Teaching and Improving Clinical Counseling Skills: Teaching Counseling Microskills to Audiology Students: Recommendations from Professional Counseling Educators (2024)

Professional Counseling

It may be helpful to begin with a definition and overview of the scope of professional counseling. Counseling is defined as “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.”^1(p.368)Professional counselors have at a minimum a master's graduate degree in counseling. Broadly speaking, they assess, diagnose, and treat mental disorders using evidence-based interventions. Professional counselors assist individuals struggling to cope with typical life stressors (e.g., birth of a child, relationship issues, midlife career change) and individuals in crisis (e.g., death of a loved one, natural or human-caused disasters). Professional counselors, often with a certification specialty in rehabilitation counseling, also assist individuals with disabilities with adjustment, secondary and comorbid mental health symptoms, and case management.²Professional counseling is grounded in a holistic philosophy of mental health, with a focus on proactive wellness, empowerment, and self-actualization.³

Professional counselor education programs are accredited by the Council for Accreditation of Counseling and Related Educational Programs.⁴Professional counselors abide by the American Counseling Association code of ethics.⁵⁶They are certified nationally by the National Board for Certified Counselors or Commission on Rehabilitation Counselor Certification. Licensure is required to practice professional counseling. Requirements for licensure vary slightly by state, (e.g., in Pennsylvania, professional counselors are licensed by the Pennsylvania State Board of Social Workers, Marriage and Family Therapists, and Professional Counselors). Licensure boards require that professional counselors complete a 60-hour accredited graduate program in counseling and complete a required number of postgraduation supervised clinical hours (ranging from 1,000 to 4,000 depending on state licensing board).⁷

Professional counselors are trained in both basic counseling skills, also known as microskills and evidence-based psychotherapy. The therapeutic process has many influencing factors that are difficult to learn and execute in practice. The counseling profession found that graduate students were not able to practice evidence-based psychotherapy effectively without basic skills (e.g., what to say, how to say it, how to behave in session).⁸⁹Thus, counseling and counseling psychology fields developed a microskills training approach to break down the therapeutic process into basic skills that facilitate a therapeutic alliance.⁸⁹Microskills are basic counseling skills that assist rapport building and begin the therapeutic process. They include listening, nonverbal communication, silence, empathy, and responding (i.e., reflections, questioning, summarizing, and paraphrasing). Students refine these skills before learning ways to conceptualize primary problems and provide treatment with theory-driven, evidence-based practice. Microskills are necessary but not sufficient for conducting professional counseling and facilitating therapeutic change; assessment, techniques, and evidence-based interventions are also necessary.⁸⁹

Psychotherapy involves the application of higher-level evidence-based counseling interventions to treat individuals with various mental health issues and diagnoses. Professional counselors are trained to evaluate the needs of the client, the evidence available, and their personal skill set to develop individualized treatment plans. The amount of training that is required to provide psychotherapy varies depending on the intervention, but typically requires training above the rigorous requirements for professional counselors. Training often involves a minimum of (1) education (i.e., a minimum of a master's degree in a counseling or related field) and (2) supervised clinical experience. For example, much evidence in the counseling field supports cognitive and behavioral interventions. The criteria for becoming a certified cognitive-behavioral therapist are: (1) a masters or doctoral degree in counseling or a related field, (2) 6 years of postgraduate experience providing cognitive behavioral therapy (CBT), (3) three letters of recommendation from mental health professionals who are familiar with the applicant's cognitive-behavioral skills, and (4) successful completion of a certification program in CBT recognized by the National Association of Cognitive-Behavioral Therapists.¹⁰Training standards for other evidence-based treatment interventions, such as mindfulness-based stress reduction and dialectical behavioral therapy, are comparable to CBT in time and rigor. These evidence-based interventions are powerful, and to avoid causing harm, clinicians should be well trained.

Counseling in Audiology

It can be difficult to differentiate the scope of practice for professional counselors versus rehabilitation professionals who utilize counseling in their specialty, such as audiology. This can be a problematic distinction due to ethical requirements to practice within one's scope of practice and expertise. The wordcounselingappears five times in the American Speech-Language Hearing Association (ASHA) scope of practice.¹¹It is referred to as a method and essential role in audiology practice.¹¹In the rehabilitation section, the ASHA indicates that audiologists are to develop treatment plans that include counseling related to psychosocial problems or adjustment to “hearing loss and other auditory dysfunction.”¹¹It also refers to using counseling as a method for the “assessment and non-medical management of tinnitus.”¹¹Similar to ASHA, the American Academy of Audiology references counseling six times in the published scope of practice.¹²The referenced use of counseling is similar to the ASHA scope of practice. It mentions “the audiologist determines the appropriateness of amplification systems for persons with hearing impairment, evaluates benefit, and provides counseling and training regarding their use” and “counseling regarding hearing loss, the use of amplification systems and strategies for improving speech recognition is within the expertise of the audiologist.”¹²It is clearly in the audiologist's scope of practice to provide education, instruction, and advice about audiologic conditions and treatment services. However, the more difficult distinction is counseling related to problematic psychosocial issues presented by the patient.

