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Tony Rousmaniere, Psy.D. - Guest
Tony Rousmaniere, Psy.D. is President of Sentio University, a new Marriage and Family Therapist graduate school. He provides workshops, webinars, and advanced clinical training and supervision to clinicians around the world. Dr. Rousmaniere is the author/co-editor of over a dozen books on deliberate practice and psychotherapy training and two series of clinical training books: “The Essentials of Deliberate Practice” (APA Press) and “Advanced Therapeutics, Clinical and Interpersonal Skills” (Elsevier). In 2017, he published the widely-cited article in The Atlantic Monthly, “What your therapist doesn’t know”. Dr. Rousmaniere supports the open-data movement and publishes his aggregated clinical outcome data, in de-identified form, on his website at www.drtonyr.com. A Fellow of the American Psychological Association, Dr. Rousmaniere was awarded the Early Career Award by the Society for the Advancement of Psychotherapy (APA Division 29). Dr. Rousmaniere’s research focuses on clinical training and supervision, including using Deliberate Practice to improve the effectiveness of clinical training and supervision, the use of technology in supervision, and empirical methods to assess the effectiveness of supervision. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D. (00:24):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c):(3): nonprofit, so all donations are tax deductible. Today I'll be speaking with Tony Rousmaniere, who is the president of EP University, a new marriage and family therapy graduate school.
Keith Sutton, Psy.D. (02:28):
He provides workshops, webinars, and advanced clinical training and supervision to clinicians around the world. Tony is the author and co-editor of over a dozen books on deliberate practice and psychotherapy training, and two series of clinical training books: The Essentials of Deliberate Practice and Advanced Therapeutics: Clinical and Interpersonal Skills. In 2017, he published the widely cited article in The Atlantic Monthly, What Your Therapist Doesn’t Know. Tony supports the open data movement and publishes his aggregated clinical outcome data in de-identified form on his website at drtonyr.com. A fellow of the American Psychological Association, Tony was awarded the Early Career Award by the Society for the Advancement of Psychotherapy, Division 29.Let's listen to the interview. Hi, Tony. Welcome.
Tony Rousmaniere, Psy.D. (03:21):
Hi, Keith. Thanks for having me. It's great to be here.
Keith Sutton, Psy.D. (03:21):
Yeah, definitely. So, Tony, you and I know each other back from our early career days. We were in an early career consultation group, and recently you were reaching out about some of the work that you're doing on deliberate practice and supervision, and so I was really intrigued to hear more. And before we get to that, I always like to hear about folks’ thinking and evolution of thinking—how they got to doing what they're doing.
Tony Rousmaniere, Psy.D. (03:47):
Yeah, sure. I mean, you know me from way back, right after I graduated, and you welcomed me into your consultation group, which was really great. Back then it really kind of helped—and you gave me some really good career advice right out of graduate school in terms of setting up a private practice. So I just want to thank you for that. It really kind of helped me get the ball rolling. I mean, you had some really good advice on that. I'm sure—maybe you've already done it—but someday you should do a podcast episode just on that. I mean, really, the best career advice I've ever heard about setting up a private practice came from you.
Keith Sutton, Psy.D. (04:23):
Oh, great.
Tony Rousmaniere, Psy.D. (04:24):
So thank you for that. But yeah—when did I graduate? I think it was 2008 or something like that. And I spent my time in graduate school, like most trainees, trying to become a better therapist. Right? That's why I became a therapist—because I wanted to help my clients. And I think that's true for basically all of us.
And I had this kind of nagging feeling throughout graduate school that while I was learning a lot about therapy—I was getting really good at writing about therapy. I could write really good therapy, and I could talk about really good therapy. You know, we could debate what's better, CBT or psychodynamic, or whatever. We could have these really interesting conversations.
But if you watched videos of me actually doing therapy at the time, you would see something totally different. Which means that throughout graduate training, my intellectual knowledge of therapy kept increasing, while my ability to actually perform therapy was maybe increasing a little, but not nearly as quickly.
Keith Sutton, Psy.D. (05:34):
Sure.
Tony Rousmaniere, Psy.D. (05:36):
And, you know, this was frustrating. I wanted to get a lot better because I noticed—I started tracking my outcome data with my clients, and I noticed that a fair amount of them were not improving. You know, some percent would drop out, and some percent would even deteriorate, meaning their symptoms would get worse during treatment, which was, you know, very frustrating. When I added it all up, I found that about 50% of my clients were not improving in their symptoms, which—you know, at first I felt really ashamed and embarrassed. I was like, oh my gosh, maybe I'm not cut out for this, you know, because no one at school was talking about it.
Yeah. We were reading all these books about how great these models were, and, you know, empirically validated...
Keith Sutton, Psy.D. (06:22):
Sounds so linear, like just do this, this, and this, and yeah, they're going to get better.
Tony Rousmaniere, Psy.D. (06:25):
Follow this protocol, which was validated by these RCTs, and then boom. And, you know, we'd hear about these miracle cases, and you go to the conferences and no one was talking about their deterioration. You know, they would talk about these one-session miracle cases.
And then I started to read the research literature on psychotherapy outcomes, and I found that my outcomes were actually quite average across the field. Yeah. Across the whole field, roughly 50% of clients don't improve. You know, there's a lot of variance in that, but—so I was a perfectly average trainee.
Keith Sutton, Psy.D. (07:05):
Sure. Okay.
Tony Rousmaniere, Psy.D. (07:09):
That, you know, was not where I wanted to be. Yeah. Yeah. I wanted to be better, and I tried many things. I attended a lot of workshops. I did a lot of consultations. I read a lot of books. And I still never really got the feeling like, okay, this is reliably making me better.
Keith Sutton, Psy.D. (07:31):
Right.
Tony Rousmaniere, Psy.D. (07:32):
This is really, like, the key. And then one day—I was a big fan of Scott Miller.
Keith Sutton, Psy.D. (07:38):
I still am. Yeah. I was wondering about which outcome research you were reading and what measures you were using.
Tony Rousmaniere, Psy.D. (07:43):
Yeah. So I was using a variety of measures. Scott Miller really—and then also Barry Duncan—really inspired me to start doing FIT.
Keith Sutton, Psy.D. (07:50):
Yeah.
Tony Rousmaniere, Psy.D. (07:51):
And then, you know, your consultation group--
Keith Sutton, Psy.D. (07:53):
Feedback-informed treatment.
Tony Rousmaniere, Psy.D. (07:54):
Feedback-informed treatment. Yeah. Yeah. Your consultation group was really good for reinforcing that and guiding me in that.
Keith Sutton, Psy.D. (08:01):
Yeah, because I've been using that since—gosh—what was that, 2004? You know, the Outcome Rating Scale and Session Rating Scale, Scott Miller’s and Barry Duncan’s measures. And really the idea that by tracking outcome and by getting feedback, you can increase outcome by 65% regardless of theoretical orientation.
Tony Rousmaniere, Psy.D. (08:20):
Yeah. Yeah. So you were an early proponent of that, and you were really good. I had kind of heard about it, but you were really good at showing me clinical examples. And then I met other people who were really into it. So I started doing that, and that helped. I mean, that's valuable.
But one thing people have found, including Scott, is there's kind of like a ceiling with FIT in terms of—it can help you identify which clients are at risk of deterioration, which sometimes we don't see. You know, as therapists, we have blind spots.
Keith Sutton, Psy.D. (08:56):
Right.
Tony Rousmaniere, Psy.D. (08:58):
And sometimes clients don't want to tell us because, you know, they just want to be nice. And so, the FIT measures are good at identifying clients at risk of deterioration. But they don’t tell you what to do next—like how to fix it.
Keith Sutton, Psy.D. (09:16):
Sure.
Tony Rousmaniere, Psy.D. (09:18):
Right?
Keith Sutton, Psy.D. (09:19):
Mm-hmm.
Tony Rousmaniere, Psy.D. (09:20):
And so that—and this is something Scott Miller figured out, and I'm sure your listeners have heard of Scott Miller.
Keith Sutton, Psy.D. (09:29):
Yeah. We did a podcast with him, actually, also.
Tony Rousmaniere, Psy.D. (09:31):
Excellent. Excellent. So almost everything I've done since then is based on his work. So I stand on his shoulders. He's been one of the most important mentors for me throughout my career.
And he noticed that, yeah, FIT was helping therapists identify when clients weren't improving—but it didn’t say what to do next. Like, how do we help?
And what he turned toward and started talking about was deliberate practice.
Keith Sutton, Psy.D. (10:00):
Hmm.
Tony Rousmaniere, Psy.D. (10:02):
And I can describe what that is. Please do. Yeah. Briefly, if you like. Definitely. So the easiest way to describe it is in a metaphor. Did you play any sports or musical instruments growing up, like in high school?
Keith Sutton, Psy.D. (10:18):
I skied.
Tony Rousmaniere, Psy.D. (10:20):
Skied. Okay. Were you on a team?
Keith Sutton, Psy.D. (10:22):
No. No.
Tony Rousmaniere, Psy.D. (10:23):
Okay. Did you play any sports on a team or any musical instruments with a teacher?
Keith Sutton, Psy.D. (10:28):
I played Little League for two years. The first year we won one game, and the second year we won zero games. Okay. That counts. That's the extent of my team sports.
Tony Rousmaniere, Psy.D. (10:37):
That counts. Great. So Little League, so that's baseball, right?
Keith Sutton, Psy.D. (10:39):
Yep. Yep. Okay.
Tony Rousmaniere, Psy.D. (10:41):
So imagine you went to your Little League teacher or coach and said, “Coach, I love this. I love baseball. I think I'm kind of talented at it. In fact, I think I want to play professionally someday.”
“But I just want to be honest with you, I don't have time to practice. I can't go to practice. I've got school, I've got work, I've got my family. I just have too many commitments. How about instead of going to baseball practice, I do 3000 hours of baseball games,”
“And I write down notes. I even videotape some games, and I'll meet with you for one-on-one supervision or group supervision every week to discuss the games. And then I'll try to improve, but no practice.” Do you think that would get you up to Major League Baseball?
Keith Sutton, Psy.D. (11:34):
I don't know. I imagine it would help and improve, but I don't know if it's going to give you those—what is it—like 10,000 hours or something?
Tony Rousmaniere, Psy.D. (11:42):
Bingo.
Keith Sutton, Psy.D. (11:42):
Bingo.
Tony Rousmaniere, Psy.D. (11:42):
Yeah. So I would be very surprised if you could find a coach who would endorse that the way to get to Major League Baseball would be to just play—just play baseball—supervised experience.
Keith Sutton, Psy.D. (11:56):
Sure.
Tony Rousmaniere, Psy.D. (11:57):
Without practice. However, that is our model of training therapists. If we get a lot of experience providing therapy--
Keith Sutton, Psy.D. (12:11):
Yeah.
Tony Rousmaniere, Psy.D. (12:13):
—which sometimes we call practice, but it isn't practice. Providing therapy to a real client is actually work performance.
Keith Sutton, Psy.D. (12:20):
Yeah.
Tony Rousmaniere, Psy.D. (12:22):
And the reason is, when you have a real client in front of you, you can't rehearse. You can't say, “Client, I just learned this great new method, Internal Family Systems, and I want to try this one technique 50 times, and you tell me which time feels the best.”
Keith Sutton, Psy.D. (12:40):
Sure.
Tony Rousmaniere, Psy.D. (12:41):
Right. To do that, you need to have what we call deliberate practice or rehearsal, which is separate from the work performance.
Keith Sutton, Psy.D. (12:52):
So these are kind of like the role plays that all graduate students hate, but I think are so valuable. For both licensed and graduate students, I think it's so valuable to actually have that experience practicing.
