Selected items from archived Educators Newsletter:

Inspiration from the field: Easing students into practice

Melanie Brede, MS, RD, CSSD, is a preceptor who works at the University of Virginia’s Student Health Center. She has this strategy for interns who want to practice counseling with patients in an outpatient setting when their skill level is not yet adequate. First, she assigns Counseling Tips to the interns to read. Then they observe one of her sessions and use the Counseling Session Feedback Form to pick out the skills they see demonstrated. If Melanie is seeing a client who would feel uncomfortable with an intern in the room, she lets the interns use the Feedback Form with a previously recorded session.

Interns get frustrated when we don’t let them counsel real clients. When they do work with clients, they understandably focus on the content of what they need to cover because this is fairly new to them. Their process tends to get off track, and we cringe. This interim step of focused observation gives them experience with attending to the process when it’s easy to get distracted by the content. It may be useful to set up the observation session by promising to discuss the nutrition issues afterward, but emphasizing that you want them to focus this time on tallying open and closed questions or by noticing the client’s “change talk.”

You could choose the Tips or you could let the interns choose a few (thereby demonstrating choice). You and the interns could design the observation exercise based on the Tips chosen. For example, an intern may be fascinated with self-disclosure and what to do when clients ask personal questions. You would assign Tips #1, Self -Disclosure, and #18, How to Handle Personal Questions. Then during the session, the intern can be assigned to jot down any self-disclosure on your part and/or note times she would have been tempted to add something about herself if she were the counselor. Afterward, discuss the pros and cons of each example of disclosure.

Q: I have your Toolbox of materials and am teaching counseling skills to undergraduates for the first time. Can you give me ideas for using the basic exercises for first-time mock counseling?

A: I would start with the Mirroring Exercise since the process of reflecting is so critical to all counseling. Some students are natural mirrors, and reflecting will come easily since they already do it in their social conversations. For them, you are highlighting a natural process they can employ strategically with clients. Other students do not yet mirror out loud in their social interactions, and the skill will be difficult and take practice. All students will benefit from your suggestion to practice it with friends and bring their experiences to the next class.

The Unpacking Exercise gives students a chance to practice focusing on what is important to the client without the distraction of nutrition content. I have often seen even experienced nutrition counselors get off track quickly when instructed to unpack what is important to their mock client when the topic is nutrition or health. Instructing the “client” to talk about something that matters to him (unrelated to health or food) makes it more likely that the counselor will not get off track and give advice too soon. The counselor can focus on exploring the topic in detail, practicing open-ended questions and reflecting.

The Elicit/Provide/Elicit Exercise works well, too. Students may be excited about providing nutrition advice. Introducing this process for embedding the advice in a client-centered frame early in their training will serve them well later.

Q. Should I introduce  the concept of supervision to my students and interns?

A. Yes. Early and often!

The concept of  supervision has been only sporadically adopted in our field. In simple terms supervision is any interaction with a professional colleague for the purpose of maximizing the quality of practice. It is used extensively in counseling fields both in training and on-going practice. This process includes case consultation as well as counseling designed to advance the supervisee’s skills.

Students, even at the undergraduate level  can be introduced to the term and given an explanation of it’s purposes and value. In classes where counseling skills are taught and practiced, the feedback process employed in the training  is a type of supervision. Urge students to look for such support and guidance throughout their careers.

Interns expect to receive supervision in their work. They can be encouraged to continue this learning process as they begin their careers and on-going! Let them know that they will need to actively seek out this feedback once they are practicing.

Here is a pdf of Counseling Tip # 11, Professional Supervision.  Feel free to use as a class handout. It is included in Chapter 11 of  Counseling Tips for Nutrition Therapists: Practice Workbook, Vol 1.

Inspiration from the field: Providing counseling experience for interns

Melanie Brede, MS, RD, CSSD

Molly shared with me the program she has developed for training interns counseling skills. I tried it out this winter. The University of Virginia interns spend one week each with me in the Student Health Center. They have one other outpatient rotation through the hospital’s outpatient nutrition counseling center (all sorts of patients), and bits of outpatient woven into rotations through the oncology, diabetes, and renal clinics. These clinic experiences are much more education focused than counseling focused. My department houses a Peer Health Education (PHE) program with 40+ undergraduate PHEs who do limited nutrition education in one-on-one sessions and group presentations. I was able to use these PHEs to enhance the experience for the interns.

All the interns very much enjoyed using the materials. They were able to absorb the content efficiently/effectively by listening to the podcasts. They used the accompanying articles primarily as supplements. The case examples helped illustrate points. They also found the sample “Protocols” helpful. For example, the list of steps to take in dealing with resistance.

Prior to experimenting with your new materials, to structure their rotation with me, I had selected a number of your Tips as part of their required reading for the rotation. Then during the week I’d have them sit in on as many of my sessions as possible and/or listen to sessions I’d recorded. I’d have them complete the Counseling Session Feedback Form for several of these sessions, and we’d debrief after sessions. As much as possible, I’d have them conduct some sessions and I would sit in to evaluate their work and be available when they needed help.

