Effective Use of Simulated Clients in Teaching Motivational

Interviewing in Child WelfareChris Wirt, LCSW-C

Debra Linsenmeyer, LCSW-CBarbara Nathanson, LCSW-C

Nancy Budd Culpepper, Clinical Education and Evaluation Laboratory – Interim Director

University of Maryland, Baltimore

June 3, 2016

Incorporating Simulated Clients Into Child Welfare Education

• Context: UMSSW Title IV-E Child Welfare Education Program incudes required child welfare coursework and field placements in public child welfare agencies. (55 MSW & 10 BSW students annually)

• Faculty Field Units and “regular” employee field instructors

• Field placements in full range of public child welfare services from CPS, Family Preservation, Foster Care and Adoption

Incorporating Simulated Clients Into Child Welfare Education

• 2006- Maryland Introduced “Family Centered Practice” mode for public child welfare programs.

• More emphasis on engagement and collaboration skills for workforce

• Feedback from students asking for more “skills development”

• 2008—First Pilot in which students interviewed standardized clients portraying the same child welfare client.

Incorporating Simulated Clients Into Child Welfare Education

• 2011-2014 NCWWI traineeship grant supports the use of standardized child welfare “clients” for skills development; videotapes and live supervision

• Focus on clinical skills vs program specific activities.

• Now: simulated client interview as part of orientation process in the fall (before field begins) & termination process in the spring for 1st year students.

Benefits of Using Simulated Clients in Child Welfare Education

• Measure effectiveness of skills training• Provide opportunities to practice specific skills with

specific child welfare issues• Overcomes some of the potential ethical and logistical

difficulties of evaluating students’ skills with actual CW clients

• Interviews are taped and can be used in field instruction• Opportunity for immediate feedback • Interviews can be “paused” for consultation during

interviews

What is a Simulated Client?

• Also referred to as:– Standardized Patient (SP)– Standardized Client – Standardized Participant (SP)

What is a Simulated Client?• Simulated Client’s are individuals who are trained to

present a patient/client case scenario (i.e., affect, health/social history and PE findings) in the same way in every encounter with students to ensure a standardized assessment.

• In SP cases, everything from patient affect, personal history, and physical findings are provided by the case developers in the case design.

• The trainer of the SP, with feedback from the case developers, ensures that the SP is presenting the patient/client scenario as written.

Why use simulated clients in educational curriculum?

• SP’s provide a pool of ready, willing and able individuals who are carefully training according to the objectives of each project.

• SP encounters are controlled, making them safe for both the student and the trained patient/client.

• SP encounters can be reproduced consistently for ongoing standardized assessment and instruction of students.

Why use simulated clients in educational curriculum? (con’t)

• SP’s can be trained in specific elements of instruction, feedback, and/or assessment of clinical skills.

• A large body of research has been produced over the past 30 years proving the reliability and validity of SP testing.

• At the University of Maryland, SP’s are used in Medicine, Nursing, Pharmacy, Social Work, Genetics Counseling, Physical Therapy and other health and non-health related programs. Course surveys repeatedly report a high student satisfaction level with well-developed standardized participant encounters.

Use of Simulated Clients Teaching Using “Live Supervision”

Title IV-E Students learn using Live Supervision during training prior to the fall semester, with follow-up training in the winter break.

Live Supervision is also used in a semester-long Motivational Interviewing class.

Use of Simulated Clients Teaching Using “Live Supervision”

Small Group of students complete interviews with trained actors while the group and trainer observe from another room.

Trainer communicates to the student through a microphone and earpiece.

Use of Simulated Clients Teaching Using “Live Supervision”

Brief instruction – “Reflect that.”Specific instruction – “Say ‘What are three ways that you want to be a better mom?’”Time-Out – Pause the interview for longer instructionStep-Out – Student leaves the interview room for more detailed discussion then return to the interview.