Tony Rousmaniere, Psy.D. (13:06):
Bingo. Perfect. Bingo. Yeah. So these are like role plays, as you say, graduate students hate. Now I want to emphasize that it's not just graduate students who hate them. Licensed therapists--
Keith Sutton, Psy.D. (13:19):
One, like these things. Every workshop they do, there's a role play.
Tony Rousmaniere, Psy.D. (13:23):
Yeah. I know you've led a lot of workshops, so you see this. And people are like, “Oh, no, no, no, no. I'd rather just talk about the model than actually role play doing it.”
Right. And yet, when you're giving a workshop, I mean, how much more valuable is the actual rehearsal rather than talking about it?
Keith Sutton, Psy.D. (13:43):
Yeah. It's that experiential aspect--
Tony Rousmaniere, Psy.D. (13:46):
Bingo.
Keith Sutton, Psy.D. (13:46):
—that you don't get if you're just all cognitive. And that's why, especially too, I really am a big proponent of one-way mirror training.
Tony Rousmaniere, Psy.D. (13:52):
Bingo.
Keith Sutton, Psy.D. (13:53):
Because you're actually being guided to do something different at the moment.
Tony Rousmaniere, Psy.D. (13:58):
Bingo. The experiential training—there’s a lot of research that shows experiential training is just way more effective than academic training with therapy, because therapy is a performance art. Yeah. Therapy is—it is not a philosophy. You're not writing down things and giving it to your client. You're performing in an improvised fashion with your client. By performing, I don’t mean faking it—you’re authentic—but it is a performance. You're doing it rather than thinking or writing about it.
Keith Sutton, Psy.D. (14:29):
Like a dance or something like that.
Tony Rousmaniere, Psy.D. (14:31):
Bingo. Yeah. Or an improvised jazz performance maybe.
Keith Sutton, Psy.D. (14:36):
Exactly.
Tony Rousmaniere, Psy.D. (14:37):
Or something like that. But I wanted to emphasize what you said about no one seeming to like it. And deliberate practice research actually shows this—that when it's good deliberate practice, it's not super fun. Because deliberate practice, when it's done well, is done right at the zone of your competencies, or at the edge of your competencies. It's called the zone of proximal development.
Keith Sutton, Psy.D. (15:04):
Yes.
Tony Rousmaniere, Psy.D. (15:05):
So just beyond your ability. I know you do training in Emotion Focused Therapy for couples, right?
Keith Sutton, Psy.D. (15:11)
Yes.
Tony Rousmaniere, Psy.D. (15:13):
Okay. And I presume when you're doing the rehearsals, the role plays, you're trying to help the trainees—even licensed therapists—kind of stretch, try something they haven't been able to do before.
Keith Sutton, Psy.D. (15:24):
Definitely.
Tony Rousmaniere, Psy.D. (15:25):
So that's called the zone of proximal development—just beyond your ability. And when you're rehearsing just beyond your ability, you're going to screw up.
Keith Sutton, Psy.D. (15:38):
Yeah. It feels uncomfortable.
Tony Rousmaniere, Psy.D. (15:40):
It's uncomfortable. And as therapists, we know there are multiple levels of discomfort. There's the discomfort of, “Okay, here's a skill I haven't really mastered.” There's also discomfort like, “Here's some emotional material that's being stirred up by what we're doing.” And that can be uncomfortable as well.
Keith Sutton, Psy.D. (16:01):
Well, I think in the field too, you can talk a good game, but then when you're actually doing a role play or you're showing a video, it's a whole other level. That can bring up a lot of anxiety or embarrassment or so on. Because like you're saying—on paper versus in action.
Tony Rousmaniere, Psy.D. (16:18):
Right. That's where the rubber hits the road. Now, I know this is something that you encouraged me to do early on, which is record videos of my work. And I did a lot of that, and that was super helpful.
Keith Sutton, Psy.D. (16:31)
Great.
Tony Rousmaniere, Psy.D. (16:32):
And unfortunately, not everyone does that. Not every graduate program does that. And if we don't watch videos of our own work, we can end up with this kind of split reality where we have an image in our mind of what we're doing, which is a little different from what we're actually doing. So we actually encourage therapists to watch videos of their work throughout their entire career and use that as a basis for deliberate practice.
Keith Sutton, Psy.D. (17:00):
Well, and it's so important too. I've actually been doing this recently because I have some licensed therapists that I do consultation groups with, and I have some folks in our nonprofit which I'm supervising. And so I also show some of my work, sometimes something from that week that I was showing. And sometimes I'm just figuring out what I'm doing and actually putting it into words by trying to explain what I'm doing—something I might be doing naturally. And then it makes you think about it, right? This feedback loop of doing it, thinking about why you're doing it, and then noticing where I'm like, “Oh, I should have done this here. I wonder why I didn't do that.”
Tony Rousmaniere, Psy.D. (17:39):
Now, I want to underline a few things in what you just said. First of all, you're developing a meta-awareness of your own work. Which is very hard to do while you're working with a client because you're so focused on attuning with them.
Right? There's probably some meta-awareness going on, but not a lot. And that's appropriate. We really want to focus on the client and attune with the client.
Keith Sutton, Psy.D. (18:05):
Definitely.
Tony Rousmaniere, Psy.D. (18:17):
So it really does take reflection—and not just intellectual reflection, but watching video later—to get the full amount of meta-reflection on your work.
Keith Sutton, Psy.D. (18:17):
Definitely.
Tony Rousmaniere, Psy.D. (18:18):
So there's that. Second of all, I want to point out that you're still watching videos of your work. You're still analyzing your own work. You're still being surprised by your own work.
Keith Sutton, Psy.D. (18:29):
Yeah, definitely.
Tony Rousmaniere, Psy.D. (18:37):
Now, you are extremely successful. You're very established. You don't need to do this.
Keith Sutton, Psy.D. (18:38):
Well, I want to keep getting better and better. There's always something to learn.
Tony Rousmaniere, Psy.D. (18:41):
Okay. So I want to highlight this for the listeners. I mean, you could coast, Keith. You could easily coast from now on and just rely on your reputation and you'd be fine. The board of psychology is not expecting you to do this. No one's expecting you to do this. It's internal motivation to get better. Which I think is so important to highlight, because that's what it takes in our field and many other fields. Work performance is public.
Keith Sutton, Psy.D. (19:15):
Yeah.
Tony Rousmaniere, Psy.D. (19:15):
So if you were, let's say, a basketball player—or let's say you pursued the career in Major League Baseball you dreamed about in Little League, when a baseball player performs, it's public.
Keith Sutton, Psy.D. (19:28):
Yeah. People are seeing that.
Tony Rousmaniere, Psy.D. (19:31):
Everyone sees. They don't have the option of hiding their work. They don't have the option of telling themselves stories about their performance.
Keith Sutton, Psy.D. (19:40):
Yeah.
Tony Rousmaniere, Psy.D. (19:41):
If you were an artist, your work would be public. If you were an actor, your work would be public. If you were a pilot, your work would be public. I would say therapists—we have the distinct disadvantage that our work is extremely private. And there are good reasons for that around confidentiality. I'm not arguing against that. I'm just saying it works against our ability to improve our performance.
Keith Sutton, Psy.D. (20:13):
Yeah. Yeah. Definitely. And I think that unless you're in—like, we've got a group practice, and the research has also shown if you're in a group practice you tend to have better outcomes because you are looking at your work from other perspectives. But in private practice, if you're not getting consultation, if you're not talking with colleagues, you're just kind of doing what you're doing. Then yeah—there are no outside eyes to look at that. And I think that's why a lot of burnout also happens. Oftentimes, part of dealing with burnout is not only self-care, but also going to trainings, getting consultation, getting excited about doing something new or trying something new, or moving beyond feeling helpless or not—like you were saying with your clients—feeling like, “Ah, I don't feel like I'm achieving enough. You know, 50% aren't improving.” Then when you start working on improving that, that brings a lot of energy.
Tony Rousmaniere, Psy.D. (21:10):
Yeah. Yeah. It brings a lot of energy, but it's not all comfortable energy.
Keith Sutton, Psy.D. (21:14):
Yes, that's true. Yes. Be willing to go outside that, to stretch and to stretch. Yeah, definitely. To stretch.
Tony Rousmaniere, Psy.D. (21:21):
Now the top performers in every field stretch throughout their whole career. Right? The top musicians don't stop getting coaching. They don't stop practicing. If you listen to interviews with Yo-Yo Ma or the top musicians or the top athletes, they actually practice more than everyone else.
Keith Sutton, Psy.D. (21:44):
Yeah.
Tony Rousmaniere, Psy.D. (21:45):
So somehow therapists have ended up in a culture where that’s not the standard. The standard is once you graduate from graduate school, once you get licensed, you stop being supervised, you stop being coached, and then you just coast. People have this idea that as long as I keep doing therapy, I'm getting better. Research shows repeated work performance itself does not make you better.
Keith Sutton, Psy.D. (22:20):
Yes.
Tony Rousmaniere, Psy.D. (22:20):
I would use a metaphor. I got my driver's license maybe 30 years ago. I am not a better driver after 30 years of driving. I got a lot of miles under my belt.
Keith Sutton, Psy.D. (22:39):
Yeah.
Tony Rousmaniere, Psy.D. (22:41):
And it's because I'm not getting feedback. Well, sometimes I even get feedback. I'm just not rehearsing based on that feedback.
Keith Sutton, Psy.D. (22:47):
Sure.
Tony Rousmaniere, Psy.D. (22:49):
That's how we get better.
Keith Sutton, Psy.D. (22:51):
Yeah. And I always think—and I don't know how true this is—the Michael Jordan story that he got cut or something from his high school basketball team. So it wasn't that he was naturally so much better than others at basketball, but it was about deliberate practice. When he would play and take shots, he would calculate and notice and get that feedback and keep working on tweaking things, rather than just shooting free throw after free throw aimlessly. It's not only about the hours, but how you're actually doing it during those hours.
Tony Rousmaniere, Psy.D. (23:27):
Yeah. So just mindlessly rehearsing something won't make you better.
Keith Sutton, Psy.D. (23:31):
Yeah.
Tony Rousmaniere, Psy.D. (23:32):
If I wanted to learn to play golf and I just went out to a golf course and started swinging a golf club or whatever it is, I would not get better. If I had a coach watching me and saying, "Tony, do this a little better. Do this a little better. Lift your elbow, lift your shoulder," I could get better quite quickly.
Keith Sutton, Psy.D. (23:52):
Yeah.
Tony Rousmaniere, Psy.D. (23:54):
So the question is, how do we apply this to psychotherapy? We've got some really good models for psychotherapy. But
then the question is, how do we practice them?
Keith Sutton, Psy.D. (24:06):
Yes.
Tony Rousmaniere, Psy.D. (24:07):
Now there are some models like EFT for couples, which have gotten a good head start on this where there are a lot of ways to rehearse as part of the training.
Keith Sutton, Psy.D. (24:16):
Definitely. Part of the core skills is a huge aspect of doing lots of role plays and experiencing the different positions of the couples and the therapists.
Tony Rousmaniere, Psy.D. (24:28):
Right. So many models of therapy unfortunately don't have that.
Keith Sutton, Psy.D. (24:32):
Yes.
Tony Rousmaniere, Psy.D. (24:32):
Or maybe a supervisor here or there has improvised something, but it's not really a standardized part of the pedagogy. Yeah. And so that is what we have dedicated ourselves to. We've got a book series with the American Psychological Association where we are partnering with some leading teachers and supervisors for the major models of therapy.
Keith Sutton, Psy.D. (24:57):
Great.