To make a suggested distinction, these scope of practices were compared with counseling specialty scopes of practice.²It is important to note that there is overlap between the Scope of Practice for Rehabilitation Counseling and the reviewed audiology scope of practices.²¹¹¹²Both fields indicate that it is an essential role of audiologistsandrehabilitation counselors to counsel related to psychosocial adjustment to disability.²¹¹¹²Patients are best served by clinicians who are well trained and specialized in the disability or condition. Here, counselors are well trained and specialized in counseling but not all audiologic conditions, whereas audiologists are specialized in audiologic conditions but not counseling. It is reasonable and necessary for audiologists to become trained in basic counseling methods so that they may provide counseling for adjustment and psychosocial aspects specific to a patient's condition. Although overlapping, this is a useful practice of counseling for practicing audiologists.

It is, however, important to begin to make a distinction between psychosocial aspects of audiologic conditions and comorbid mental health conditions, as the line is often unclear in real-life clinical practice. In the cases of complex audiologic problems with presenting mental health symptoms (e.g., severe cases of tinnitus), it is necessary to have both a counselor and audiologist providing treatment to the patient.¹³It is outside the scope of practice for audiologists to determine if presenting mental health problems (anxiety, depression) are solely attributed to the audiologic condition (i.e., tinnitus) or impacting other areas of life as well. Thus, a minimum of a referral to a counselor or psychologist is necessary for a formal mental health assessment in those situations. Individuals with prolonged disability and pain conditions often develop significant comorbid mental health conditions that require the previously mentioned evidence-based psychotherapy interventions.¹³Although the criteria for provision of evidence-based psychotherapy mentioned previously (CBT, mindfulness-based stress reduction, dialectical behavioral therapy ) does not necessarily exclude audiologists, the level of training required is typically above and beyond what Au.D. students and professionals experience in their formal education and postgraduation experiences.

Active Listening

Active listening is the foundational microskill required to foster a therapeutic alliance with patients.²¹This skill is often overlooked as easy or self-explanatory; however, active listening is one of the most challenging microskills both to learn and maintain as a new or experienced professional.²²Evidence also suggests that active listening is one of the most influential microskills for improving clinical outcomes and patient/clinician relationships.²¹Active listening is dependent on the clinician being fully present to the patient and situation. This requires that the clinician is able to manage internal thoughts, dialogue, and distractions to fully concentrate on the patient.²²Full presence requires advanced concentration and self-monitoring of metacognition.¹⁸Active listening is not simply accurate repetition of the words, though that is a component of demonstrating listening. It requires that clinicians also simultaneously note nonverbal messages, affective messages, expressed thought processes, and patterns of behavior.²²For example, a client shares the following statement with their clinician: “I am just really frustrated with my teacher asking me to repeat myself over and over. I get that repeating is better than pretending to understand me when they don't, but I am sick of it. So, I have stopped participating in class.” The clinician must be actively listening on the specific affective messages expressed (“frustration,” “sick of it”), the scenario described (interaction with teacher in likely group setting), the nonverbal behaviors (in this example eyes watering with slumped posture), and patterns of behavior (withdrawal from class participation). The clinician must observe, listen, and note all of these things prior to expressively responding to the patient.²²

When considering active listening, it is helpful to consider the opposite of active listening. Gerard Edgan presented several forms of “inactive or inadequate listening” that are commonly used by helping professionals, including the following: (1) nonlistening or no presence; (2) partial listening or incomplete presence; (3) tape-recorder listening, or simply repeating words without conveying understanding of feelings or meanings behind the words; and (4) rehearsing, or when the professional stops listening to plan their response.²²These forms of inactive listening are habitual, and health and rehabilitation professionals can easily fall into them, especially in high-stress and time-limited situations. In these situations, clinicians may listen to react and respond, when they should be listening to understand the patient's perspective, problem, emotions, and opinions before considering the appropriate response.²²

Errors in listening or inadequate listening have countless etiologies. Graduate students and new professionals often lack confidence in their skills and knowledge base.²³This can cause novice clinicians to be preoccupied with how to respond or to make a clinical judgment rather than listening to the patient.²⁴Novice clinicians also have difficulty integrating patient messages that are being communicated through various channels. Experienced clinicians are often more proficient in active listening and gathering the necessary information through verbal messages, nonverbal messages, thought processes, patterns of behavior, and so on. However, clinicians are at risk for burnout, high stress, and limited time.²⁵These stressors can lead to working on autopilot without being fully present to the patient.²⁴Thus, active listening is a microskill that requires constant monitoring once mastered.