As we’ve experimented with various strategies and your materials, I’m beginning to find a structure that seems to flow well. I  have one of our PHEs do a “practice session” with the intern early in the week. I’m finding this step extremely helpful in assessing their baseline skills. I can more efficiently direct the intern in our limited time. For example, if the intern is doing well with open ended questions, I have her focus on another skill. It seems that both I and the intern feel more confident and less. And in situations where it is hard to give the intern the opportunity to practice with a real patient (patients that aren’t well matched, cancellations/no-shows, etc), having the practice session guarantees an opportunity for the intern to gain some experience.

I’m also finding that when the interns listen to the podcasts, use the notes, and do the readings, they are more ready to use the Counseling Session Feedback Form. Since the podcasts are short, it is easy to productively and flexibly structure their time between reviewing materials, sitting in on sessions, listening to recorded sessions, conducting their own sessions, and completing other health promotion programming assignments.

It makes sense that interns (and all of us!) develop counseling skills over time. I am hopeful that I will be able to coordinate with the other preceptors in this internship program to have the interns utilize parts of the materials you’ve developed during their rotation with me and parts in their other rotation(s). I think that the way you’ve structured the materials will make this easily doable, and I’m confident that we’ll be putting our heads together before the next class to develop a schedule and plan.

Inspiration from the field: Engaging Students

Shelley Mesznik, MA RD CDE CDN is an instructor at Teacher’s College, Columbia University. She has taught nutrition counseling to graduate students for many years and loves experimenting with new assignments.

“I gave a new assignment this year regarding your tips. It worked very well.  I’ll do it again next semester. Half the class bought Volume 1 and the other half bought Volume 2 of your tips.  I broke up the class into 5 groups of 5 students each. I asked each group to read 10 tips assigned by me in such a way that all 50 tips were covered.

“Part 1 of the assignment was written. They had to summarize each of their 10 tips (for practice paraphrasing) in writing and describe in writing how the tips tie in with what the student knows about Motivational Interviewing (review for the student of the spirit, principles and tools of MI). They also wrote about which tip was most useful, which most difficult, and which they were already using.

“Part 2 asked the group to get together and select two out of the ten tips that they considered to be the best and do a presentation to the class. They had freedom to do the presentation anyway they wanted to, but they only had 6 minutes for 2 tips.

“The groups were fabulous. Some used PowerPoint. Most groups role played the tips. It was entertaining, educational, and creative.

The ten tips that were presented were then put into the Tip Olympics. The class voted and chose which tip it found best for a Gold Medal, second place got Silver, and third got Bronze.

“My teaching assistant took the list of 10 tips and typed it up. The students received a handout of the 10 tips they had selected and would be voting on. I felt that the list was a good handout for beginning counselors.”

Q: How to give interns useful counseling training when they are only observing sessions? 

A: Give them a specific assignment.

It is a challenge to provide real counseling experience to interns in settings where it is not appropriate to allow them to provide this service to patients. They may only be able to observe. In most cases the intern’s attention is on the content of the session. This is, of course, important. However, if we want them to learn quality counseling process, it is essential to attend to the counseling process as well.

Experiment with various assignments that focus the intern’s attention on process. For example:

Provide a simple list of the phases of a session and ask them to jot down a few words from each phase that they observed.Review the process of reflection and ask them to tally up the number of reflections they hear the counselor make. Some interns may be able to categorize the various types of reflections.Assign them to tally up all the change talk they hear from the client.  For more advanced practice, notice how many of the change talk statements were reflected. Pick a few examples of the change talk and jot down how you could have reflected it.Tally up the counselor’s open and closed questions. Attend to affirmations provided by the counselor and jot down some that could have been offered.

Q: What can we do as educators when we get stuck in class while trying to model the client-centered process!! 

A: Keep it simple and focused.

Determine ahead what specific techniques you want to demonstrate and limit the demo to a short section of a client session. Students will likely be able to take this in better anyway. For example, demonstrate the opening of a session with rapport-building strategies, or just focus on agenda-setting or on the advice-giving section of the session.

Avoid the “client from hell.”  When we ask someone to role-play a client they will naturally take on a negative stereotype. (For an example, see this humorous YouTube video.)  This is kind of role-play is of minimal value to demonstrate effective counseling process. When asking a student to “be a client” direct her to be real and actually engage with you as herself.

Consider developing a relationship with a colleague who is willing to come into the classroom and model the client. Talk ahead about the purpose of your demonstration and the elements of the case you want to point up. Then run the session ad lib.

If you do not feel competent enough to spontaneously demonstrate in class, stick with using videos. Consider working on your competence by practicing specific skills one at a time with our own clients or with a colleague.

Finally, if you get stuck in front of the students use it as a learning experience for them on how difficult these skills are and how much they will need to practice to gain competence.

Inspiration from the field: An externship for more counseling practice

Dawn Clifford, PhD, RD
Assistant Professor and Director,
Didactic Program in Dietetics
California State University , Chico

Our undergraduate dietetic students take a Nutrition Counseling and Education course. In the counseling half of the course, I cover the characteristics of a counselor, applying the nutrition care process to a counseling setting, motivational interviewing, non-diet approaches to counseling as well as physical activity counseling. At the end of the semester, students participate in a videotaped role play experience, but this just whets their appetite. On our exit surveys each year, many students stated that they wanted more time to get comfortable with nutrition counseling. We couldn’t split the course into two and add more units, so we came up with an alternative: an optional 1-unit nutrition counseling training internship for students.