Tony Rousmaniere, Psy.D. (24:58):
And we go to them and we say, identify 10 or 12 skills from your model of therapy. And we will help you develop deliberate practice exercises for those skills. Now, ideally, these are skills where there's a sweet spot for deliberate practice. These are skills that the trainee—and by trainee I'm speaking broadly; it could be a licensed therapist who's picking up this model later in their career—but it's a skill that the learner understands intellectually. So maybe they could write a paper about it, but might have trouble performing it.
Keith Sutton, Psy.D. (25:41):
Yes.
Tony Rousmaniere, Psy.D. (25:41):
Particularly with a client in a higher emotional arousal situation. And so we develop a deliberate practice exercise, which is basically scripted role plays. We then send the exercise out to test sites. We have volunteer test sites around the world that are testing these exercises.
Tony Rousmaniere, Psy.D. (26:01):
They videotape themselves testing the exercise, send us the video, and we look at the video and see, is this going how we hoped? And then we revise the exercise. This goes for about a year. Then we've got a book. Our first book was Deliberate Practice for Emotion-Focused Therapy for Individuals.
Keith Sutton, Psy.D. (26:19):
Okay. Great.
Tony Rousmaniere, Psy.D. (26:20):
And then we got Deliberate Practice for CBT. We're about to release Deliberate Practice for Child and Adolescent Therapy, for Motivational Interviewing, for Systemic Family Therapy. And then there's a bunch of other books in the works—for DBT, a DPI—so it just kind of keeps going down the line.
Keith Sutton, Psy.D. (26:38):
Wonderful.
Tony Rousmaniere, Psy.D. (26:40):
Yeah.
Keith Sutton, Psy.D. (26:40):
Very cool. Yeah. I think that's what I've noticed also, especially in supervising and consultations, is that some of the common factors go down to the relationship between the therapist and the client. Particularly I've found motivational interviewing invaluable for that ability to attune with your client and really get on the same page before you're moving forward. Because many therapists tend to jump ahead of the client when the client's not on the bus with them or they're pulling them along. That's where you get those alliance difficulties. But as you're saying, there's also the techniques and putting those in, and I'm thinking of exposure work.
Keith Sutton, Psy.D. (27:32):
Particularly my first time doing it, I was like, gosh, am I supposed to have them doing deep breathing or what? And it wasn't until I saw the Obsessed series from A&E with real therapists doing real exposure work with OCD that it clicked. That's something I do with the folks I'm training—showing them these videos and helping them see, because yeah, there are those skills that go beyond the intellectual and into how you sit with these things too.
Tony Rousmaniere, Psy.D. (28:02):
Right. Many trainees find that when they're doing exposure with a client, it's actually an exposure for both people.
Keith Sutton, Psy.D. (28:10):
Yes, totally. Totally.
Tony Rousmaniere, Psy.D. (28:11):
Right? Because as therapists, we have to attune with the person going through the exposure, so we're going to feel that. And so--
Keith Sutton, Psy.D. (28:21):
Especially if you're new and you don't yet have the confidence that this is going to work. With EMDR or exposure, you're asking the person to do something that brings up intense emotion. And when you haven't done it before, and you haven't seen it work time after time, sometimes you sit there thinking, oh gosh, am I doing the right thing here?
Tony Rousmaniere, Psy.D. (28:45):
Yeah. What's going to happen here? Yeah. Right. Is my client going to fall over from this? So if given the opportunity to rehearse, trainees can feel a lot more confident before performing with a real client.
Keith Sutton, Psy.D. (29:01):
Yeah.
Tony Rousmaniere, Psy.D. (29:03):
So there's something you said that I want to highlight again—you mentioned the common factors. These are the variables in therapy identified to be most helpful, often more helpful than the specific factors from specific therapy models. This is based on the work of Bruce Wampold, John Norcross, and a whole bunch of people. And Scott Miller talks about this a lot. Our books are focused on the specific models of therapy. However, we've noticed that the majority of the skills across the books are very similar.
Keith Sutton, Psy.D. (29:51):
Hmm. Interesting.
Tony Rousmaniere, Psy.D. (29:53):
They focus first on building an alliance, building positive regard and trust, building expectations, getting agreement on the tasks of therapy, the goals of therapy, addressing ruptures—these are all common factors.
Keith Sutton, Psy.D. (30:07):
Yeah, totally.
Tony Rousmaniere, Psy.D. (30:08):
And it's cool seeing how each model is almost like a different style or approach, but they're aiming in the same direction.
Keith Sutton, Psy.D. (30:19):
Yeah. And they're also building on that foundation. Hmm.
Tony Rousmaniere, Psy.D. (30:24):
Yeah. Someone raised—I'm forgetting who it was—an interesting theory the other day: that the specific models of therapy are really just helping therapists with different personality styles use common factors, and we're going to use them differently depending on our personality style.
Keith Sutton, Psy.D. (30:43):
Depending on the therapist’s personality style. Yes. Yeah.
Tony Rousmaniere, Psy.D. (30:46):
Yeah. And then ideally that matches with the client's personality style. Yeah. When you have a good match, then you're, you know, good to go. Definitely.
Keith Sutton, Psy.D. (30:52):
Definitely. Yeah. And I think that that piece too, you know, that also—I mean, I think where the theory and technique come into play also with the alliance—is that the more the therapist feels confident in whatever they're doing, and that it makes sense to them, they're not just doing CBT, for example, because somebody said it was good, but they like—that's their worldview. Right. That our perceptions are colored by—you know, our experience is colored by our perceptions. Right. You know, when it's kind of more of a lived experience as well as, you know, just having that roadmap and knowing where you are in the therapy and where you're going, that translates to how you are with the client. Yeah. But it sounds like you could intermix different kinds of approaches to get to that same end of the confidence and feeling competent and all those pieces.
Tony Rousmaniere, Psy.D. (31:47):
Yeah. I mean, I totally agree. Like, if you look at expert performers in music or sports—I mean, even sports—they will bring in techniques from other performers, like from other methods. And they'll kind of integrate them in. And sometimes the very top performers are integrating a whole bunch of different material which they've learned throughout their career. But I want to emphasize that they're not just reading books about it—they're rehearsing it. Yeah. So it's embodied. And so it's kind of—we call it muscle memory.
Keith Sutton, Psy.D. (32:19):
Yeah.
Tony Rousmaniere, Psy.D. (32:20):
So the skills are in your bones. So, for example, when you're working with a couple and let's say it's a high-conflict couple, you know, these EFT skills are in your bones. And it can just come out immediately, you know what I mean? And that's because you've rehearsed it.
Keith Sutton, Psy.D. (32:34):
Yeah, yeah. Definitely. Yeah. And it takes time, especially with EFT. You know, I trained in that for many, many years before I got certified as a certified supervisor. But I kind of felt like once I really got that process orientation, it was almost like—there's a scene in the Matrix movie where all of a sudden you start seeing all the ones and zeros coming down and just kind of seeing the whole—everything in this different light. And it's hard to unsee it after that. But again, that process of getting from here to there takes time. Yeah. It's hard to—you can't quite rush it.
Tony Rousmaniere, Psy.D. (33:13):
No, you can't. Now, I remember when I was starting out, I would read books on psychotherapy theory, and I would memorize the book, and I'd even sometimes memorize the lines that, like, Beck or whoever was saying. And then I would get really frustrated and disappointed when it just—like, when it wouldn't work for me.
Keith Sutton, Psy.D. (33:30):
You know--
Tony Rousmaniere, Psy.D. (33:31):
And it's because I was in this model of like, “I just need intellectual understanding. That's enough.” When really, that's crazy. That's not nearly enough. I needed many years of rehearsal before it could move into muscle memory, and I'd be able to perform it in a very flexible, intuitive, adaptable way.
Keith Sutton, Psy.D. (33:54):
Timing is so important too. Bingo. Again, the kind of—the orchestra or the dance of the therapy—when you're going to introduce information. I think for a lot of folks early in their training, oftentimes they're only seeing maybe five, ten hours at a time a week, but they're talking to supervisors and group supervisors and in their classes. And then once they finally get into the session, you know, they've talked five hours about the one-hour session, and then right off the bat they're like, “Well, I think this is what's going on.” And the person's like, “No, I don't think so.” And you're like--
Tony Rousmaniere, Psy.D. (34:29):
I remember that. Oh, you're totally triggering me. I totally remember exactly that.
Keith Sutton, Psy.D. (34:34):
I thought that—you know, you think you figured it out, and then you're like, why didn’t that work? And then again realizing that it takes time to learn those nuances and the timing and when that's going to come in. Now, from what I understand too, there’s some good research on folks that are in training and their effectiveness. Because there is actually a bit of a mindset of trying to learn and trying to think differently versus folks maybe that have been in practice so long but aren't necessarily doing that deliberate practice.
Tony Rousmaniere, Psy.D. (35:07):
Yeah. So trainees have an advantage where they do not consider themselves to be experts. And they do not have this kind of reputation or whatever to defend. Right. And so they can often be more open to feedback, more open—you know, like, I remember my supervisors: “Just tell me what to do. I'm open.” Yeah. I want to--
Keith Sutton, Psy.D. (35:35):
Know what to do. I'll take anything.
Tony Rousmaniere, Psy.D. (35:36):
Yeah, yeah. Anything. Right. And so we found this when we go around and do workshops and we ask for volunteers from the audience. It's actually a lot more stressful and vulnerable when someone who's been licensed for 20 years volunteers. Because they have this whole reputation or self-image to defend. Right. And so that is an advantage for trainees. Unfortunately, most graduate schools—the tradition in therapy training is to really emphasize the academics and under-emphasize experiential training. Like, you might get some experiential training a little bit in your practicum, a little bit here and there. I know systemic family training is better at this. So there are some that are better than others. But typically, we're still using Freud's model of training.
Tony Rousmaniere, Psy.D. (36:37):
Yeah. Even CBT training uses Freud’s model, which is a lot of lecture, a lot of reading, a lot of writing, and then supervised performance with real clients. We were going around doing workshops and teaching faculty how to incorporate more deliberate practice in their courses. They would get excited, and then come back three months later and say they couldn’t do it. There was too much inertia. No one said, “Don’t do it.” There were no bad guys trying to stop them. There was just too much inertia at their university, and given all the other demands, they couldn’t do it. We realized it was unfair for us to try to get everyone else to implement these changes.
Tony Rousmaniere, Psy.D. (37:23):
So about a year and a half ago, we decided we had to open our own graduate school. And that’s what we’re doing now. We are forming Sentia University and starting with an MFT graduate program, a standalone graduate program in California, unaffiliated with any other school, because we knew that if we affiliated with another school, we would get caught up in their inertia. We filed all the paperwork, which, let me tell you, if you ever think about starting a graduate school, there’s a lot of paperwork. It’s everything I spent my career trying to avoid, and now I have to do all of it times ten. Our paperwork is being processed by the California regulators. In roughly two years, we’ll begin admissions for our new MFT graduate program.
Where is that going to be located? It’s located in California. The actual classes will be online, but the practicum will be a mixture of online and in-person in different locations.
Keith Sutton, Psy.D. (38:36):
Oh, wonderful.
Tony Rousmaniere, Psy.D. (38:38):
What we’re doing differently is that 50% of every class will be rehearsal.
Keith Sutton, Psy.D. (38:46):
Very good.
Tony Rousmaniere, Psy.D. (38:46):
And when I say every class, I mean literally every class. That includes an assessment class, an ethics class—literally every class. Fifty percent of a three-hour class will be spent rehearsing key skills. We’re developing exercises for all these classes. You go through an entire MFT curriculum, and we have exercises for every class.
Keith Sutton, Psy.D. (39:12):
Very cool. I taught a graduate school class this summer, and in the final assignment I had them do a stage four session of evolving structural strategic family therapy, or the four-stage model. As the professor, it was interesting to see twenty videos of role plays and look at them almost like coding a research experiment. Just from watching people do it, I realized that when they did this, it went off track; when they did that, it stayed on track. Those nuances are helpful feedback for teachers too—refining key moments they can guide someone around.
