story short, after trying to interview all my favorite therapists and trying to understand how to practice skills, I ended up meeting Tony and we started developing ways to bring this deliberate practice theory and research into the field of psychotherapy.

I have to say off the bat that nothing is new in everything we're doing. It's just trying to distill something that others have come before. I want to give a shout out to David Burns because David Burns very early on emphasized the need for role play and training through role plays.

I'm sure all of you had a lot of training that had zero procedural elements. That's our emphasis.

Tony: Alex and I have explored using deliberate practice across a wide variety of therapy models. I'm curious what Alex has to say, but I would say that team CBT is possibly the easiest fit for deliberate practice. Team CBT was basically doing all this already. It wasn't codified under the term deliberate practice perhaps, but all the components were already there.

If you see the components on the screen, the baseline effectiveness, team CBT is really good at measurement, just routine measurement session after session. It's really good at explaining it to clients, getting the client on board, which is really important. Systematic feedback throughout training and feedback also from the client and then skill rehearsal.

I think this is a very natural fit for team CBT for trainees to learn deliberate practice. Team CBT also has a culture of continual skill development across a career.

In graduate school, we use a competency model of training, which makes sense. It's great to be competent on days that I can achieve it. But one of the potential problems with this is it can imply that once you hit competence, then you're competent and then you move on and then you don't have to do anymore.

When really, we know that those of us who collect outcome data find out that there is room for improvement throughout the whole rest of our career. There's definitely a need to get client feedback throughout the rest of our career. This is something that Team CBT is in the DNA of Team CBT and deliberate practice emphasizes these factors.

Alexander: Let me just add one last thing. The idea that the ego of the therapist kind of has to die in order for the therapist to get better.

I know it's a core idea also in team CBT, and one of the main struggles we have noticed in the mission towards Excellence is our own clinicians' shame and self-criticism. This comes up through the process of trying to monitor our outcomes and improve over time. I can speak for myself, even when I forced myself to video record and do outcome monitoring with my patients, there were days when the last thing I wanted was to look at the outcomes or the videotape. It takes something out of us, at least at first, and so we've actually viewed it. I'm so happy that the Feeling Good Institute exists and all of you are here because I now believe it takes a culture to do this routinely. It's actually not fair to ask one therapist or a small group of therapists to do this hard work by themselves. The more people are talking about it, un-shaming each other about it, the only way I think our field will progress. So, I want to again commend you guys for the hard work in that.

Tony: You all do really well at the culture piece, which is really essential.

What we're looking at here is a chart for the Zone of Proximal Development, which is the zone in which a trainee or a therapist, a practitioner, should practice. We don't want it to be too easy and we don't want it to be too hard. When you look at it visually, you think, "Oh, that makes sense, it's not that big a deal," but it can be hard to figure this out when you're working with a trainee or a licensed therapist. We find that we want to continually check in with our trainees or therapists. How hard does this feel? Sometimes it's too easy, sometimes it's too hard, and then we want to continually adjust practice to make it right for each person. This is a continual process and it takes supervisors a while to learn how to do this. We do a one-year supervision residency at Centio where we spend a year getting supervisors up to speed in using deliberate practice. We found most supervisors are really good at talking about theory, they're really good at case conceptualization because those are things that are really taught in graduate school. When it comes to helping zoning in on a specific training Zone of Proximal Development and helping them rehearse the same skills again and again, that's something most of us did not learn in graduate school, so it can take some time.

Alexander: Just to add to what Tony is saying, if you're practicing something and it feels too easy, chances are you're not actually consolidating anything, not really working a lot. Chances are if it feels too hard, because a lot of people try to push themselves over the edge, they try, some people feel that if I'm at a nine or 10, that's a good sign. You're probably not consolidating, not learning a lot if you are pushing yourself.

I just also want to say a small, very cool historical link to this expression of challenging but not overwhelming. I started to use this a lot in the practice writings that we did as an expression for the Zone of Proximal Development. I stole the expression "challenging but not overwhelming" from a therapist, CBT therapist, called Wendy Dryden who was supervised under David Burns back when there was no real training in England in RVT and CBT. So in some weird way, the "challenging but not overwhelming" expression comes from Team CBT originally. You see, everything comes together, and it was their expression for if you want to provide good exposure exercises for your clients, the exposure exercise should be "challenging but not overwhelming". So we know this intuitively for our clients, but we've taken some time to apply it for ourselves in our own skills training. That's kind of the irony.