One unit at Chico State means three hours each week learning and practicing their skills. The unit is a pass/fail. They are asked to keep track of their hours, and as long as they complete their hours, they pass. One hour each week is spent in class. They are given ideas for spending their other two hours each week. They can (1) read articles and books on nutrition counseling, (2) watch counseling videos that have been uploaded to their class page, (3) practice their OARS (open-ended question, affirmations, reflections, and summaries) during conversations with friends, or (4) shadow other nutrition counselors through a program we have on campus, FitU (www.csuchico.edu/fitu). (Note: Our FitU counseling office has a mirrored window and clients sign a release stating that they agree to observation by others in training.)

During the one hour nutrition counseling training class each week, we revisit the topics covered in the Nutrition Counseling and Education course. We mainly focus our attention on motivational interviewing and incorporating non-diet approaches into counseling sessions. Towards the end of the semester, we cover MNT-based counseling. During the hour I spend the first 5-10 minutes revisiting a topic from their Nutrition Counseling and Education course. Next, students spend 30 minutes practicing that technique/skill with a partner in a role play experience. We spend about 10 minutes debriefing. We also discuss any counseling experiences they either had or observed the week before. This exposes them to the concept of professional supervision and the importance of de-briefing with other counselors.

The only assigned reading is Secrets of Feeding a Health Family, by Ellyn Satter . I’m a big fan of the Satter Eating Competence Model. I ask them to read this book prior to the start of the semester. Throughout the semester, as we discuss counseling techniques, we refer back to the ultimate goal of producing competent eaters.

While I haven’t conducted any formal assessment, students do report feeling more confident in their motivational interviewing skills by the end of the semester. They seem to appreciate the additional opportunity and I encourage them to include this internship opportunity on their resume. Completing this internship experience is a requirement for serving as a nutrition counselor for our FitU program.

Inspiration from the field: Using real client session recordings

Students and interns often say they want to hear/see real client sessions.  Several preceptors and a DI director have told me they make use of their own client session recordings. (I believe they are all audio recordings. This makes obtaining permission easier. )

Or course, confidentiality is a concern. I will share here the process I use when asking a client to record a session. I first say that I have a  request and it is fine with me if they say “no” to it. I tell them I am working to improve my counseling technique and that it is useful for me to go back over my sessions. I would be interested in audio-recording this session, but only if it’s OK with them. The majority of my clients agree readily. If I sense any hesitation at all, I say, “let’s not do it then.” During the recording I make sure not to use the client’s full name.   If after recording it, I believe I might wish to share it with other professionals, I then ask the client for permission to do that, making clear I will not put it on the internet, only let a few colleagues listen. Again, I make clear that it’s fine if they say “no.”  When you let students/interns know the careful process you used to obtain permission you are also modeling professional behavior.

There are lots of ways to use session recordings:

Listen for the client’s “change talk.”

Listen for the open-ended questions that elicited the most useful client responses.

Tally up the number and types of reflections the counselor made.

Tally up open and closed questions.

You may feel uncomfortable letting interns listen to your less-than-perfect sessions. All of our sessions are imperfect and we are always a work in progress. You can share this with the interns and even go over the moments you wish you had done something differently. They learn even more this way and will see you model on-going improvement toward excellence.

Q: Many of my students seem to think they will not need counseling skills as a dietitian. They are just focusing on what to tell their patients, not how they will tell them. Any ideas for getting through to them?

A: We all know  that dietitians are more effective in all settings when they have good communication and counseling skills.  For example, those in food service need to supervise the work of others and this can involve urging an employee to make a behavior change.  In research settings where subjects in some groups are asked to make diet changes, the research will be most effective if we are effective change agents. Clinical dietitians are generally asked to do little behavior change counseling. However, interactions with their patients (and other medical staff) will be more successful if they are skilled at effective communication.

You can, of course, make the above points and more. In addition a simple experiential exercise will have more impact. Here is one for students who still think all they need to do is tell patients what to do and they will do it.

1. Ask for one student to volunteer to discuss a health change she wishes to make. (Be sure it’s real, not made up.) Examples might be: flossing more, eating more fruit, exercising more, drinking more water, etc. Ask her to briefly tell the class what the change is and then to leave the room for a few minutes and jot down all the ideas she has to address the issue.

2. Ask the remaining students to brainstorm advice and ideas they would give the volunteer. Encourage them to be creative. Write all the ideas on a board.

3. Ask the volunteer to come back in and review the list of ideas on the board. Ask her to cross off things she already has on her list, has already tried that didn’t work or just doesn’t like for any reason. Encourage her to tell the others why she is crossing off each one.

4. Discuss what they learned from this. How might they do something differently than they had planned with patients. If they don’t mention it, point out that the volunteer had some ideas already that the counselor could elicit with an open-ended question.