Tony Rousmaniere, Psy.D. (40:03):
What you’re describing is an ideal learning situation for trainees. Your trainees are very lucky. Many trainees won’t get a lot of that.
Keith Sutton, Psy.D. (40:16):
Yeah.
Tony Rousmaniere, Psy.D. (40:17):
I know a lot of faculty who want to provide that. They just don’t know how, because they weren’t taught to do that, and the university isn’t providing the resources. There are no bad guys here. No one is stopping them. There just aren’t structural supports.
Keith Sutton, Psy.D. (40:34):
Yeah. It’s just doing what was done before. There’s a woman, Judy Hess, in the Bay Area. She’s retired now, but she taught a family therapy class where students brought in their family if they were local, and they would do a family therapy session. Or they would role-play if the family wasn’t available, or have the family over the phone or video. It gave students an experiential experience. That was at CIIS, the California Institute for Clinical Studies.
Tony Rousmaniere, Psy.D. (41:09):
Yeah. They’re a little progressive.
Keith Sutton, Psy.D. (41:10):
They have all sorts of interesting things going on.
Tony Rousmaniere, Psy.D. (41:13):
Talk about experiential. She was from the MFT tradition, and as I understand it, the MFT training tradition has always been a generation ahead of the other associations in terms of experiential training. So we’re starting with an MFT program, and then we’re going to open a psychology program, a counseling program, and a social work program. We want to start from the very first class—with deliberate practice in everything. Everything will be videotaped. Everyone will be watching their videos. No one will hide anything. There will be a culture of that from the very beginning.
Keith Sutton, Psy.D. (41:52):
Good.
Tony Rousmaniere, Psy.D. (41:53):
The other thing we’re doing differently is using FIT—feedback-informed treatment—in all the practicums, and trainees will look at their aggregate outcome data.
Tony Rousmaniere, Psy.D. (42:08):
And it's going to be shared in the graduate program. It's going to be shared in the practicum. And it's going to be like an athlete. They know their scores.
Keith Sutton, Psy.D. (42:18):
Yeah.
Tony Rousmaniere, Psy.D. (42:19):
Right. Everyone knows each other's scores. They can be okay with it being average or whatever. They know their batting average, they know what they're doing. It’s like an actor. Everyone knows what you're doing. Everyone knows what you're screwing up. It destigmatizes it; it takes the shame out of it. And it's like, okay, we've all got strengths, we've all got weaknesses, and we're going to work on it.
Keith Sutton, Psy.D. (42:41):
Great. That's wonderful. Are you going to do some research on this training program?
Tony Rousmaniere, Psy.D. (42:46):
Yeah. We’ve got a team of researchers collecting data all the way through the whole thing. And then over time, we're going to use that data to see how this is helping, how it’s not helping, what we can improve. I assume there’s no way we're going to get everything right out of the gate. It’ll take 20, 30 years to figure out how to really do this well.
Keith Sutton, Psy.D. (43:06):
Yeah.
Tony Rousmaniere, Psy.D. (43:08):
So we're also going to open-source all our training materials so other graduate programs can use them however they want. And hopefully they'll collect data as well.
Keith Sutton, Psy.D. (43:18):
That’d be--
Tony Rousmaniere, Psy.D. (43:18):
Great. And then as a field, we can move toward more effective methods of training.
Keith Sutton, Psy.D. (43:25):
Perfect. That sounds great. That’s taking it to the next level—having that different experience and practicing from the start of graduate school. I imagine those students will come out after those two years in a much different place than other folks, maybe MFTs who have only gotten maybe 500 hours of practice, supervised but not observed like that.
Tony Rousmaniere, Psy.D. (43:54):
Yeah. Usually students might get 500 hours of performance with a client.
Keith Sutton, Psy.D. (44:02):
Exactly.
Tony Rousmaniere, Psy.D. (44:03):
Supervised performance. What worries me is that I graduated with zero hours of actual practice. I had a lot of supervised performance, and so that's our baseline—zero.
Keith Sutton, Psy.D. (44:15):
Yeah, that's true.
Tony Rousmaniere, Psy.D. (44:17):
So there’s a lot of room to grow above that.
Keith Sutton, Psy.D. (44:23):
Yeah. Good. That’s great. I think it's so important to look at your videos, to role-play. There’s so much you can learn about yourself. In supervision with my supervisors, applying some EFT—like, “What was happening for you then that led you to say X, Y, or Z in that moment?” The more in tune they are with themselves, the more they can see how that might be influencing the decisions they make in sessions, which they may not have been aware of.
Tony Rousmaniere, Psy.D. (45:01):
Yeah. This is super important. Psychodynamic therapists might call it countertransference. CBT therapists might call it experiential avoidance. Every model has its own word for it. But it’s also called the person of the therapist.
Keith Sutton, Psy.D. (45:17):
Right.
Tony Rousmaniere, Psy.D. (45:18):
And this is really, really important, and this is something we try to integrate into deliberate practice. You're not just rehearsing how to creatively and improvisationally respond to the client. You're also rehearsing self-awareness of yourself as the therapist. And you're developing awareness of your own weaknesses—like, whoa, maybe when I work with an angry man, I start to have anxiety. Or maybe when I work with children who are being abused, I have all this really strong anger that I need to process. Something like that. We all have triggers, right?
Keith Sutton, Psy.D. (46:00):
Yeah. I was at a conference this last weekend. We brought out Dick Schwartz, and he was talking about when he’s working with a couple and one of the partners has the same parts as he does, sometimes he might react in a certain way and then actually be like, “Oh, sorry, that’s one of my parts. I need to put that to the side right now.” Or again, using that within the framework of the therapy—speaking to one’s own parts, or being aware of the parts that might be coming up.
Tony Rousmaniere, Psy.D. (46:28):
Bingo. Bingo. So I know when I was going through graduate school, my supervisor would talk about that, and that helped. And I went to my own therapy and I would talk about it, and that helped. And I definitely encouraged trainees to do that. What I was missing, though, was rehearsing with that state of my own emotional arousal.
Keith Sutton, Psy.D. (46:50):
Mm.
Tony Rousmaniere, Psy.D. (46:51):
Yeah. And so something I started doing later was watching videos of myself doing therapy with clients who triggered my own countertransference. And while I watched the video, I would just be aware of my own countertransference—or my own parts, in IFS language—and I would rehearse how to engage despite that.
Keith Sutton, Psy.D. (47:14):
Mm.
Tony Rousmaniere, Psy.D. (47:15):
And it's almost like how firefighters will rehearse how to do their job while they're terrified.
Keith Sutton, Psy.D. (47:21):
Yeah. Yeah.
Tony Rousmaniere, Psy.D. (47:22):
Right? I mean, we're firefighters, emotionally.
Keith Sutton, Psy.D. (47:26):
Yeah. Yeah, totally. Well, it's like boot camp or something like that, where they increase that emotional intensity during the training so that when they’re in those situations—triggered and in fight-or-flight—they can still perform.
Tony Rousmaniere, Psy.D. (47:41):
I mean, I would suggest our job, in some ways—some people might not like this—but in some ways our work is harder than firefighters or soldiers or people working in high-arousal situations, because their goal is to end it.
Keith Sutton, Psy.D. (47:56):
Yeah.
Tony Rousmaniere, Psy.D. (47:57):
Right? The firefighter goes into the building, and there’s not much discussion or negotiation. They’ll just grab you and run out of the building.
Keith Sutton, Psy.D. (48:07):
Sure.
Tony Rousmaniere, Psy.D. (48:08):
We have to go into the burning building—metaphorically speaking—and sit down with a client and be like, “How are you feeling? What are your goals? Would you like to leave the building?” And the client might be like, “Oh no, no, no, I’ve been here a long time, it’s not a big deal.” And we have to say, “It’s okay to leave the building.” They might say, “I’m scared to go out through that door.” Then we say, “Okay, how about the window?” They say, “I’m scared of heights.” And then we’re like, “Okay, why don’t we sit in this burning building for three months and build a relationship and trust before we try to leave?”
Keith Sutton, Psy.D. (48:37):
Yeah. Well, unfortunately for us as therapists, we get to leave that building and come back every week and only spend an hour, rather than getting burned up like the firemen. But definitely, I think that idea is right—seeing that. And I think that’s also where boundaries come in for therapists, because sometimes that’s hard. They’re like, “Your building’s on fire,” and the person is like, “Ah, I’m okay here.” And then when the therapist leaves after the hour, the whole week they’re thinking, “Oh, they’re still in this.” Part of beginning to learn boundaries is seeing where you begin and the client ends, so you're not necessarily getting pulled in.
And in motivational interviewing they call it the “righting reflex”—you know what’s right, and you try to get them onto the “right side,” which can lead to strong-arming clients or pulling them along. That ends up leading to so-called resistance. One of the things I learned from motivational interviewing, even before graduate school, is that resistance is due to the therapist, not necessarily the client. And when we’re hitting up against resistance, it means—just like you said with those clients who don’t improve—rather than saying “they’re resistant clients,” looking at what am I doing here? Is there something I need to be doing differently, learning, or figuring out? And turning back inward.
Tony Rousmaniere, Psy.D. (49:56):
Yeah. So I would suggest it’s not just learning about resistance, or boundaries, or patience—it’s--
Keith Sutton, Psy.D. (50:04):
Rehearsing it. Yeah. Rehearsing.
Tony Rousmaniere, Psy.D. (50:06):
Exactly. Because learning about something is often not enough when you have to perform it in a high-emotional-arousal situation, with a lot of countertransference. I got pretty good at understanding my theory, but just knowing it intellectually isn’t the whole story.
Keith Sutton, Psy.D. (50:24):
Yeah. It’s like teaching someone a deep-breathing exercise—they might be able to do it in the office, but when they start spiraling, or even as therapists, when we get triggered, that stuff goes out the window. You’re in that amygdala, limbic-zone mode.
Tony Rousmaniere, Psy.D. (50:38):
Right. So we’ve actually created video exercises specifically for what you’re talking about—around boundaries.
Keith Sutton, Psy.D. (50:45):
Okay.
Tony Rousmaniere, Psy.D. (50:46):
This is a perennial challenge, no matter what model of therapy you’re doing. We’ve got sample video exercises for free on our university website, cent.org. We encourage therapists and trainees to use them—they’re all open source. Any faculty or supervisors listening are welcome to use these exercises in their courses. They give trainees a chance to rehearse challenging moments in therapy, often including boundaries, before they’re really in it with a client.
Keith Sutton, Psy.D. (51:28):
Yeah. Definitely. Well, this is wonderful. I love the work that you’re doing. Coming from that place of wanting to improve and develop, focusing on deliberate practice is so important. I’m really glad you’ve built on that, seen the gaps in training, and created something that helps the field. It’s really awesome work.
Tony Rousmaniere, Psy.D. (52:02):
Thank you, Keith. I had a number of experiences, including your consultation group, that really helped me see this as a universal challenge. It helped de-stigmatize it, move past shame, and realize: if I want to get better, I need to practice. It’s not magic—it just takes work.
Keith Sutton, Psy.D. (52:32):
Definitely. I know some therapists feel burnt out, thinking clients never change. I couldn’t imagine that, because for better or worse, I’m endlessly hopeful. I see clients rising—like a phoenix from the ashes. Maybe not immediately, maybe not every week, but it can happen. That’s why patience, skill development, and practice are so important.
Tony Rousmaniere, Psy.D. (53:13):
Exactly. There’s reason to hope. We have entire careers to keep improving, helping more clients. It’s inspiring to meet trainees and therapists so dedicated to continual career improvement.