Learning to refine active listening skills can be broken down into a few steps for Au.D. students. First, students must learn to listen and remember the words another individual is sharing. Accuracy is crucial for rapport building and clinical decision making.²⁴Clinicians can learn to accurately identify the situation, key details shared, and specific emotion words used. It can also instantly build rapport if a clinician is able to listen and remember names that the patient shares. Listening to verbal messages with accuracy can require weeks of practicing listening. The best way to develop this skill is to check for accuracy with the other individual (including the situation described, key details, names shared, and emotion words/affective messages). It can be helpful to eliminate any nonverbal input while refining this microskill (e.g., not looking at the other person). It can also be helpful to start with short time lengths (2 to 3 minutes) and build to longer time periods (15 minutes), as it is an exercise in concentration and memory. Following mastery of listening accurately to verbal communication, students can add nonverbal input into the skill-building exercises. The types of nonverbal communication are covered in detail in the next section. Ultimately, students must train themselves to become fully focused and concentrated to actively listen to a patient.

Nonverbal Communication

Receiving nonverbal communication from patients is critical for active listening and building therapeutic alliance.²²²⁶However, clinicians also are sending nonverbal messages to patients, which can significantly impact the development of therapeutic rapport.²⁴²⁷Thus, developing the microskill to both read nonverbal messages from patients and monitor personal nonverbal output is critical for Au.D. students.

Nonverbal communication is a broad concept; it encompasses a range of skills that are worth differentiating.²⁸Nonverbal communication skills include: facial expressions, eye contact, physical gestures, paralanguage, posture, proximity, and autonomic display.²⁸Paralanguage includes voice tone, pacing, and volume. Posture includes body angle and orientation, back posture, hand placement, leg placement, and position in a chair.¹⁸²⁸Proximity refers to the body positioning and physical space between two individuals (i.e., the clinician and the patient).²⁶²⁸The physical setting and space also impacts proximity. For instance, is there a table between the clinician and patient? Is the patient across from the clinician or diagonally opposite? Finally, autonomic display is also a nonverbal message that impacts the therapeutic relationship.²⁶²⁷²⁹Common autonomic displays that negatively influence therapeutic relationships include sweat production, flushed face, blotchy skin, shallow breathing, stomach noises, tear production, and so on. These physical reactions occur automatically when the autonomic nervous system engages, often under pressure or stress.

All of the nonverbal behaviors and messages mentioned are culturally dependent and influenced by personal preferences, norms, and abilities. Some individuals may be uncomfortable with too much or too little eye contact, as this is a culturally dependent form of communication.¹⁸Nonverbal communication can be influenced by physical or cognitive conditions. Clinicians should be cognizant of disability conditions that influence nonverbal behaviors. For example, individuals with autism spectrum disorder might have very limited facial expressions directed to the examiner. Thus, nonverbal communication must be interpreted on an individual basis within the cultural context of the patient.

It is important for clinicians to not only recognize the patient's nonverbal message, but evaluate the congruence of the nonverbal behavior with verbal expressions of the patient.¹⁸For instance, a patient who describes tinnitus by saying he “cannot stand the pain anymore,” but smiles at the clinician. In this scenario, the patient may smile when under extreme distress because it is not culturally acceptable to display negative emotions. This nonverbal incongruence is worth recognizing in a therapeutic setting, because it could influence assessment, treatment plan, and future clinical interactions.

Clinicians also must monitor nonverbal messages communicated to the patient. Most clinicians are used to monitoring their own facial expressions and physical gestures. Paralanguage can be difficult for clinicians to monitor, as it is due to a lack of awareness or a clinician's tendency to automatically mirror nonverbal messages. The former can be remedied with focused monitoring and feedback. The latter, unconscious mirroring, is more difficult to control. For instance, a patient who is in pain may loudly express anger regarding unpleasant symptoms, and a clinician may unconsciously mirror this with a loud and fast-paced response. In this instance, mirroring of nonverbal affect does not serve to help the therapeutic alliance or environment.¹⁸At the same time, mirroring nonverbal messages can be effective and appropriate in many clinical situations, such as during grieving, when mirroring paralanguage can build rapport, trust, and the therapeutic alliance.¹⁸Clinicians should be cognizant and reflective of the clinical utility of mirroring nonverbal messages in varying situations.¹⁸Finally, clinicians' autonomic display is a very challenging aspect of nonverbal communication that is difficult to manage in a clinical setting. This is particularly common and difficult for graduate students experiencing anxiety in new clinical experiences.²⁴²⁷Stress management and relaxation techniques can be helpful to manage visible distress.