Tony: So, these are the steps in deliberate practice. We want to kind of bring a skill or challenging moment to life. This is called State Dependent Learning. So, as opposed to theoretical learning, we're doing this in a role play that hopefully evokes some emotional reaction from the therapist. Just like your client, I think some people here might have noticed that therapy can evoke emotional reactions from therapists from time to time. That's good, it means we have functioning limbic systems. We just want to rehearse in that state. We go right into the role play and then we go through a process of getting feedback and repeating. This is how deliberate practice is different than traditional. In many traditional role plays, you'll just go through 10 minutes of a therapy session or 20 minutes of a therapy session. In deliberate practice, we'll repeat the same skill again and again and again with the goal of it moving into what's called procedural memory for the therapist, so you can access it and just use the skill even if you're feeling a bit of anxiety yourself or whatever you're feeling in the moment. Then we only move on at that point.

Maor: I just want to say before we move on that I think this part here about the five to 10 times of repeat changed with our practice of things, thanks to you guys. In a particular great way, two things I'd say are kind of outstanding to me. One is how quickly there's this expectation of how uncomfortable we want to feel with not bringing a skill or a moment to life. We now train our trainers to be very uncomfortable talking about anything unless we're bringing a moment into life and want to dive into it very quickly and then stay there, stay in that rehearsal, and repeat with very brief feedbacks many many times. I think that took our trainings and kind of gave them an incredible boost.

Tony: Thank you for that. It's typically a big step for many trainers because what we've been taught in graduate school is to keep talking, which has limited benefit for the learner. We have a saying: the trainer or supervisor is not providing the training, the rehearsal is providing the training. The supervisor's job is to guide the rehearsal, but otherwise get out of the way and let the rehearsal do the work.

Alexander: This is the danger zone where the trainer is providing feedback. We have to be very careful and disciplined about how much feedback and how to give feedback during rehearsal. This is one of the hardest things we need to train our supervisors to do. Tony and I noticed in ourselves we would constantly give feedback that was just a bit too long. After a while, five minutes pass, ten minutes pass. All of us do this. It's an exposure exercise to be able to just say what you need to say. The two types of feedback that we want to give during the practice are what you might call negative or corrective feedback, and positive and reinforcing feedback. Importantly, we need both. We need to highlight the things that the trainee is doing well, and consistently point to one corrective thing that they could be doing better. I'm saying one corrective thing because anytime your trainee does something, you might be able to pick out ten different corrective feedbacks that you could provide. Do not provide the ten corrective feedbacks. That will overwhelm everyone in the room and that will be your temptation. So the discipline is, what is the one most important thing you want to tell them to try new? What's the one corrective feedback? Try to make it as short, clear, actionable as possible. Focus on the clinician's behavior, not theory. Tony, you want to jump in on that as well?

Tony: Yeah, it takes our supervisors about a year to really get good at this. We've been trained to talk. In graduate school, we're graded on our ability to use multi-syllable words, sound convincing, and write long papers. After years of graduate school, we get really good at that, but it's all counterproductive for training. You want to have a little bit of theory, a little bit of case conceptualization, but then you want to move on and rehearse the skill. The challenge is, especially if you're working with more beginning trainees, you will see five or ten different ways for someone to improve their performance. But if you've ever learned a sport or a musical instrument, if your coach or teacher was telling you five new things as feedback, you'd get overwhelmed. We really only learn one thing at a time. So a lot of the challenge for supervisors with deliberate practice is the challenge of restraint.