Keith Sutton, Psy.D. (53:38):
Yeah. It keeps me energized. Hey Tony, it was great to connect with you again. You’re doing incredible work—thank you for coming on the podcast. We’ll definitely link to the university and all the resources.
Tony Rousmaniere, Psy.D. (53:52):
Thank you, Keith. This has been really fun talking about it.
Keith Sutton, Psy.D. (53:55):
Great. Take care.
Tony Rousmaniere, Psy.D. (53:56):
Okay. Bye.
Keith Sutton, Psy.D. (53:58):
Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults, with our licensed experienced therapists in-person in the Bay Area, or throughout California online, and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships and low fee treatment through our nonprofit Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC’s website at sfbacc.org. BACC is a 501(c):(3): nonprofit so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c):(3): nonprofit, so all donations are tax deductible. Today I'll be speaking with Tony Rousmaniere, who is the president of EP University, a new marriage and family therapy graduate school.
Keith Sutton, Psy.D. (02:28):
He provides workshops, webinars, and advanced clinical training and supervision to clinicians around the world. Tony is the author and co-editor of over a dozen books on deliberate practice and psychotherapy training, and two series of clinical training books: The Essentials of Deliberate Practice and Advanced Therapeutics: Clinical and Interpersonal Skills. In 2017, he published the widely cited article in The Atlantic Monthly, What Your Therapist Doesn’t Know. Tony supports the open data movement and publishes his aggregated clinical outcome data in de-identified form on his website at drtonyr.com. A fellow of the American Psychological Association, Tony was awarded the Early Career Award by the Society for the Advancement of Psychotherapy, Division 29.Let's listen to the interview. Hi, Tony. Welcome.
Tony Rousmaniere, Psy.D. (03:21):
Hi, Keith. Thanks for having me. It's great to be here.
Keith Sutton, Psy.D. (03:21):
Yeah, definitely. So, Tony, you and I know each other back from our early career days. We were in an early career consultation group, and recently you were reaching out about some of the work that you're doing on deliberate practice and supervision, and so I was really intrigued to hear more. And before we get to that, I always like to hear about folks’ thinking and evolution of thinking—how they got to doing what they're doing.
Tony Rousmaniere, Psy.D. (03:47):
Yeah, sure. I mean, you know me from way back, right after I graduated, and you welcomed me into your consultation group, which was really great. Back then it really kind of helped—and you gave me some really good career advice right out of graduate school in terms of setting up a private practice. So I just want to thank you for that. It really kind of helped me get the ball rolling. I mean, you had some really good advice on that. I'm sure—maybe you've already done it—but someday you should do a podcast episode just on that. I mean, really, the best career advice I've ever heard about setting up a private practice came from you.
Keith Sutton, Psy.D. (04:23):
Oh, great.
Tony Rousmaniere, Psy.D. (04:24):
So thank you for that. But yeah—when did I graduate? I think it was 2008 or something like that. And I spent my time in graduate school, like most trainees, trying to become a better therapist. Right? That's why I became a therapist—because I wanted to help my clients. And I think that's true for basically all of us.
And I had this kind of nagging feeling throughout graduate school that while I was learning a lot about therapy—I was getting really good at writing about therapy. I could write really good therapy, and I could talk about really good therapy. You know, we could debate what's better, CBT or psychodynamic, or whatever. We could have these really interesting conversations.
But if you watched videos of me actually doing therapy at the time, you would see something totally different. Which means that throughout graduate training, my intellectual knowledge of therapy kept increasing, while my ability to actually perform therapy was maybe increasing a little, but not nearly as quickly.
Keith Sutton, Psy.D. (05:34):
Sure.
Tony Rousmaniere, Psy.D. (05:36):
And, you know, this was frustrating. I wanted to get a lot better because I noticed—I started tracking my outcome data with my clients, and I noticed that a fair amount of them were not improving. You know, some percent would drop out, and some percent would even deteriorate, meaning their symptoms would get worse during treatment, which was, you know, very frustrating. When I added it all up, I found that about 50% of my clients were not improving in their symptoms, which—you know, at first I felt really ashamed and embarrassed. I was like, oh my gosh, maybe I'm not cut out for this, you know, because no one at school was talking about it.
Yeah. We were reading all these books about how great these models were, and, you know, empirically validated...
Keith Sutton, Psy.D. (06:22):
Sounds so linear, like just do this, this, and this, and yeah, they're going to get better.
Tony Rousmaniere, Psy.D. (06:25):
Follow this protocol, which was validated by these RCTs, and then boom. And, you know, we'd hear about these miracle cases, and you go to the conferences and no one was talking about their deterioration. You know, they would talk about these one-session miracle cases.
And then I started to read the research literature on psychotherapy outcomes, and I found that my outcomes were actually quite average across the field. Yeah. Across the whole field, roughly 50% of clients don't improve. You know, there's a lot of variance in that, but—so I was a perfectly average trainee.
Keith Sutton, Psy.D. (07:05):
Sure. Okay.
Tony Rousmaniere, Psy.D. (07:09):
That, you know, was not where I wanted to be. Yeah. Yeah. I wanted to be better, and I tried many things. I attended a lot of workshops. I did a lot of consultations. I read a lot of books. And I still never really got the feeling like, okay, this is reliably making me better.
Keith Sutton, Psy.D. (07:31):
Right.
Tony Rousmaniere, Psy.D. (07:32):
This is really, like, the key. And then one day—I was a big fan of Scott Miller.
Keith Sutton, Psy.D. (07:38):
I still am. Yeah. I was wondering about which outcome research you were reading and what measures you were using.
Tony Rousmaniere, Psy.D. (07:43):
Yeah. So I was using a variety of measures. Scott Miller really—and then also Barry Duncan—really inspired me to start doing FIT.
Keith Sutton, Psy.D. (07:50):
Yeah.
Tony Rousmaniere, Psy.D. (07:51):
And then, you know, your consultation group--
Keith Sutton, Psy.D. (07:53):
Feedback-informed treatment.
Tony Rousmaniere, Psy.D. (07:54):
Feedback-informed treatment. Yeah. Yeah. Your consultation group was really good for reinforcing that and guiding me in that.
Keith Sutton, Psy.D. (08:01):
Yeah, because I've been using that since—gosh—what was that, 2004? You know, the Outcome Rating Scale and Session Rating Scale, Scott Miller’s and Barry Duncan’s measures. And really the idea that by tracking outcome and by getting feedback, you can increase outcome by 65% regardless of theoretical orientation.
Tony Rousmaniere, Psy.D. (08:20):
Yeah. Yeah. So you were an early proponent of that, and you were really good. I had kind of heard about it, but you were really good at showing me clinical examples. And then I met other people who were really into it. So I started doing that, and that helped. I mean, that's valuable.
But one thing people have found, including Scott, is there's kind of like a ceiling with FIT in terms of—it can help you identify which clients are at risk of deterioration, which sometimes we don't see. You know, as therapists, we have blind spots.
Keith Sutton, Psy.D. (08:56):
Right.
Tony Rousmaniere, Psy.D. (08:58):
And sometimes clients don't want to tell us because, you know, they just want to be nice. And so, the FIT measures are good at identifying clients at risk of deterioration. But they don’t tell you what to do next—like how to fix it.
Keith Sutton, Psy.D. (09:16):
Sure.
Tony Rousmaniere, Psy.D. (09:18):
Right?
Keith Sutton, Psy.D. (09:19):
Mm-hmm.
Tony Rousmaniere, Psy.D. (09:20):
And so that—and this is something Scott Miller figured out, and I'm sure your listeners have heard of Scott Miller.
Keith Sutton, Psy.D. (09:29):
Yeah. We did a podcast with him, actually, also.
Tony Rousmaniere, Psy.D. (09:31):
Excellent. Excellent. So almost everything I've done since then is based on his work. So I stand on his shoulders. He's been one of the most important mentors for me throughout my career.
And he noticed that, yeah, FIT was helping therapists identify when clients weren't improving—but it didn’t say what to do next. Like, how do we help?
And what he turned toward and started talking about was deliberate practice.
Keith Sutton, Psy.D. (10:00):
Hmm.
Tony Rousmaniere, Psy.D. (10:02):
And I can describe what that is. Please do. Yeah. Briefly, if you like. Definitely. So the easiest way to describe it is in a metaphor. Did you play any sports or musical instruments growing up, like in high school?
Keith Sutton, Psy.D. (10:18):
I skied.
Tony Rousmaniere, Psy.D. (10:20):
Skied. Okay. Were you on a team?
Keith Sutton, Psy.D. (10:22):
No. No.
Tony Rousmaniere, Psy.D. (10:23):
Okay. Did you play any sports on a team or any musical instruments with a teacher?
Keith Sutton, Psy.D. (10:28):
I played Little League for two years. The first year we won one game, and the second year we won zero games. Okay. That counts. That's the extent of my team sports.
Tony Rousmaniere, Psy.D. (10:37):
That counts. Great. So Little League, so that's baseball, right?
Keith Sutton, Psy.D. (10:39):
Yep. Yep. Okay.
Tony Rousmaniere, Psy.D. (10:41):
So imagine you went to your Little League teacher or coach and said, “Coach, I love this. I love baseball. I think I'm kind of talented at it. In fact, I think I want to play professionally someday.”
“But I just want to be honest with you, I don't have time to practice. I can't go to practice. I've got school, I've got work, I've got my family. I just have too many commitments. How about instead of going to baseball practice, I do 3000 hours of baseball games,”
“And I write down notes. I even videotape some games, and I'll meet with you for one-on-one supervision or group supervision every week to discuss the games. And then I'll try to improve, but no practice.” Do you think that would get you up to Major League Baseball?
Keith Sutton, Psy.D. (11:34):
I don't know. I imagine it would help and improve, but I don't know if it's going to give you those—what is it—like 10,000 hours or something?
Tony Rousmaniere, Psy.D. (11:42):
Bingo.
Keith Sutton, Psy.D. (11:42):
Bingo.
Tony Rousmaniere, Psy.D. (11:42):
Yeah. So I would be very surprised if you could find a coach who would endorse that the way to get to Major League Baseball would be to just play—just play baseball—supervised experience.
Keith Sutton, Psy.D. (11:56):
Sure.
Tony Rousmaniere, Psy.D. (11:57):
Without practice. However, that is our model of training therapists. If we get a lot of experience providing therapy--
Keith Sutton, Psy.D. (12:11):
Yeah.
Tony Rousmaniere, Psy.D. (12:13):
—which sometimes we call practice, but it isn't practice. Providing therapy to a real client is actually work performance.
Keith Sutton, Psy.D. (12:20):
Yeah.
Tony Rousmaniere, Psy.D. (12:22):
And the reason is, when you have a real client in front of you, you can't rehearse. You can't say, “Client, I just learned this great new method, Internal Family Systems, and I want to try this one technique 50 times, and you tell me which time feels the best.”
Keith Sutton, Psy.D. (12:40):
Sure.
Tony Rousmaniere, Psy.D. (12:41):
Right. To do that, you need to have what we call deliberate practice or rehearsal, which is separate from the work performance.
Keith Sutton, Psy.D. (12:52):
So these are kind of like the role plays that all graduate students hate, but I think are so valuable. For both licensed and graduate students, I think it's so valuable to actually have that experience practicing.
Tony Rousmaniere, Psy.D. (13:06):
Bingo. Perfect. Bingo. Yeah. So these are like role plays, as you say, graduate students hate. Now I want to emphasize that it's not just graduate students who hate them. Licensed therapists--
Keith Sutton, Psy.D. (13:19):
One, like these things. Every workshop they do, there's a role play.
Tony Rousmaniere, Psy.D. (13:23):
Yeah. I know you've led a lot of workshops, so you see this. And people are like, “Oh, no, no, no, no. I'd rather just talk about the model than actually role play doing it.”