A simple nonverbal microskills framework, S-O-L-E-R, is often taught in professional counseling graduate programs.²²This framework can serve as a beginning for graduate students learning to master nonverbal communication in a clinical setting.²²Sconstitutes body posture and positioning of the clinician, specifically “facing the client squarely.” This body posture communicates engagement and is best without a table or desk between client and patient.²²O, or “adopt an open posture,” also refers to postural positioning of the clinician. Specifically, a clinician should avoid crossing legs and arms, as this is often viewed as an unwelcoming posture in American culture.²²Leaning toward a client, orL, is another postural behavior that can be beneficial for the therapeutic relationship.²²However, this should be monitored for cultural preferences, because too much engagement can overwhelm some patients. Egan's framework also includesE, or “maintain good eye contact,” as a clinician nonverbal behavior to monitor.²²Direct eye contact is often an indicator of engagement in American culture; however, similar to leaning, this can fluctuate between individuals for cultural and personal reasons. Finally, the S-O-L-E-R framework suggests that clinicians remain “relaxed and natural” in clinical interactions.²²Nervous behaviors such as fidgeting, twirling hair, postural collapse, paralanguage suggesting discomfort, and shaking legs communicates discomfort to patients, which fails to create a safe environment for the patient.²²This framework can serve as a starting point for Au.D. students when learning nonverbal microskills.

Silence

Silence occurs when neither the clinician nor patient are speaking in a clinical encounter.³⁰³¹Silence can be used for different purposes. One purpose of silence is for counselors to organize their thoughts and identify an appropriate response.³⁰³¹This can be a helpful complimentary microskill to active listening. Active listening requires full attention and presence, which can lead to breaks in conversation while a counselor thinks about how to best respond. A second purpose of silence is to deepen therapeutic insight, facilitate the client's internal reflection, and solicit a response from the client.³⁰³¹Although audiologists may not need to use silence to deepen insight, silence is a useful microskill to honor emotional moments in a clinical encounter, not rush the client, and give the patient time to generate responses.³⁰³¹Audiologists will likely use silence for this purpose often when delivering difficult news to a patient. Silence allows a patient to process, react, and understand the difficult news. For instance, many individuals find it jarring and invalidating for a helping professional to move too quickly from difficult news (e.g., learning their child is deaf) to suggestions for treatment. In this scenario, silence is a useful therapeutic microskill to allow patients appropriate time for processing difficult news.

Not only are the purposes or intentions of silence complicated, silence is a difficult microskill to execute properly. Effective use of silence in a therapeutic manner requires that the clinician is comfortable and fully present while using silence.³⁰³¹Silence is uncomfortable or awkward when clinicians are anxious, internally distracted, or uncomfortable.³⁰This is difficult for students, because students often report distress and discomfort during silences. Students tend to be unsure of themselves during a clinical encounter, which causes them to be internally distracted or anxious during lapses in conversation with the patient.

Silence is a controversial microskill due to the variability in patient responses. Silence can convey empathy and facilitate positive change, but can also be detrimental to the therapeutic alliance.³⁰³¹Research has found that some individuals view silence as a display of empathy, respect, active listening, and comfort.³⁰³¹However, research also found that other individuals view silence as anxiety provoking, abandonment, and agitating.³⁰³¹Similar to nonverbal communication, silence is culturally dependent and individualized. This, along with the clinician's comfort and presence, contributes to the variable reactions to silence.³⁰Many experienced counselors report to use silence only once a strong working therapeutic alliance is established and avoid this microskill with extremely agitated clients.³⁰³¹

Silence is not typically covered in basic microskills training resources.¹⁸²²However, we suggest that this microskill is taught in audiology graduate programs precisely due to its controversial nature. It is necessary for beginning clinicians to, at a minimum, understand the varying implications of using silence in a clinical encounter. Graduate students and new clinicians are often uncomfortable with silence in a clinical encounter, causing them to become internally distracted, anxious, and preoccupied with the correct response. Silence is a useful and necessary microskill for delivering difficult news, which is a common scenario in audiology clinical practice. Thus, it is necessary for Au.D. students to understand the varying purposes of silence, controversial responses to silences, and establish comfort with using silence clinically when appropriate for the patient. Comfort with silence often comes with exposure, experience, and confidence. Repetitive practice of using silence in simulated clinical sessions increases exposure and allows students to receive feedback regarding their visible comfort while using silence.