Mike: I love that you said that, Tony. Having worked in addictions, I would say it's addictive for us supervisors to theorize. I call it the addiction of theorizing and we get drawn into it. I'm glad too that you pointed out that there's a culture shift that we make. At the Feeling Good Institute, we've been really approaching shifting our culture in two ways. There are two venues that we utilize in implementing deliberate practice. One is through a specific skill training session. When we do our teaching and training sessions, infusing deliberate practice through that, where you identify a skill, you're learning a new skill. You might be brand new to this approach and there's a description and criteria that's set out ahead of time. Then we dive into the practice. It remains somewhat theoretical because it's not about a specific case but a skill. You can use a book or material to serve as a guide. It's much like if you wanted to learn the piano and you picked up a book that says how to learn the piano on your own. It gives you a little bit of teaching but then it gives you lots of practice exercises and then you practice those exercises. The other way we're shifting our culture is through our case consultation. A therapist or clinician brings a case where they're feeling a little stuck or unsure, maybe not confident in a certain place, and we pinpoint that moment. Then we jump right into roleplay. We may not even know what the skill is they need to practice, but we have them say, "Okay, what did your patient or client say? Now, how would you naturally respond?" Then we can uncover what the skill is that needs to be practiced in that scenario. It's like when I took piano lessons. My teacher would say, "Okay, now play the song for me." Then she would say, "Okay, this is where you're stuck. Here's what I want you to practice." That's exactly what we're doing with deliberate practice. She wouldn't say, "Let's play all the songs," and talk generally about theory and Beethoven and other things. She'd say, "No, you need to practice your D scale so you can get that run." Then I'd practice a D scale, which isn't a song. It sounds kind of boring just practicing the scale. It's hard, but once you do it, that scale becomes intuitive. Then when you get into the song, the music comes to life. That's really what we're doing with therapy until it becomes intuitive with those specific skills.

You know, without that beautiful flow, you won't know what you don't know. So, when Tony, Alex, Maor, and I first started working on the skill training aspect, we were very excited. I remember doing a workshop with Dr. Burns. We met for dinner before the workshop. You can go to the next slide, Maor. The first thing he said to me was, "Oh, Mike, it's so great to see you. Tell me where you're stuck with your clients or patients." Then I said, "Oh, you know, sometimes I wait too long with the invitation." He said, "Well, let's practice right now." So, when you said, "Hey, I think TEAM was a great mix with the practice," I thought this was David's passion. When I did a podcast with him, he said, "I love what you're doing. Can we elevate this? Can we take our trainings and show people how to do this with more intentionality, more effectiveness?" So, with TEAM CBT, we follow the TAM model of testing and measurement, so you know where you're at and where to go. Empathy is infused into everything that we do and is a foundation for pretty much every form of therapy. But a lot of times, we don't practice it. We think we're good, but we're not. Then the agenda setting, assessment of resistance, is really the heart of TEAM that David developed, followed by our methods, our behavioral, our cognitive, and other methods. So, in the book, we included an overview of deliberate practice, how to do deliberate practice, as well as actual practice exercises, much like that piano manual that gives you exercises. Then, at the end, a session transcript from a live demo that we did in Poland. Heather Cay and I did a live demo with a young therapist, a brilliant, amazing young guy. So, you can follow through the whole progression and the model. So, I'm going to hand it over to Mo, and he's going to walk us through a couple of the exercises so that you can get a sense of what they look like.

Maor: Thanks, Mike. I wanted to try to help you have an image in your mind about how a deliberate practice session looks like. In some ways, a lot of the work that we did with Tony and Alex around setting up these exercises was around distilling the skill criteria. So, for this, the very first thing that we teach in TEAM CBT, and we do this also in the comprehensive training that we provide for therapists, is how to use what we call testing or basically measurement in therapy. We all know that using measurement in therapy routinely will enhance your therapy skills and will enhance your effectiveness. That's been tested and proven very clearly. But so few of us actually practice it. So, in TEAM CBT, we use measurements before and after each and every session, and in some ways also during the session. So, the first skill that we came up with is how to actually introduce the use of measurement to patients. It needs a certain kind of assertiveness and gumption from the therapist to be able to stop the patient and ask them to do something, rather than just listen. And of all things, a survey. We have certain expectations from the patient that are not easy to set. So, maybe we could take a look at the skill criteria and maybe we can launch the poll right now about this. When we have a deliberate practice session about the use of measurement, we have very clear, very specific skill criteria that the person practicing can give as feedback. We practice in dyads, and the guidance to the practitioners is to give feedback only based on the skill criteria. Then, using this approach to very short feedback, one item of feedback like Alex was saying, and then doing it again and again. We just repeat this very small moment in time of adding this, practicing the skill set, introducing measurement to our patients. So, maybe we could end the poll right now, and we can kind of just share the results. So, I see that we have about 6% of our audience who feel extremely confident in doing this in real life. And I'd say we have a lot fewer who are feeling somewhat or moderately confident or not at all confident. Let me kind of show you how we would be in a skill practice with us. So, when you were doing this in real life, we have dyads, and the person practicing as a therapist doesn't have the skill criteria or the response in front of them. They have to improvise this response kind of out of thin air. They want to remember what the skill criteria are without looking at them and actually be able to provide them. Sometimes what people do is they start with the skill criteria in front of them and then put them aside for the subsequent rehearsals. Of course, the person giving the feedback always has the skill criteria in front of them so they can give accurate feedback.