Right. And yet, when you're giving a workshop, I mean, how much more valuable is the actual rehearsal rather than talking about it?
Keith Sutton, Psy.D. (13:43):
Yeah. It's that experiential aspect--
Tony Rousmaniere, Psy.D. (13:46):
Bingo.
Keith Sutton, Psy.D. (13:46):
—that you don't get if you're just all cognitive. And that's why, especially too, I really am a big proponent of one-way mirror training.
Tony Rousmaniere, Psy.D. (13:52):
Bingo.
Keith Sutton, Psy.D. (13:53):
Because you're actually being guided to do something different at the moment.
Tony Rousmaniere, Psy.D. (13:58):
Bingo. The experiential training—there’s a lot of research that shows experiential training is just way more effective than academic training with therapy, because therapy is a performance art. Yeah. Therapy is—it is not a philosophy. You're not writing down things and giving it to your client. You're performing in an improvised fashion with your client. By performing, I don’t mean faking it—you’re authentic—but it is a performance. You're doing it rather than thinking or writing about it.
Keith Sutton, Psy.D. (14:29):
Like a dance or something like that.
Tony Rousmaniere, Psy.D. (14:31):
Bingo. Yeah. Or an improvised jazz performance maybe.
Keith Sutton, Psy.D. (14:36):
Exactly.
Tony Rousmaniere, Psy.D. (14:37):
Or something like that. But I wanted to emphasize what you said about no one seeming to like it. And deliberate practice research actually shows this—that when it's good deliberate practice, it's not super fun. Because deliberate practice, when it's done well, is done right at the zone of your competencies, or at the edge of your competencies. It's called the zone of proximal development.
Keith Sutton, Psy.D. (15:04):
Yes.
Tony Rousmaniere, Psy.D. (15:05):
So just beyond your ability. I know you do training in Emotion Focused Therapy for couples, right?
Keith Sutton, Psy.D. (15:11)
Yes.
Tony Rousmaniere, Psy.D. (15:13):
Okay. And I presume when you're doing the rehearsals, the role plays, you're trying to help the trainees—even licensed therapists—kind of stretch, try something they haven't been able to do before.
Keith Sutton, Psy.D. (15:24):
Definitely.
Tony Rousmaniere, Psy.D. (15:25):
So that's called the zone of proximal development—just beyond your ability. And when you're rehearsing just beyond your ability, you're going to screw up.
Keith Sutton, Psy.D. (15:38):
Yeah. It feels uncomfortable.
Tony Rousmaniere, Psy.D. (15:40):
It's uncomfortable. And as therapists, we know there are multiple levels of discomfort. There's the discomfort of, “Okay, here's a skill I haven't really mastered.” There's also discomfort like, “Here's some emotional material that's being stirred up by what we're doing.” And that can be uncomfortable as well.
Keith Sutton, Psy.D. (16:01):
Well, I think in the field too, you can talk a good game, but then when you're actually doing a role play or you're showing a video, it's a whole other level. That can bring up a lot of anxiety or embarrassment or so on. Because like you're saying—on paper versus in action.
Tony Rousmaniere, Psy.D. (16:18):
Right. That's where the rubber hits the road. Now, I know this is something that you encouraged me to do early on, which is record videos of my work. And I did a lot of that, and that was super helpful.
Keith Sutton, Psy.D. (16:31)
Great.
Tony Rousmaniere, Psy.D. (16:32):
And unfortunately, not everyone does that. Not every graduate program does that. And if we don't watch videos of our own work, we can end up with this kind of split reality where we have an image in our mind of what we're doing, which is a little different from what we're actually doing. So we actually encourage therapists to watch videos of their work throughout their entire career and use that as a basis for deliberate practice.
Keith Sutton, Psy.D. (17:00):
Well, and it's so important too. I've actually been doing this recently because I have some licensed therapists that I do consultation groups with, and I have some folks in our nonprofit which I'm supervising. And so I also show some of my work, sometimes something from that week that I was showing. And sometimes I'm just figuring out what I'm doing and actually putting it into words by trying to explain what I'm doing—something I might be doing naturally. And then it makes you think about it, right? This feedback loop of doing it, thinking about why you're doing it, and then noticing where I'm like, “Oh, I should have done this here. I wonder why I didn't do that.”
Tony Rousmaniere, Psy.D. (17:39):
Now, I want to underline a few things in what you just said. First of all, you're developing a meta-awareness of your own work. Which is very hard to do while you're working with a client because you're so focused on attuning with them.
Right? There's probably some meta-awareness going on, but not a lot. And that's appropriate. We really want to focus on the client and attune with the client.
Keith Sutton, Psy.D. (18:05):
Definitely.
Tony Rousmaniere, Psy.D. (18:17):
So it really does take reflection—and not just intellectual reflection, but watching video later—to get the full amount of meta-reflection on your work.
Keith Sutton, Psy.D. (18:17):
Definitely.
Tony Rousmaniere, Psy.D. (18:18):
So there's that. Second of all, I want to point out that you're still watching videos of your work. You're still analyzing your own work. You're still being surprised by your own work.
Keith Sutton, Psy.D. (18:29):
Yeah, definitely.
Tony Rousmaniere, Psy.D. (18:37):
Now, you are extremely successful. You're very established. You don't need to do this.
Keith Sutton, Psy.D. (18:38):
Well, I want to keep getting better and better. There's always something to learn.
Tony Rousmaniere, Psy.D. (18:41):
Okay. So I want to highlight this for the listeners. I mean, you could coast, Keith. You could easily coast from now on and just rely on your reputation and you'd be fine. The board of psychology is not expecting you to do this. No one's expecting you to do this. It's internal motivation to get better. Which I think is so important to highlight, because that's what it takes in our field and many other fields. Work performance is public.
Keith Sutton, Psy.D. (19:15):
Yeah.
Tony Rousmaniere, Psy.D. (19:15):
So if you were, let's say, a basketball player—or let's say you pursued the career in Major League Baseball you dreamed about in Little League, when a baseball player performs, it's public.
Keith Sutton, Psy.D. (19:28):
Yeah. People are seeing that.
Tony Rousmaniere, Psy.D. (19:31):
Everyone sees. They don't have the option of hiding their work. They don't have the option of telling themselves stories about their performance.
Keith Sutton, Psy.D. (19:40):
Yeah.
Tony Rousmaniere, Psy.D. (19:41):
If you were an artist, your work would be public. If you were an actor, your work would be public. If you were a pilot, your work would be public. I would say therapists—we have the distinct disadvantage that our work is extremely private. And there are good reasons for that around confidentiality. I'm not arguing against that. I'm just saying it works against our ability to improve our performance.
Keith Sutton, Psy.D. (20:13):
Yeah. Yeah. Definitely. And I think that unless you're in—like, we've got a group practice, and the research has also shown if you're in a group practice you tend to have better outcomes because you are looking at your work from other perspectives. But in private practice, if you're not getting consultation, if you're not talking with colleagues, you're just kind of doing what you're doing. Then yeah—there are no outside eyes to look at that. And I think that's why a lot of burnout also happens. Oftentimes, part of dealing with burnout is not only self-care, but also going to trainings, getting consultation, getting excited about doing something new or trying something new, or moving beyond feeling helpless or not—like you were saying with your clients—feeling like, “Ah, I don't feel like I'm achieving enough. You know, 50% aren't improving.” Then when you start working on improving that, that brings a lot of energy.
Tony Rousmaniere, Psy.D. (21:10):
Yeah. Yeah. It brings a lot of energy, but it's not all comfortable energy.
Keith Sutton, Psy.D. (21:14):
Yes, that's true. Yes. Be willing to go outside that, to stretch and to stretch. Yeah, definitely. To stretch.
Tony Rousmaniere, Psy.D. (21:21):
Now the top performers in every field stretch throughout their whole career. Right? The top musicians don't stop getting coaching. They don't stop practicing. If you listen to interviews with Yo-Yo Ma or the top musicians or the top athletes, they actually practice more than everyone else.
Keith Sutton, Psy.D. (21:44):
Yeah.
Tony Rousmaniere, Psy.D. (21:45):
So somehow therapists have ended up in a culture where that’s not the standard. The standard is once you graduate from graduate school, once you get licensed, you stop being supervised, you stop being coached, and then you just coast. People have this idea that as long as I keep doing therapy, I'm getting better. Research shows repeated work performance itself does not make you better.
Keith Sutton, Psy.D. (22:20):
Yes.
Tony Rousmaniere, Psy.D. (22:20):
I would use a metaphor. I got my driver's license maybe 30 years ago. I am not a better driver after 30 years of driving. I got a lot of miles under my belt.
Keith Sutton, Psy.D. (22:39):
Yeah.
Tony Rousmaniere, Psy.D. (22:41):
And it's because I'm not getting feedback. Well, sometimes I even get feedback. I'm just not rehearsing based on that feedback.
Keith Sutton, Psy.D. (22:47):
Sure.
Tony Rousmaniere, Psy.D. (22:49):
That's how we get better.
Keith Sutton, Psy.D. (22:51):
Yeah. And I always think—and I don't know how true this is—the Michael Jordan story that he got cut or something from his high school basketball team. So it wasn't that he was naturally so much better than others at basketball, but it was about deliberate practice. When he would play and take shots, he would calculate and notice and get that feedback and keep working on tweaking things, rather than just shooting free throw after free throw aimlessly. It's not only about the hours, but how you're actually doing it during those hours.
Tony Rousmaniere, Psy.D. (23:27):
Yeah. So just mindlessly rehearsing something won't make you better.
Keith Sutton, Psy.D. (23:31):
Yeah.
Tony Rousmaniere, Psy.D. (23:32):
If I wanted to learn to play golf and I just went out to a golf course and started swinging a golf club or whatever it is, I would not get better. If I had a coach watching me and saying, "Tony, do this a little better. Do this a little better. Lift your elbow, lift your shoulder," I could get better quite quickly.
Keith Sutton, Psy.D. (23:52):
Yeah.
Tony Rousmaniere, Psy.D. (23:54):
So the question is, how do we apply this to psychotherapy? We've got some really good models for psychotherapy. But
then the question is, how do we practice them?
Keith Sutton, Psy.D. (24:06):
Yes.
Tony Rousmaniere, Psy.D. (24:07):
Now there are some models like EFT for couples, which have gotten a good head start on this where there are a lot of ways to rehearse as part of the training.
Keith Sutton, Psy.D. (24:16):
Definitely. Part of the core skills is a huge aspect of doing lots of role plays and experiencing the different positions of the couples and the therapists.
Tony Rousmaniere, Psy.D. (24:28):
Right. So many models of therapy unfortunately don't have that.
Keith Sutton, Psy.D. (24:32):
Yes.
Tony Rousmaniere, Psy.D. (24:32):
Or maybe a supervisor here or there has improvised something, but it's not really a standardized part of the pedagogy. Yeah. And so that is what we have dedicated ourselves to. We've got a book series with the American Psychological Association where we are partnering with some leading teachers and supervisors for the major models of therapy.
Keith Sutton, Psy.D. (24:57):
Great.
Tony Rousmaniere, Psy.D. (24:58):
And we go to them and we say, identify 10 or 12 skills from your model of therapy. And we will help you develop deliberate practice exercises for those skills. Now, ideally, these are skills where there's a sweet spot for deliberate practice. These are skills that the trainee—and by trainee I'm speaking broadly; it could be a licensed therapist who's picking up this model later in their career—but it's a skill that the learner understands intellectually. So maybe they could write a paper about it, but might have trouble performing it.
Keith Sutton, Psy.D. (25:41):
Yes.
Tony Rousmaniere, Psy.D. (25:41):
Particularly with a client in a higher emotional arousal situation. And so we develop a deliberate practice exercise, which is basically scripted role plays. We then send the exercise out to test sites. We have volunteer test sites around the world that are testing these exercises.