Various Uses for Simulated Clients in Title IV-E Curriculum

Research –Simulated client interviews were used as a means of testing student’s use of Motivational Interviewing Skills. Interviews were recorded and “coded” using the Motivational Interviewing Treatment Integrity Coding Manual (MITI)

Various Uses for Simulated Clients in Title IV-E Curriculum

Testing –Simulated Client interviews are used for a graded test as a part of a semester-long course.

Interviews are graded based on coding with the MITI and are reviewed individually with each student.

Use of Simulated Clients Simulated Interview

Students complete a 20 minute interview with a standardized client which is recorded and reviewed with their field instructor.

Various Uses for Simulated Clients in Title IV-E Curriculum

• Field Instructors or IV-E faculty review the practice interview individually with each student

• This process is often incorporated into supervision early in the semester

• Review can include the Motivational Interviewing Rating Scale

• Students report that the interview is most helpful when reviewed with faculty

University of Maryland Baltimore (UMB) Clinical Education and Evaluation Lab

• Development and administration of clinical skills assessment, communication skills evaluation, and clinical and non-clinical teaching programs for medicine, nursing, pharmacy, social work and other professional programs on and outside the UMB campus.

• Development and administration of group formative SP activities for students, faculty and staff

• Clinical and non-clinical case writing and development of evaluation strategies.

• Training standardized patients.

Training Actors to Simulate Child Welfare Clients

• SP’s are trained to:– provide a realistic portrayal of an actual

client– provide accurate and consistent portrayal of

the simulated case– document and assess the actions of the

learner

Training Actors to Simulate Child Welfare Clients

• SP training begins with reviewing the elements of the simulated case and understanding the details of the client’s life.

• The client’s affect is carefully examined and discussed.• Learning objectives are reviewed and discussed to

assure SP understanding of direction and outcomes.• Pertinent curricular content is outlined and discussed

to assure that desired learner behaviors are appropriately positively or negatively reinforced during SP encounters.

Training Actors to Simulate Child Welfare Clients

• If available, video of prior case portrayal is reviewed and critiqued.

• Role playing done with faculty in a group setting allows for discussion and portrayal/response standardization.

• Evaluative checklists and cues for checklist items are reviewed and discussed.

• Feedback guidelines are reviewed and discussed.

Training Actors to Simulate Child Welfare Clients

• “The Change Talk Problem”

• Change Talk is unique and very personal to a client and is very difficult to “simulate.”

• We have had to adjust our training in order for our students to effectively practice evoking change talk from our simulated clients.

Surface Level (Open reply if

asked)

Deeper Level (Requires the

student to accurately reflect

or ask for elaboration)

Deepest Level (Requires

demonstration of strong

understanding of the client through

complex reflections)

Desire

Wants control of her life

Want to keep her job

Wants to be able to “drink responsibly”

and fears that if she continues, she’ll

have to quit completely like

those “AA people” say.

She doesn’t want her drinking to effect her son. Is embarrassedthat her son saw her

drunk and doesn’t ever want that to happen

again.

“The Change Talk Problem”

Training Actors to Simulate Child Welfare Clients

• The case for simulation:– Standardized learning and assessment

• what information may be volunteered to the learner• what information must be elicited from the SP• strategies for responding to good open-ended

questioning or poor questioning• strategies for responding to unanticipated questions

(e.g. neutral answers)– Reinforcement, both positive and negative, of learner skills– Creating challenge moments for students to navigate

Questions/Comments

References• Hohman, M. (2012). Motivational Interviewing in social work practice. The

Guildford Press, New York, New York.• Miller, W.R. & Rollnick, S., (2013). Motivational Interviewing: Helping People

Change; 3rd ed., NY: The Guilford Press.• Miller, W.R., Moyers, T.B., Ernst, D., & Amrhein, P. (2003). Manual for

Motivational Interviewing Skill Code (MISC) Version 2.0. Albuquerque, NM: The University of New Mexico.