Conveying Empathy

Experiencing and conveying empathy are central to developing a strong therapeutic alliance with patients.³²³³There is little consensus on the definition of empathy; however, it is understood to be a process in which a person understands the experience of another person while still maintaining their own point of view.³³³⁴³⁵Empathy consists of cognitive and affective processes, because an individual conceptually understands another's point of view (cognitive) and has emotional reactions to the other person (affective).³³³⁴³⁵The first step is for therapists to understand their patient's experience, feelings, and cognitive state.³³³⁵³⁶Errors in this step will prevent therapists from conveying empathy and establishing a strong relationship. The second step is for therapists to convey this understanding and empathy to the patient in a genuine way.^33343536This section will discuss the microskill of conveying empathy rather than discussing the cognitive, emotional, and biological processes of accurately understanding another's point of view. Graduate students and new clinicians often have natural abilities for step 1 but have difficulty conveying empathy (step 2).

Conveying empathy refers to a clinician communicating their understanding of the patient's point of view with accuracy and unconditional positive regard.³³³⁵To convey empathy, clinicians use all of the previously covered microskills (i.e., listening, nonverbal communication, silence) in addition to verbal microskills not covered in this article (e.g., paraphrase, emotion reflections, simple reflections, encouragers, questioning, summarizing). Perhaps most important to conveying empathy is the clinician's accuracy.²³³³A clinician must accurately communicate an understanding of the patient's experiences, reported problems, and feelings. To do this, clinicians can start with verbal reflections of the patient reported problems and experiences to express understanding.³⁵It can be helpful for clinicians to use phrases such as “Correct me if I'm wrong . . . ,” “Let me make sure I understand . . . ,” or “Is that right?” so that the patient is given an opportunity to correct the clinician if he or she is off.³⁵

Conveying empathy also requires that clinicians communicate an understanding of the patient's emotional valence and intensity.²³³³Thus, clinicians should utilize accurate verbal reflections (i.e. matching the emotional language of the patient). For instance, a patient explains that they are feeling frustrated and furious about their situation. A clinician wouldnotbe conveying empathy if they later referenced or summarized the patient's feelings of anger and stress, because these are different feelings with less intensity. Using the wrong emotion words with a patient can be invalidating and harmful to the therapeutic relationship, especially if the word used is of lesser intensity, whereas matching emotion language has been shown to predict the feeling of empathy.²³³⁵

Finally, clinicians' expressive nonverbal messages influence conveyed empathy and the therapeutic relationship. Matching nonverbal messages and behaviors of a patient can convey understanding of a patient's emotional state.²³For instance, a clinician matches their patient's quiet, slow-paced paralanguage while discussing the limited treatment options for their child. It would detract from empathy to talk quickly and loud during visible patient distress. A clinician can also display empathy through visible engagement, warmth, and attitudes of acceptance during a clinical encounter. This microskill can be difficult for graduate students and new clinicians, because nerves and lack of confidence can cause students to display incongruent nonverbal behaviors.²³

Conveying empathy becomes more natural and genuine with experience; however, graduate students can benefit from learning appropriate and inappropriate empathetic statements. First, it is important to distinguish empathy from sympathy, because students often confuse the two.³⁷Empathetic statements should serve to convey understanding of the patient's perspective and feelings.³⁷Sympathy refers to “heightened awareness of another's plight as something to be alleviated.”^37(p.314)Though slight, this distinction between understanding and awareness of suffering is crucial for establishing a therapeutic alliance. Particularly in rehabilitation settings and populations, clinicians should attempt to avoid conveying that conditions need to be fixed or alleviated. Statements that reflect understanding are empathetic, such as “I can see that is really difficult for you,” “That sounds very frustrating,” or “How terrible.” Statements that reflect sympathy are slightly different, such as “I'm sorry that happened to you” or “I can't even imagine how difficult that is.” The first set of examples indicates that the clinician is joining with and understanding the patient whereas the second set of examples suggests pity and a lack of understanding. Students can be taught to conceptually understand and use basic empathetic statements and then master genuine delivery of these statements.

Orientation to Teaching Counseling Microskills

Clinical educators are tasked not only with imparting knowledge, but with facilitating and monitoring students' clinical performance as well. It is important to acknowledge the difference between learning information and developing skills. Skills are not learned or mastered through traditional forms of teaching content (i.e., didactic instruction and examinations).³⁸Clinicians develop skills through practice, repetition, feedback, and evaluation. Thus, it is necessary to utilize experiential and performance-based learning in clinical rehabilitation graduate training programs.³⁸

We subscribe to constructivist learning theory and believe in the importance of experiential learning. Research supports the use of constructivist teaching over teacher-centered classrooms in counseling graduate programs.³⁸Constructivist learning theory can be conceptualized through the differentiation between student/learner-centered and teacher-centered classrooms.³⁸³⁹Teacher-centered classrooms tend to utilize didactic- and lecture-based instruction.³⁹Student-centered learning, a form of constructivist learning, consists of collaborative learning between the teacher, student, and peers. Student-centered learning tends to be more individualized, because classroom activities and projects are tailored to each students' needs and require active involvement of the students.³⁹