Tony Rousmaniere, Psy.D. (26:01):
They videotape themselves testing the exercise, send us the video, and we look at the video and see, is this going how we hoped? And then we revise the exercise. This goes for about a year. Then we've got a book. Our first book was Deliberate Practice for Emotion-Focused Therapy for Individuals.
Keith Sutton, Psy.D. (26:19):
Okay. Great.
Tony Rousmaniere, Psy.D. (26:20):
And then we got Deliberate Practice for CBT. We're about to release Deliberate Practice for Child and Adolescent Therapy, for Motivational Interviewing, for Systemic Family Therapy. And then there's a bunch of other books in the works—for DBT, a DPI—so it just kind of keeps going down the line.
Keith Sutton, Psy.D. (26:38):
Wonderful.
Tony Rousmaniere, Psy.D. (26:40):
Yeah.
Keith Sutton, Psy.D. (26:40):
Very cool. Yeah. I think that's what I've noticed also, especially in supervising and consultations, is that some of the common factors go down to the relationship between the therapist and the client. Particularly I've found motivational interviewing invaluable for that ability to attune with your client and really get on the same page before you're moving forward. Because many therapists tend to jump ahead of the client when the client's not on the bus with them or they're pulling them along. That's where you get those alliance difficulties. But as you're saying, there's also the techniques and putting those in, and I'm thinking of exposure work.
Keith Sutton, Psy.D. (27:32):
Particularly my first time doing it, I was like, gosh, am I supposed to have them doing deep breathing or what? And it wasn't until I saw the Obsessed series from A&E with real therapists doing real exposure work with OCD that it clicked. That's something I do with the folks I'm training—showing them these videos and helping them see, because yeah, there are those skills that go beyond the intellectual and into how you sit with these things too.
Tony Rousmaniere, Psy.D. (28:02):
Right. Many trainees find that when they're doing exposure with a client, it's actually an exposure for both people.
Keith Sutton, Psy.D. (28:10):
Yes, totally. Totally.
Tony Rousmaniere, Psy.D. (28:11):
Right? Because as therapists, we have to attune with the person going through the exposure, so we're going to feel that. And so--
Keith Sutton, Psy.D. (28:21):
Especially if you're new and you don't yet have the confidence that this is going to work. With EMDR or exposure, you're asking the person to do something that brings up intense emotion. And when you haven't done it before, and you haven't seen it work time after time, sometimes you sit there thinking, oh gosh, am I doing the right thing here?
Tony Rousmaniere, Psy.D. (28:45):
Yeah. What's going to happen here? Yeah. Right. Is my client going to fall over from this? So if given the opportunity to rehearse, trainees can feel a lot more confident before performing with a real client.
Keith Sutton, Psy.D. (29:01):
Yeah.
Tony Rousmaniere, Psy.D. (29:03):
So there's something you said that I want to highlight again—you mentioned the common factors. These are the variables in therapy identified to be most helpful, often more helpful than the specific factors from specific therapy models. This is based on the work of Bruce Wampold, John Norcross, and a whole bunch of people. And Scott Miller talks about this a lot. Our books are focused on the specific models of therapy. However, we've noticed that the majority of the skills across the books are very similar.
Keith Sutton, Psy.D. (29:51):
Hmm. Interesting.
Tony Rousmaniere, Psy.D. (29:53):
They focus first on building an alliance, building positive regard and trust, building expectations, getting agreement on the tasks of therapy, the goals of therapy, addressing ruptures—these are all common factors.
Keith Sutton, Psy.D. (30:07):
Yeah, totally.
Tony Rousmaniere, Psy.D. (30:08):
And it's cool seeing how each model is almost like a different style or approach, but they're aiming in the same direction.
Keith Sutton, Psy.D. (30:19):
Yeah. And they're also building on that foundation. Hmm.
Tony Rousmaniere, Psy.D. (30:24):
Yeah. Someone raised—I'm forgetting who it was—an interesting theory the other day: that the specific models of therapy are really just helping therapists with different personality styles use common factors, and we're going to use them differently depending on our personality style.
Keith Sutton, Psy.D. (30:43):
Depending on the therapist’s personality style. Yes. Yeah.
Tony Rousmaniere, Psy.D. (30:46):
Yeah. And then ideally that matches with the client's personality style. Yeah. When you have a good match, then you're, you know, good to go. Definitely.
Keith Sutton, Psy.D. (30:52):
Definitely. Yeah. And I think that that piece too, you know, that also—I mean, I think where the theory and technique come into play also with the alliance—is that the more the therapist feels confident in whatever they're doing, and that it makes sense to them, they're not just doing CBT, for example, because somebody said it was good, but they like—that's their worldview. Right. That our perceptions are colored by—you know, our experience is colored by our perceptions. Right. You know, when it's kind of more of a lived experience as well as, you know, just having that roadmap and knowing where you are in the therapy and where you're going, that translates to how you are with the client. Yeah. But it sounds like you could intermix different kinds of approaches to get to that same end of the confidence and feeling competent and all those pieces.
Tony Rousmaniere, Psy.D. (31:47):
Yeah. I mean, I totally agree. Like, if you look at expert performers in music or sports—I mean, even sports—they will bring in techniques from other performers, like from other methods. And they'll kind of integrate them in. And sometimes the very top performers are integrating a whole bunch of different material which they've learned throughout their career. But I want to emphasize that they're not just reading books about it—they're rehearsing it. Yeah. So it's embodied. And so it's kind of—we call it muscle memory.
Keith Sutton, Psy.D. (32:19):
Yeah.
Tony Rousmaniere, Psy.D. (32:20):
So the skills are in your bones. So, for example, when you're working with a couple and let's say it's a high-conflict couple, you know, these EFT skills are in your bones. And it can just come out immediately, you know what I mean? And that's because you've rehearsed it.
Keith Sutton, Psy.D. (32:34):
Yeah, yeah. Definitely. Yeah. And it takes time, especially with EFT. You know, I trained in that for many, many years before I got certified as a certified supervisor. But I kind of felt like once I really got that process orientation, it was almost like—there's a scene in the Matrix movie where all of a sudden you start seeing all the ones and zeros coming down and just kind of seeing the whole—everything in this different light. And it's hard to unsee it after that. But again, that process of getting from here to there takes time. Yeah. It's hard to—you can't quite rush it.
Tony Rousmaniere, Psy.D. (33:13):
No, you can't. Now, I remember when I was starting out, I would read books on psychotherapy theory, and I would memorize the book, and I'd even sometimes memorize the lines that, like, Beck or whoever was saying. And then I would get really frustrated and disappointed when it just—like, when it wouldn't work for me.
Keith Sutton, Psy.D. (33:30):
You know--
Tony Rousmaniere, Psy.D. (33:31):
And it's because I was in this model of like, “I just need intellectual understanding. That's enough.” When really, that's crazy. That's not nearly enough. I needed many years of rehearsal before it could move into muscle memory, and I'd be able to perform it in a very flexible, intuitive, adaptable way.
Keith Sutton, Psy.D. (33:54):
Timing is so important too. Bingo. Again, the kind of—the orchestra or the dance of the therapy—when you're going to introduce information. I think for a lot of folks early in their training, oftentimes they're only seeing maybe five, ten hours at a time a week, but they're talking to supervisors and group supervisors and in their classes. And then once they finally get into the session, you know, they've talked five hours about the one-hour session, and then right off the bat they're like, “Well, I think this is what's going on.” And the person's like, “No, I don't think so.” And you're like--
Tony Rousmaniere, Psy.D. (34:29):
I remember that. Oh, you're totally triggering me. I totally remember exactly that.
Keith Sutton, Psy.D. (34:34):
I thought that—you know, you think you figured it out, and then you're like, why didn’t that work? And then again realizing that it takes time to learn those nuances and the timing and when that's going to come in. Now, from what I understand too, there’s some good research on folks that are in training and their effectiveness. Because there is actually a bit of a mindset of trying to learn and trying to think differently versus folks maybe that have been in practice so long but aren't necessarily doing that deliberate practice.
Tony Rousmaniere, Psy.D. (35:07):
Yeah. So trainees have an advantage where they do not consider themselves to be experts. And they do not have this kind of reputation or whatever to defend. Right. And so they can often be more open to feedback, more open—you know, like, I remember my supervisors: “Just tell me what to do. I'm open.” Yeah. I want to--
Keith Sutton, Psy.D. (35:35):
Know what to do. I'll take anything.
Tony Rousmaniere, Psy.D. (35:36):
Yeah, yeah. Anything. Right. And so we found this when we go around and do workshops and we ask for volunteers from the audience. It's actually a lot more stressful and vulnerable when someone who's been licensed for 20 years volunteers. Because they have this whole reputation or self-image to defend. Right. And so that is an advantage for trainees. Unfortunately, most graduate schools—the tradition in therapy training is to really emphasize the academics and under-emphasize experiential training. Like, you might get some experiential training a little bit in your practicum, a little bit here and there. I know systemic family training is better at this. So there are some that are better than others. But typically, we're still using Freud's model of training.
Tony Rousmaniere, Psy.D. (36:37):
Yeah. Even CBT training uses Freud’s model, which is a lot of lecture, a lot of reading, a lot of writing, and then supervised performance with real clients. We were going around doing workshops and teaching faculty how to incorporate more deliberate practice in their courses. They would get excited, and then come back three months later and say they couldn’t do it. There was too much inertia. No one said, “Don’t do it.” There were no bad guys trying to stop them. There was just too much inertia at their university, and given all the other demands, they couldn’t do it. We realized it was unfair for us to try to get everyone else to implement these changes.
Tony Rousmaniere, Psy.D. (37:23):
So about a year and a half ago, we decided we had to open our own graduate school. And that’s what we’re doing now. We are forming Sentia University and starting with an MFT graduate program, a standalone graduate program in California, unaffiliated with any other school, because we knew that if we affiliated with another school, we would get caught up in their inertia. We filed all the paperwork, which, let me tell you, if you ever think about starting a graduate school, there’s a lot of paperwork. It’s everything I spent my career trying to avoid, and now I have to do all of it times ten. Our paperwork is being processed by the California regulators. In roughly two years, we’ll begin admissions for our new MFT graduate program.
Where is that going to be located? It’s located in California. The actual classes will be online, but the practicum will be a mixture of online and in-person in different locations.
Keith Sutton, Psy.D. (38:36):
Oh, wonderful.
Tony Rousmaniere, Psy.D. (38:38):
What we’re doing differently is that 50% of every class will be rehearsal.
Keith Sutton, Psy.D. (38:46):
Very good.
Tony Rousmaniere, Psy.D. (38:46):
And when I say every class, I mean literally every class. That includes an assessment class, an ethics class—literally every class. Fifty percent of a three-hour class will be spent rehearsing key skills. We’re developing exercises for all these classes. You go through an entire MFT curriculum, and we have exercises for every class.
Keith Sutton, Psy.D. (39:12):
Very cool. I taught a graduate school class this summer, and in the final assignment I had them do a stage four session of evolving structural strategic family therapy, or the four-stage model. As the professor, it was interesting to see twenty videos of role plays and look at them almost like coding a research experiment. Just from watching people do it, I realized that when they did this, it went off track; when they did that, it stayed on track. Those nuances are helpful feedback for teachers too—refining key moments they can guide someone around.
Tony Rousmaniere, Psy.D. (40:03):
What you’re describing is an ideal learning situation for trainees. Your trainees are very lucky. Many trainees won’t get a lot of that.
Keith Sutton, Psy.D. (40:16):
Yeah.
