How often do you know what to do in a situation, but you don’t do it? Knowing what you should do and actually doing it are two different things. One of my past supervisors described this as the difference between “knowing knowledge” and “doing knowledge.” Just like music or athletic skills, patients must go through a process to use therapy skills in daily life. Therapists use the term skills transfer to describe the learning process from knowing to doing.

Patients accomplish a skills transfer through a series of steps. Some steps happen in therapy, and others require work between sessions. One can only learn so much attending therapy sessions without following through. This is why doing therapy homework matters!   

Steps to Successful Skills Transfer

Direct Teaching

You can’t engage in a behavior you don’t know how to do. The first crucial step to skills transfer requires direct teaching. This step primarily happens during therapy. People with social skills difficulties, such as those with autism, benefit from direct teaching as they have difficulty learning from observation alone. Regardless of diagnosis, we can’t simply assume someone knows how to do the desired skill.

My first supervisor explained the necessity of teaching skills with this humorous quip: “most of therapy requires stating the obvious without saying ‘you idiot’ afterwards.” I’m not calling us “idiots” for not knowing something; however, this illustrates that something may seem obvious to one person that is unknown to someone else.

Over the years, I have had patients who were therapists or children of therapists. Even these patients needed the same or similar instruction. Occasionally I could cover a topic more briefly, but I often taught a topic that was entirely new to them. The reality is there is always something to learn.

I had a memorable experience with this when I attended my first national convention in 2004. I sat near Richard Woodcock in several sessions. At the time he was a 76-year-old legend in the field well-known for his tests of cognitive ability. He seemed to show genuine interest in every session. I finally got up the nerve to say hello to him. I commented that it was neat to see him attending these sessions. He simply replied that this is how he learns. I was very impressed by this man’s humility and willingness to learn. 

Most people do not learn effectively after one period of direct instruction. In fact, repeated instruction is more effective than using multiple modalities (e.g., seeing, hearing, reading) of presentation (Schneider, Healy, Carlson, Buck-Geengler, & Barshi, 2019).

Modeling

The next step for skills transfer is modeling or showing someone how to complete a skill. Modeling can take place during therapy. I commonly use modeling in Parent Child Interactive Therapy (PCIT). During PCIT, we start by teaching the parent skills such as praise. Then, I play the parent’s role for 5 minutes of child-directed interaction, so the parent can see how the skill works in real life with their child. This modeling helps put the puzzle pieces together and gives the parent a new perspective on the skill and their parenting.

Another form of modeling is through watching other individuals’ behaviors in real life, which happens outside of therapy sessions. In the PASS program (from Safe and Civil Schools), a staff member accompanies a child to another classroom. Together, they watch the kids in the class, looking for models of the target behavior.

There are many ways patients use modeling to develop skills. A social story (described in Avoid Avoiding: Tips for Overcoming Anxiety and Tips for Successful Potty Training) can allow the patient to see the skill from a new perspective. Even for adults, reading success stories can be inspirational when developing a skill.

Visual modeling involves using pictures as reminders of the skill. For example, I pasted pictures of an adult with autism accomplishing his morning routine onto a poster board. The pictures made the routine easy to follow and did not require a high reading level.

Parents can model skills for their children through their own words and actions. They might say, “I am upset because that person was rude to me in the pickup line. Let me take a deep breath. That helped me feel calmer!”  

Role play

Role play takes a skill from watching to doing in a safe environment. This is a common learning technique. For example, team sports usually involve running through plays multiple times to ensure the actual game goes smoothly. Training for first responders includes running through the motions of specific situations to prepare them for real-life scenarios.

When I teach how to do timeout in therapy, I often use puppets where the patient practices placing the puppet in timeout using the correct procedures. This role play helps both the parent and the child retain the information. Patients report greater success with timeout after a single session of role-play practice.

Patients can sometimes do role-play activities at home. For example, a patient who is working on social skills or managing anxiety with an upcoming job interview can practice mock interview scenarios with their parents.  

Coaching in Context

Coaching in context helps the patient practice a skill with guidance. Just like an apprenticeship, the individual practices the skills under the direction of a knowledgeable mentor. In team or individual sports, athletes would not perform as well without the guidance of their coach during the game/competition. Coaches yell advice from the sidelines or make adjustments during timeouts. Similarly, patients can learn therapy skills better when practicing with timely guidance.