Constructivist learning also strives to assess student performance in realistic contexts and address relevant problems.²⁸This teaching philosophy is congruent with the task of developing clinical skills with experiential activities. We find that students conceptually understand a skill but falter with the execution. For instance, an entire class will be able to discuss the importance of the microskill, anticipate scenarios to utilize that skill, and discuss hypothetical problems or barriers to utilizing the skill. However, upon engaging the class in a role-play evaluation, less than a third of students are able to effectively demonstrate the skill. Thus, our courses have been modified to have minimal didactic instructionorconceptual discussions (less than 20 minutes per 3-hour course) and instead consist of several hours of structured role-plays and classroom group activities to demonstrate skills. We find that students learn through doing as opposed to though readings, lectures, intellectual discussions, or passive observations. It is often students' insecurities or nerves that prevent them from effectively demonstrating a counseling microskill, which is only remedied through practice and experience. Evidence supports the use of experiential learning activities in the development of basic and advanced counseling skills.⁴⁰Thus, experiential classroom activities are critical to learning counseling microskills.⁴⁰⁴¹⁴²

We use a variety of experiential learning activities, such as role-play activities, simulated patients, video tape recording, and real-life patients, in our clinical courses to both maximize our students' skill development and best evaluate student progress. We recommend that audiology instructors utilize these methods to teach and evaluate counseling microskills. The following section details these methods and provides recommendations for those teaching counseling microskills in audiology graduate programs.

Microskill Sequence

We recommend that audiology instructors teach basic counseling microskills to students early in clinical graduate programs.²⁰These are foundational skills that facilitate the therapeutic alliance between clinician and patient. In our experience, students need to master counseling microskills (e.g., listening) before learning more complex microskills (e.g., reflection). It is important to note that being proficient at basic counseling microskills is not sufficient for meeting standards of clinical excellence.⁹Basic counseling microskills serve as a foundation for learning more complex clinical interventions that are specific to the profession and clinical context.⁸⁹²⁰

Our basic counseling microskills course begins with active listening, the most foundational and difficult microskill. Active listening is the sole focus of the course for 3 to 5 weeks, depending on the students' ability to master the skill. Following demonstration of competence in listening, the course progresses to instruction in nonverbal communication. Students typically require 2 to 3 weeks to learn and demonstrate basic competency in nonverbal communication skills. Up until this point, students are not verbally responding or asking questions during practice activities and recorded evaluations but only focusing on listening and nonverbal accuracy. Following mastery of nonverbal communication, our students are taught silence and verbal responses. Verbal responses include paraphrase, emotion reflections, simple reflections, encouraging, questioning, summarizing, and challenging. However, verbal response curriculum will likely be specific to professional specialty because there are different needs for different professional roles. We teach empathy shortly after introducing verbal responses, because empathy is demonstrated through both nonverbal and verbal communication. Our basic skills course continues on to teach other skills specific to the profession of counseling. This sequence of basic microskills allows students to scaffold their microskills beginning with the most foundational and crucial counseling skill of active listening. It is recommended that the same sequence is utilized in counseling classes for Au.D. students, and microskills necessary for audiology settings are suggested to be taught after empathy (e.g., teaching skills to deliver difficult news or assess risk).

Classroom Role-Play

There are several practical and structural suggestions for instructors teaching counseling microskills through individual or group role-play classroom activities.

1. Students may initially feel more comfortable practicing in dyads or small groups rather than a full classroom role-play. It is difficult for students to evaluate one another when one student is acting as the clinician and the other as the patient. Thus, we recommend small groups of three or four so that there can be student observers evaluating the role-play. It is helpful if instructors assign roles to each student in the group. For instance: student one acts as the clinician demonstrating the new skill; student two acts as the patient; student three observes the scenario for a previously learned skill; student four observes the scenario for the newly learned skill. Observers are able to focus on providing feedback on the role-play scenario, and this ensures that all group members are involved in the learning process.

2. We find it helpful for the instructor to spend equal time (even a minute or less) with each group during role-plays. This allows the instructor to evaluate the class's overall understanding and ability to utilize the new skill. This builds in time for formative assessment and each student receives some feedback, if only brief, from the instructor each week. This can help shape their development rather than waiting for feedback on larger assignments.

3. Timing is critical when managing an experiential classroom. Strict timing structures are necessary to ensure that role-play scenarios are completed and every student is able to practice the skill. We utilize countdown timers to alert the class at the start and end of each role-play. In our experience, microskills are present or absent within the first few minutes of a clinical scenario. Thus, long extended role-plays are not necessary. We typically structure multiple role-plays throughout the class that are only 2 to 10 minutes in length. It is more important for a student to try several times and grow with a skill than have only one extended role-play.