Tony Rousmaniere, Psy.D. (40:17):
I know a lot of faculty who want to provide that. They just don’t know how, because they weren’t taught to do that, and the university isn’t providing the resources. There are no bad guys here. No one is stopping them. There just aren’t structural supports.
Keith Sutton, Psy.D. (40:34):
Yeah. It’s just doing what was done before. There’s a woman, Judy Hess, in the Bay Area. She’s retired now, but she taught a family therapy class where students brought in their family if they were local, and they would do a family therapy session. Or they would role-play if the family wasn’t available, or have the family over the phone or video. It gave students an experiential experience. That was at CIIS, the California Institute for Clinical Studies.
Tony Rousmaniere, Psy.D. (41:09):
Yeah. They’re a little progressive.
Keith Sutton, Psy.D. (41:10):
They have all sorts of interesting things going on.
Tony Rousmaniere, Psy.D. (41:13):
Talk about experiential. She was from the MFT tradition, and as I understand it, the MFT training tradition has always been a generation ahead of the other associations in terms of experiential training. So we’re starting with an MFT program, and then we’re going to open a psychology program, a counseling program, and a social work program. We want to start from the very first class—with deliberate practice in everything. Everything will be videotaped. Everyone will be watching their videos. No one will hide anything. There will be a culture of that from the very beginning.
Keith Sutton, Psy.D. (41:52):
Good.
Tony Rousmaniere, Psy.D. (41:53):
The other thing we’re doing differently is using FIT—feedback-informed treatment—in all the practicums, and trainees will look at their aggregate outcome data.
Tony Rousmaniere, Psy.D. (42:08):
And it's going to be shared in the graduate program. It's going to be shared in the practicum. And it's going to be like an athlete. They know their scores.
Keith Sutton, Psy.D. (42:18):
Yeah.
Tony Rousmaniere, Psy.D. (42:19):
Right. Everyone knows each other's scores. They can be okay with it being average or whatever. They know their batting average, they know what they're doing. It’s like an actor. Everyone knows what you're doing. Everyone knows what you're screwing up. It destigmatizes it; it takes the shame out of it. And it's like, okay, we've all got strengths, we've all got weaknesses, and we're going to work on it.
Keith Sutton, Psy.D. (42:41):
Great. That's wonderful. Are you going to do some research on this training program?
Tony Rousmaniere, Psy.D. (42:46):
Yeah. We’ve got a team of researchers collecting data all the way through the whole thing. And then over time, we're going to use that data to see how this is helping, how it’s not helping, what we can improve. I assume there’s no way we're going to get everything right out of the gate. It’ll take 20, 30 years to figure out how to really do this well.
Keith Sutton, Psy.D. (43:06):
Yeah.
Tony Rousmaniere, Psy.D. (43:08):
So we're also going to open-source all our training materials so other graduate programs can use them however they want. And hopefully they'll collect data as well.
Keith Sutton, Psy.D. (43:18):
That’d be--
Tony Rousmaniere, Psy.D. (43:18):
Great. And then as a field, we can move toward more effective methods of training.
Keith Sutton, Psy.D. (43:25):
Perfect. That sounds great. That’s taking it to the next level—having that different experience and practicing from the start of graduate school. I imagine those students will come out after those two years in a much different place than other folks, maybe MFTs who have only gotten maybe 500 hours of practice, supervised but not observed like that.
Tony Rousmaniere, Psy.D. (43:54):
Yeah. Usually students might get 500 hours of performance with a client.
Keith Sutton, Psy.D. (44:02):
Exactly.
Tony Rousmaniere, Psy.D. (44:03):
Supervised performance. What worries me is that I graduated with zero hours of actual practice. I had a lot of supervised performance, and so that's our baseline—zero.
Keith Sutton, Psy.D. (44:15):
Yeah, that's true.
Tony Rousmaniere, Psy.D. (44:17):
So there’s a lot of room to grow above that.
Keith Sutton, Psy.D. (44:23):
Yeah. Good. That’s great. I think it's so important to look at your videos, to role-play. There’s so much you can learn about yourself. In supervision with my supervisors, applying some EFT—like, “What was happening for you then that led you to say X, Y, or Z in that moment?” The more in tune they are with themselves, the more they can see how that might be influencing the decisions they make in sessions, which they may not have been aware of.
Tony Rousmaniere, Psy.D. (45:01):
Yeah. This is super important. Psychodynamic therapists might call it countertransference. CBT therapists might call it experiential avoidance. Every model has its own word for it. But it’s also called the person of the therapist.
Keith Sutton, Psy.D. (45:17):
Right.
Tony Rousmaniere, Psy.D. (45:18):
And this is really, really important, and this is something we try to integrate into deliberate practice. You're not just rehearsing how to creatively and improvisationally respond to the client. You're also rehearsing self-awareness of yourself as the therapist. And you're developing awareness of your own weaknesses—like, whoa, maybe when I work with an angry man, I start to have anxiety. Or maybe when I work with children who are being abused, I have all this really strong anger that I need to process. Something like that. We all have triggers, right?
Keith Sutton, Psy.D. (46:00):
Yeah. I was at a conference this last weekend. We brought out Dick Schwartz, and he was talking about when he’s working with a couple and one of the partners has the same parts as he does, sometimes he might react in a certain way and then actually be like, “Oh, sorry, that’s one of my parts. I need to put that to the side right now.” Or again, using that within the framework of the therapy—speaking to one’s own parts, or being aware of the parts that might be coming up.
Tony Rousmaniere, Psy.D. (46:28):
Bingo. Bingo. So I know when I was going through graduate school, my supervisor would talk about that, and that helped. And I went to my own therapy and I would talk about it, and that helped. And I definitely encouraged trainees to do that. What I was missing, though, was rehearsing with that state of my own emotional arousal.
Keith Sutton, Psy.D. (46:50):
Mm.
Tony Rousmaniere, Psy.D. (46:51):
Yeah. And so something I started doing later was watching videos of myself doing therapy with clients who triggered my own countertransference. And while I watched the video, I would just be aware of my own countertransference—or my own parts, in IFS language—and I would rehearse how to engage despite that.
Keith Sutton, Psy.D. (47:14):
Mm.
Tony Rousmaniere, Psy.D. (47:15):
And it's almost like how firefighters will rehearse how to do their job while they're terrified.
Keith Sutton, Psy.D. (47:21):
Yeah. Yeah.
Tony Rousmaniere, Psy.D. (47:22):
Right? I mean, we're firefighters, emotionally.
Keith Sutton, Psy.D. (47:26):
Yeah. Yeah, totally. Well, it's like boot camp or something like that, where they increase that emotional intensity during the training so that when they’re in those situations—triggered and in fight-or-flight—they can still perform.
Tony Rousmaniere, Psy.D. (47:41):
I mean, I would suggest our job, in some ways—some people might not like this—but in some ways our work is harder than firefighters or soldiers or people working in high-arousal situations, because their goal is to end it.
Keith Sutton, Psy.D. (47:56):
Yeah.
Tony Rousmaniere, Psy.D. (47:57):
Right? The firefighter goes into the building, and there’s not much discussion or negotiation. They’ll just grab you and run out of the building.
Keith Sutton, Psy.D. (48:07):
Sure.
Tony Rousmaniere, Psy.D. (48:08):
We have to go into the burning building—metaphorically speaking—and sit down with a client and be like, “How are you feeling? What are your goals? Would you like to leave the building?” And the client might be like, “Oh no, no, no, I’ve been here a long time, it’s not a big deal.” And we have to say, “It’s okay to leave the building.” They might say, “I’m scared to go out through that door.” Then we say, “Okay, how about the window?” They say, “I’m scared of heights.” And then we’re like, “Okay, why don’t we sit in this burning building for three months and build a relationship and trust before we try to leave?”
Keith Sutton, Psy.D. (48:37):
Yeah. Well, unfortunately for us as therapists, we get to leave that building and come back every week and only spend an hour, rather than getting burned up like the firemen. But definitely, I think that idea is right—seeing that. And I think that’s also where boundaries come in for therapists, because sometimes that’s hard. They’re like, “Your building’s on fire,” and the person is like, “Ah, I’m okay here.” And then when the therapist leaves after the hour, the whole week they’re thinking, “Oh, they’re still in this.” Part of beginning to learn boundaries is seeing where you begin and the client ends, so you're not necessarily getting pulled in.
And in motivational interviewing they call it the “righting reflex”—you know what’s right, and you try to get them onto the “right side,” which can lead to strong-arming clients or pulling them along. That ends up leading to so-called resistance. One of the things I learned from motivational interviewing, even before graduate school, is that resistance is due to the therapist, not necessarily the client. And when we’re hitting up against resistance, it means—just like you said with those clients who don’t improve—rather than saying “they’re resistant clients,” looking at what am I doing here? Is there something I need to be doing differently, learning, or figuring out? And turning back inward.
Tony Rousmaniere, Psy.D. (49:56):
Yeah. So I would suggest it’s not just learning about resistance, or boundaries, or patience—it’s--
Keith Sutton, Psy.D. (50:04):
Rehearsing it. Yeah. Rehearsing.
Tony Rousmaniere, Psy.D. (50:06):
Exactly. Because learning about something is often not enough when you have to perform it in a high-emotional-arousal situation, with a lot of countertransference. I got pretty good at understanding my theory, but just knowing it intellectually isn’t the whole story.
Keith Sutton, Psy.D. (50:24):
Yeah. It’s like teaching someone a deep-breathing exercise—they might be able to do it in the office, but when they start spiraling, or even as therapists, when we get triggered, that stuff goes out the window. You’re in that amygdala, limbic-zone mode.
Tony Rousmaniere, Psy.D. (50:38):
Right. So we’ve actually created video exercises specifically for what you’re talking about—around boundaries.
Keith Sutton, Psy.D. (50:45):
Okay.
Tony Rousmaniere, Psy.D. (50:46):
This is a perennial challenge, no matter what model of therapy you’re doing. We’ve got sample video exercises for free on our university website, cent.org. We encourage therapists and trainees to use them—they’re all open source. Any faculty or supervisors listening are welcome to use these exercises in their courses. They give trainees a chance to rehearse challenging moments in therapy, often including boundaries, before they’re really in it with a client.
Keith Sutton, Psy.D. (51:28):
Yeah. Definitely. Well, this is wonderful. I love the work that you’re doing. Coming from that place of wanting to improve and develop, focusing on deliberate practice is so important. I’m really glad you’ve built on that, seen the gaps in training, and created something that helps the field. It’s really awesome work.
Tony Rousmaniere, Psy.D. (52:02):
Thank you, Keith. I had a number of experiences, including your consultation group, that really helped me see this as a universal challenge. It helped de-stigmatize it, move past shame, and realize: if I want to get better, I need to practice. It’s not magic—it just takes work.
Keith Sutton, Psy.D. (52:32):
Definitely. I know some therapists feel burnt out, thinking clients never change. I couldn’t imagine that, because for better or worse, I’m endlessly hopeful. I see clients rising—like a phoenix from the ashes. Maybe not immediately, maybe not every week, but it can happen. That’s why patience, skill development, and practice are so important.
Tony Rousmaniere, Psy.D. (53:13):
Exactly. There’s reason to hope. We have entire careers to keep improving, helping more clients. It’s inspiring to meet trainees and therapists so dedicated to continual career improvement.
Keith Sutton, Psy.D. (53:38):
Yeah. It keeps me energized. Hey Tony, it was great to connect with you again. You’re doing incredible work—thank you for coming on the podcast. We’ll definitely link to the university and all the resources.
Tony Rousmaniere, Psy.D. (53:52):
Thank you, Keith. This has been really fun talking about it.
Keith Sutton, Psy.D. (53:55):
Great. Take care.
Tony Rousmaniere, Psy.D. (53:56):
Okay. Bye.
Keith Sutton, Psy.D. (53:58):
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