So, in this example, a client would say, "I'm looking forward to working with you." And a way to respond that would meet the skill criteria would be, "Me too. Let me quickly share with you how I like to keep track of your mood and how therapy is going for you. Before and after each session, you'll be asked to fill out a brief mood survey. This will take a few minutes of your time before and after we meet each session. We'll start by quickly reviewing it so I can understand how you're feeling then and there. It will also serve as another way for us to track therapy progress. Can I show you the mood survey we use right now?" So, you see, when I'm reading it, it kind of feels contrived, right? It kind of feels a little bit clunky. If I were to not read it and actually just practice it in front of you, it would look differently, and then you could give me feedback on it based on my skill criteria. So, let me try it myself right now, kind of fail gloriously in front of you. Be the client, yeah, you be the client, Mike. "Yeah, I'm looking forward to working with you."

Yes, let me take a moment here and share with you a bit about how I like to work with my patients. Before and after each session, I'll ask you to fill out a mood survey. This will take a couple of minutes for you to do, and then when we start our session, we'll review how you're doing. The reason I do this is it gives both of us a chance to know how you're doing immediately. It also helps us track how helpful this is for you over time. Can I show you how it works?

This is the first skill that we have in our training. As we were finishing up the book that we wrote together with Tony and Alex, the publisher came to us and said this is not enough for a hardcover publication. The book is structured in a very deliberate way where you go from skill to skill, kind of the way that you would follow a therapy session. But it wasn't clear to us at the time that something very special about team CBT is that it offers a workflow of how to do effective therapy.

Each consecutive chapter is a consecutive skill that you would use in the way team CBT has for effective workflow. There's a very clear workflow to the team CBT that I think is very different than most other therapies, which go through one step at a time. Testing starts the session, then we connect with empathy, issue an invitation, go to specificity, focus with conceptualization, predict the resistance that will come, and then we melt it away. We bring it to the conscious awareness of the patient, both for outcome process resistance, and then we only then get into using our methods.

Mike and I started to think, together with Jill, as we were putting together this course for therapists, how are we going to teach CBT team workflow? And then we realized, deliberate practice, of course, that's the way to teach and train and improve in anything.

We wanted to figure out how to do this, knowing that we want to move away from therapy that can be a bit reactive and meandering. The therapist is just reacting to what the patient happens to say and there's no clear direction to go. You have to trust the process and just let it go. To a certain degree, there's truth in that, that could lead to some good outcomes, but I think there's a better, more effective way of doing it if you follow the team CBT workflow.

We divided the practice of workflow, of moving in the therapy session from the beginning of the session from just saying hi to getting to focus and getting specific and moving in a very deliberate, goal-oriented approach through the process, into four skills. The first one is we combine testing, empathy, and invitation. The next step is invitation, specificity, and conceptualization. Then the therapist predicting what are going to be the challenges for the patient to overcome their symptoms and using that prediction to move to the third skill of bringing resistance to conscious awareness and helping melt it away.

We end this piece by moving the accountability to the success of therapy squarely onto the patient's shoulders, clearly outlining what is needed, the work needed in order to improve, and only then moving to the final steps of this workflow that we have of outlining a plan and starting to act on that plan.

This skill is skill number 16. We did 15 skills together with Tony and Alex, but here we are.