4. Role-play prompts can be challenging to write for classroom activities. We have found it helpful to write very brief prompts (less than a sentence), because students' acting tends to be disingenuous or preoccupied with the script when the prompt is longer. It can be helpful to give students a single emotion word to role-play so that they are able to act out a scenario that is more real to them. It is also critical that instructors balance role-play activities with both positive and negative situations. It might be helpful to remind students that classroom role-plays are simply to practice microskills rather than practice real-life clinical scenarios and decision making.

5. When the entire class is having difficulty demonstrating a new skill, having a pair of students practice in front of the class can be an effective classroom activity. Our clinical instructors randomly select students to be the clinician and the client and we provide a brief prompt. This activity can be helpful if the instructor suspects that the majority of students are incorrectly utilizing a skill, because it allows the instructor to structure all of the feedback. This activity can produce a mild amount of distress for students. Thus, it may be helpful to prep students at the beginning of class and allow them to practice in dyads before the full classroom activity.

6. We recommend that you structure reflection time after each role-play activity. As stated previously, it is helpful to assign roles to students so that they have a specific skill to reflect on following the activity. We find that it can be helpful to structure the self-reflection on performance and internal dialogue rather than skill demonstration, because students tend to give inaccurate or overly positive skill feedback to each other.

Best teaching practices in psychology and counseling support the use of role-plays and experiential learning activities in the classroom.⁴⁰⁴¹⁴²These are effective ways to use classroom time in a productive manner that facilitates skill development and refinement. However, learning and evaluating microskills should not be limited to peer role-plays. Constructivist learning theory highlights the need for relevant and realistic evaluation. Thus, we recommend the use of simulated and real patients for evaluation of microskill demonstration while utilizing peer, group, and classroom role-play for introducing, learning, and practicing new microskills.

Simulated Patients

Utilizing real patients for counseling microskill development has its advantages and disadvantages. Real patients clearly maximize the realistic learning experience. However, it is not expected that students are developmentally ready to work with real patients when learning counseling microskills very early in the graduate training programs. Educators are ethically required to consider the best interest of the patient over students' learning opportunities. If real patients are used this early in students' clinical training, faculty must commit to high levels of supervision and patient outcomes could be negatively impacted.

Simulated patients are an effective alternative to real patients when students are developing basic microskills.⁴³In fact, recent comparative research found no significant difference in learning outcomes between students practicing skills with a real patient or simulated patient.⁴⁴Both utilization of real patients and simulated patients facilitated equal student demonstration of required counseling skills.⁴⁴Simulated patients allow students to demonstrate skills under direct supervision without the risk of harm to the client. Our program utilizes simulated clients for the first two counseling courses before students move to working with real clients in practicum settings and classroom evaluation.

There are a few options to consider for utilizing simulated patients during basic counseling microskills courses. One option for the simulated patient is to hire student actors to role-play a standardized script. Another option is to hire student actors to role-play with varying scripts. Finally, the course instructor can serve as a simulated patient, (we use this option primarily for evaluation; see the following section). We do not generally recommend that students use each other for simulated clinical interactions. In our experience, students preplan the session with each other to help facilitate good grading and performance. Even though it is more convenient to have students schedule with each other, this minimizes the learning potential for the activity.

Hiring student actors for simulated clinical sessions can be time-consuming to organize, but our learning outcomes have been very positive and greatly improved from peer role-play sessions. We typically hire psychology and drama undergraduate students to complete several (three to four) clinical sessions across the course of the semester. We recommend that instructors provide actors with a brief group training prior to beginning the simulated clinical sessions with students (1 to 2 hours). The clinical sessions are video recorded. One advantage to utilizing standardized scripts for actors is that it simplifies fair grading across students. Student actor performances still vary between actors, which allows for the class to see minor human behaviors variations within the same case study. Further, developing scripts and training actors is time intensive for instructors and standard scripts can reduce unnecessary workload.

Simulated clinical sessions with actors also allow the use of watching tapes in class, because it does not violate the Health Insurance Portability and Accountability Act or patient confidentiality. Our clinical courses watch student-simulated sessions a minimum of two classes per term. This classroom activity has several benefits: students are able to see different approaches and techniques, it normalizes students' insecurities and doubts, and it allows the instructor to call attention to specific microskills with all students. One useful learning technique while watching student videos in class is to use signs or paddles that students raise when they recognize a microskill being demonstrated (example: nonverbal warmth or empathy). This ensures that students are able to recognize and identify microskills, which can be helpful for their future demonstration of the skill.