While your therapist cannot guide you in the same timely way as a coach, loved ones can. This is a reason why we require parents to be part of therapy for their minor children. Parents or other supportive individuals can respond to situations in the moment while practicing the skill throughout the week. They can directly coach you through the skill step-by-step. For example, if a child gets angry while playing with friends, the parent or teacher could pull them aside and practice the coping skill with them before they return to play.

Reinforcement

Establishing and maintaining new routines can be difficult. Actions can result in both good and bad consequences. Often good actions result in the negative consequences before the positive consequences appear. When exercising, the discomfort of sweat or aching muscles occurs before one experiences a happier mood or improved health.

Reinforcement is important. A reinforcer increases or maintains a behavior. Everyone runs on principles of reinforcement. To me, denying the basic principles of reinforcement is like saying gravity isn’t real.

Some reinforcers happen naturally and others are artificial. An artificial reinforcer can help counteract the unhelpful results of natural reinforcers. To illustrate, let’s say you have a homework assignment due. If you procrastinate by scrolling social media on the phone, you experience temporary pleasure, a natural reinforcer. Yet, your homework still awaits! Now you can add an artificial reinforcer. Once your homework is complete, you will partake in a desired food item or pleasure activity. This reinforcer counteracts the appeal of procrastination, so you can have the long-term educational benefits of finishing your homework.

Your therapist can set up a reinforcement program with you, but success depends on your efforts outside of the session. We do not age out of reinforcement! Several of my most effective practicum students and postdoctoral fellows have used self-reinforcement programs in their professional and personal lives. Everyone can benefit from using reinforcers to overcome the challenges that arise during the skills transfer process.  

Monitor and Adjust to Maintain Skills Transfer

A successful skills transfer process needs monitoring, which typically occurs in three phases. As you progress through each phase, you will work on doing the skill more independently.

Getting Started

The first phase occurs when you are getting started, and your therapist is highly involved. You may need to make frequent adjustments to see what works. You should assess progress often because you are establishing habits and setting up the right environment for effective change.

Maintenance

Next comes the maintenance phase, in which you make minor but essential adjustments with less involvement from your therapist. This phase helps you guard against drifting over time. Take the game of “telephone,” for example. When people pass a message to each other, by the end of the line, the message usually has no resemblance to its original meaning. Therapists refer to this concept with the term treatment fidelity. Over time, patients need to continue to practice their skills effectively, avoiding regression.

When my children were young, I sometimes noticed difficulty with them not following directions. When I noticed these problems, I would compare my parenting practices to my handout on giving commands. Even after teaching this concept for years, I still realized I had regressed. After reviewing the instructions, I made adjustments to improve my parenting.

Regression can occur in many situations, which is why workplaces often spend a lot of time and money on retraining. I saw this firsthand in the schools. I personally assisted two school districts in setting up the Positive Approach to Student Success (PASS) program. They had great success at first. Eventually, they began to move away from following all the details. I saw this drift with patients who were in the program the entire time. As the front-line staff lost the vision of the program, it ceased to bring about the successful results that it originally had.

Fading

The final phase, fading, occurs when the behavior becomes more ingrained. On this step, we slowly reduce the level of structure. Sometimes all structures can be taken away, and other times, some structures need to remain indefinitely. For example, I do not ever see a time in which I would get to work on time without setting my alarm clock! Similarly, most of us would not continue going to work if our paychecks stopped arriving. The end goal of this step is to become independent, so you can discontinue therapy or only have occasional checkup sessions.

Skills Transfer: Conclusion

Cognitive behavioral therapy focuses on teaching individuals skills to help them make lasting changes in their lives. The skills transfer process takes time as the patient gradually gains independence from the therapist. Completing therapy homework and practicing skills outside of the session are crucial for turning “knowing knowledge” into “doing knowledge.” If you or someone you know needs help with any step of the skills transfer process, please contact our office.  

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Post written by Dr. Gordon D. Lamb, Licensed Psychologist and Clinical Director

Please note posts are educational in nature and are not intended to replace psychological services when needed.

References

Schneider V. I, Healy A. F., Carlson K. W., Buck-Geengler C. J., & Barshi I. (2019). How much is remembered as a function of presentation modality? Memory, 27(2), 261-267.