I'm pointing out that it's Skill 16 because you can't really start at this skill. As Mike and I have been training our therapists in this approach using sequential skills 1 through 15, we realized that the first time our trainees practice using deliberate practice is very different than the 10th time. There's a certain level of expertise in deliberate practice that allows us to be more sophisticated in what we're expecting of them, and they continue to evolve as well. This skill criteria leans on the idea that you already have the other subskills, and now you're ready to see how you move from skill to skill in a therapy session practice workflow.

Here, the skill criteria is to summarize the mood survey using good empathy, then issue an invitation to work on something more specific. You have to end this with open hands, meaning that you're moving forward based on the patient's response, and you have to do it in one flow. The criteria here is to be able to do all of that in one flow. We're not going to give a lot of feedback here on how great the empathy was, but we're going to give specific feedback on how the flow went from one moment to the next, one skill to the next.

Maybe we can launch this second poll. The second poll is asking you how confident you are that you can skillfully move through testing empathy and invitation with a patient in just two minutes at the beginning of a therapy session. As you're filling this out, I probably mentioned, maybe some of you have heard me say this before, but one thing that I was horrified to realize is that I am worse as a therapist now compared to five or 10 years ago. The reason that it was horrifying was because it was true. It was so clear and evident to me.

Getting this realization has been such a great push to go and start practicing in the deliberate practice way. One of the things that I've started doing as a result of this realization of how important this scale here is, scale number 16 about moving into invitation quickly, not letting the therapy session meander, is I started noting what was the moment in time during the session, how many minutes from the beginning of the session passed before I issued the first invitation to dive into something meaningful. I wanted to feel very uncomfortable if it's minute 20. I wanted to feel very uncomfortable if it's not within really quick. This has to be a really good reason why I'm not issuing an invitation for God's sakes within the first few minutes to kick things into gear.

I'm seeing here that people find it pretty challenging. I don't see almost anyone feeling really confident with it, or even very confident. Most people are not feeling very confident with the skill. It takes a lot of practice. I fail at this every day. We're not alone.

Here's an example of what we came up with to practice this skill. This is an example of what we do now in our Practice Group in our FASTT track to level three team CBT certification. It's a six-month-long course, and in the later stages of it, our therapists are facing this vignette where the patient says, "I get so stressed when I have to go shopping and there are so many people around." That's how the patient starts their session, and you have this in front of you. Now you're expected to improvise a workflow response based on that.

Here it is: "I can see from your mood survey that you're feeling anxious a lot and nervous. You also mark that you're feeling frustrated and irritated. Would now be a good time for us to focus on one of those issues and get you some help with it, or maybe there's something else you want my help with? What would you prefer?" Here, within 30 seconds, I'm inviting our patient to kick into gear. I want everybody to feel uncomfortable during the session, at least a little bit, until we do this during the session.

The last skill that we're teaching in the workflow, one of our very last meetings in the FASTT track for Advanced DB CBT certification, is without this cheat sheet, you're sitting with your feedback provider. The patient also acts as a feedback provider in these sessions. You just kind of say how a therapy session advances so you're able to internalize this whole process from A to Z about how a therapy session would work.

I would say, "Well, I start the session by reviewing the current mood and connecting over that. Then I want to issue an invitation to focus on one of these issues or another issue that the patient is bringing up. If the patient agrees, I try to find a moment in time that they struggled with this problem. Based on that, I figure out what is the likely conceptualization. What is it that they're dealing with? Is it depression, anxiety, a habit, or a relationship problem, some combination of all of those? I use this to then predict what are going to be the main outcome and process resistance themes that the patient is going to be dealing with. Now, as I have this in mind, I'm able to go and work to first bring the outcome resistance challenges into conscious awareness to help the patient melt them away. Only after I do that, I move to process resistance questions. What is necessary, the work needed in order for them to accomplish it? Only after I feel like the patient has confronted their reasons not to change and is willing to do whatever it takes to bring about the change that they're hoping for, will I go and create a treatment plan, a set of methods that I would work with, and start practicing that. If I run out of time in the session between all that, I'll assign homework about 10 minutes before the end of the session."

I'll start assigning homework, if not before, and the session ends with the evaluation of the therapy session. We part ways, and that's how I would practice it. You'll notice that to internalize this workflow, you have to do a lot of work beforehand. It's not a skill you can master immediately. Now, I want to hand it over to Mike to discuss some of the challenges our patients are facing.