Evaluation

Clinical educators have a gatekeeping responsibility. We do our best to ensure that the students who graduate from our program are fit for professional practice. Au.D. students are evaluated on their ability to provide audiology services, and they should, as health and rehabilitation professionals, also be evaluated on their ability to successfully use basic counseling microskills. In this section, we will provide recommendations for instructors on how to evaluate students' counseling microskills, with the goal of ensuring students demonstrate minimal competency to begin clinical practice. We will also comment briefly on evaluation from the students' perspective.

Students cannot demonstrate counseling microskill proficiency through a test or writing assignment, but through skill demonstration. Evaluating counseling microskills is time-consuming. We have found that for a 50-minute session, it takes about 2 hours to watch the session and provide written feedback, and an additional 30 to 60 minutes to meet with the student to review the video and highlight clips that demonstrate areas of strength and areas for growth. Depending on the counseling course structure and class size, it can be difficult for instructors to watch every video recorded simulated clinical session. Our counseling courses typically require students to complete three or four video recorded simulated sessions and a final with the course instructor. Of the three or four recorded sessions, our instructors watch and grade a minimum of two.

We require students to watch their clinical sessions and provide a reflection on their performance and microskill demonstration. This helps the instructor assess the student's insight and ability to self-evaluate. We utilize a transcription assignment for the simulated session that we do not watch in entirety. In this assignment, students are required to transcribe the entire simulated clinical session. Following transcription, they are required to evaluate their responses (verbal and nonverbal) throughout the entire session. Instructors read the transcription and evaluation submitted by the student. Any areas of concern or interest are then watched by the instructor. This significantly reduces the amount of time watching clinical tapes and students report significant growth during this reflective assignment.

Several of our counseling courses require students to conduct a session with the instructor as client for their final examination. There are several advantages to this version of simulated clinical sessions. First, this allows the instructor to control the clinical scenario ensuring that every student encounters key clinical scenarios, decision points, or challenges that are the targets for evaluation. It also reduces workload for the instructor as the instructor can immediately evaluate student performance. Our clinical instructor simulated sessions are typically only 30 minutes in length, because the instructor can more quickly evaluate microskills when receiving them as the “patient.”

Table 1is a sample counseling microskills evaluation grading rubric similar to those used in our counseling microskills courses. It includes the four microskills highlighted in this article: listening, nonverbal communication, silence, and empathy. A description of each skill is provided. Generally, for each skill, students are considered to exceed expectations if they appropriately demonstrate the skill for at least 90% of the clinical session. This is considered exceptional and means the student is demonstrating skill above and beyond what is expected of a novice clinician. Students meet expectations if they are demonstrating the skill 75 to 90% of the time. For students who demonstrate skills inconsistently, less than 75% of the time, or not at all, they fall into one of the last three columns, and this typically indicates a need for remediation. An advantage to using a rubric like this is that you can see easily where students stand; oftentimes we will see that students generally perform well but need remediation in just one or two specific areas.

Evaluation can be difficult from the students' perspective as well. Anxiety and negative reactions to feedback in counselor training and education is well documented in counseling literature.^23454647Counseling and psychology graduate students demonstrate lowest levels in self-efficacy during the beginning terms of clinical training programs.⁴⁷This is likely due to increased awareness in areas that require growth and exposure to clinical feedback. Students are accustomed to receiving feedback on exams or papers and corrections to these types of work are less likely to be taken personally. When evaluating counseling microskills, the way students communicate, interact, and connect with others is being evaluated. This feels more personal than grades on external work (papers, exams) they have completed. Further, counseling interactions are dynamic so there is no one “right” way to execute counseling skills.⁴⁵⁴⁶This can cause students to become preoccupied with performance and evaluation. Students may also have unrealistically high expectations or perfectionistic tendencies and constructive criticism or developmental feedback can cause considerable distress.⁴⁵⁴⁶We have seen negative students' reactions to evaluation be both external (e.g., anger at faculty, blaming the patient, etc.) and internal (e.g., feelings of guilt, sadness, powerlessness, etc.).

We have found it helpful to prepare students for feedback in our program orientation and the first day of each clinical course. Students also periodically complete self-reflections and self-report assessments on reactions to feedback.⁴⁸Feedback reactions and integration are also topics of discussion with student's academic advisors. Faculty-student discussions on feedback acknowledge that feedback on counseling microskills may feel more personal than feedback on academic work. We continually reinforce to students that counseling microskills are skills that must be learned over time rather than a natural ability. Finally, we strongly recommend that students seek out their own personal counseling if they have negative reactions to evaluation that prevent them from integrating feedback and improving skills. It is essential that clinical educators openly discuss feedback with students in addition to skill evaluation, because student confidence and anxiety directly impact the ability to demonstrate natural and genuine counseling microskills with patients.²³

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