Mike: Tony and Alex have mentioned a gravitational force that pulls us away from deliberate practice. It's almost addictive for us to do anything but practice. When I think back to my mom trying to get me to practice the piano, I would do everything I could to avoid it. Here are a few things our intern group, who we're testing, came up with:

• Practicing can feel like it's happening in a vacuum. You're focusing on one thing, and it can be uncomfortable to practice with less information and to use fewer words.
• It can feel awkward, even wrong, not to focus on empathy. We're not eliminating empathy; we're just shifting our focus onto a specific skill. Once we master that skill, we infuse empathy into it.
• It can feel strange not to look at the big picture and just practice the same thing repeatedly. I have some great videos where I show myself practicing in front of my computer, going over and over again.
• It can be hard to see how it all fits together, which is why we've incorporated some of the work for practice.
• It can feel harder and weird in real therapy. You can be comfortable doing the wrong thing, but that doesn't mean you're being effective.

If you're doing the wrong thing repeatedly, you become comfortable with it. It should feel a little bit uncomfortable, can make you nervous, and that's actually the best thing that can happen. If you're not anxious, that might be a red flag. Either you're not practicing the right thing, or you're doing the wrong thing but you're comfortable with it.

Jill: We want to make sure we get a little bit of time for questions here. We have limited time now for questions. I need to leave about two minutes at the end to do the wrap-up. The questions came in the category of Team CBT questions and deliberate practice questions.

Q and A Session

Jill: I have to interrupt you for a second. So of course, once I started talking and MCing, I lost track of the time and actually, we have to be respectful of the fact that this is only a one-hour webinar. We had a couple of slides to share with you about how to learn more and to tell you about the awesome FastTrack package which includes deliberate practice. You can put them on the screen. I have to respect that if people have to run, we put the CE survey in the chat box and we'll share this information with you all via email.

So I just have a few more things to say and then we have to wrap up and I want to thank the presenters. We put in the chat box the link so you can definitely be completing the CE survey. Mike and I did that two minutes ago. You can go backwards, Maor, if you want. I will just say briefly that, you know, so much of what you learned about today, these deliberate practice exercises and tools, we've integrated into a six-month course actually that we're offering for therapists. It's called the FASTT track to level three Advanced CBT therapist certification and it's a hybrid course where we have pre-recorded home study videos of myself and David Burns and many other therapists participating in demonstrations and role plays and you can consume that information on your own and then you get to attend a weekly one-hour live online Practice Group run by either Mike or Maor, following the entire protocol that's been outlined today.

It's a total of 41 hours and 41 continuing education credits between the home study piece and the live online piece. We have had awesome feedback from the first round that we started in January, and this round is starting up on June 3. You can find out more info on our website, and we'll send you some follow-up info on it too. Next month, just to remind people, because we'll be back again, we're offering a really great presentation led by Kevin Cornelius at the Feeling Good Institute on the CBTI protocol. CBT for insomnia, I think, is something most therapists have to deal with at some point, whether it's because of depression, anxiety, stress. So this is a tool that I feel like most therapists want to have in their toolbox. I'm excited that we'll be offering it next month.

Finally, in closing, if anyone is still here, thank you all for joining us today and thank you so much to our awesome presenters. We hope that the audience found it valuable and provided you with some practical tools for improving your therapy practice. If you're considering furthering your expertise in TEAM CBT and deliberate practice, we hope that you'll join us. You can move forward on the slides, we offer CBT certification and training programs, many of which include deliberate practice.

Maor: Can I ask for a minute to ask Alex and Tony if they wanted to say a word about where they're at with the development of their amazing program down at Santio University?

Tony: Oh, thank you. I'll just say very quickly, we're starting a new MFTT (Marriage and Family Therapy) graduate program and we've started enrollment. So if you know anyone looking to enter the field, become a master's level therapist in California, send them our way. Alex just put the link in the chat.

Maor: Thank you, I envy them. I envy the people who will be your students. I think that's such an amazing opportunity.

Mike: Thanks so much everyone, it's great to see everybody.

Tony: Thanks, thank you for having us. It's great to be here.

Jill: Thank you so much, it's been wonderful to learn from you all. Have a great day, everybody.