Simulation in Psychiatry

How are these skills taught?

A variety of techniques have been used as interventions to teach skills in mental health education:

SPs [3, 610, 12, 13, 16, 21]

Mannequins [14, 15, 22, 23]

Virtual patients [24]

Virtual reality [4, 25]

Computers [1, 26, 27] and Internet [28]

Audiotapes/MP3s [5, 17, 18, 20]

In psychiatry, the process of teaching clinical skills is well suited to simulations [4, 13]. The unpredictability of when learning occurs, the constraints on service delivery as determined by reimbursement sources, the complexity of skills required, the nature of the population receiving therapy, and the time lag before trainees receive feedback create serious difficulties in teaching psychiatric skills [13]. This time lag is especially problematic for teaching new skills, as supervision does not always occur during clinical encounters [4]. Within the guild tradition of psychiatry training, trainees often see patients without the direct observation of a supervising clinician as it is felt that the negative comments made by a supervisor during an encounter with a real patient may make the trainee feel chastened. Subsequently, the patient may feel embarrassed, uncomfortable, and potentially uncared for as the focus shifts to the trainee [10]. Even when patients have agreed to participate in treatment with a supervisor in the session, some may cancel abruptly or not appear for a training session, perhaps as a result of their diagnoses [29].

Simulation helps to address these challenges. As Beutler and Harwood point out, “Specifically, contemporary technology offers a means for instituting training procedures that (a) are standardized, (b) maintain a realistic and reliable portrayal of the training stimuli, (c) allow immediate feedback on skill development, (d) can provide corrective feedback for therapist arousal of defense or anxiety, (e) are safe for both patient and therapist, and (f) are cost efficient to deliver” [4]. There are also logistical challenges associated with the evolving field of mental health. While psychiatry has become a mostly ambulatory practice with brief inpatient stays, ­medical student clerkships in psychiatry still occur on the inpatient unit, making simulations vital opportunities for trainees to practice outpatient, emergency room, and consult liaison-based clinical skills [10, 21].

A broad array of clinical skills in psychiatry is conducive to simulation training. As early as 1987, a text-based computer tool was developed for trainees to select different assessments, diagnoses, and treatments for a virtual patient. Afterward, the trainees could compare their selections to the ideal decisions, based on expert opinions, for the patient [26]. The initial interview is a critical skill for mental health clinicians in all professions, providing an opportunity for assessment of symptoms and determination of care.

Simulations have been used extensively to train in interviewing skills. As Gay and colleagues note, “simulated-patient interview provides a unique opportunity to put educational needs before patient care issues” [10]. Simulations target different areas of this process, including interpersonal skills [6, 9, 16, 30] and the establishment of rapport under time constraints [31]. Others aim to train in specific interviewing styles [12], recognition of specific diagnostic categories [11], working with difficult patients [30], and discerning latent verbal and nonverbal cues [32]. For more specific descriptions of interviewing skills targeted in simulation training, please see Table 36.2 [6, 912, 16, 27, 3032].

Table 36.2
Use of simulation to train interviewing skills

Simulation technique

Interviewing skills



Distinguishing between diagnoses in complex mental health presentations



Interpersonal effectiveness for range of psychopathologies



“Exploratory” interviewing, as opposed to a more directive series of history-taking questions



Case-based goals including:


Eliciting a history

Determining concurrent challenges

Demonstrating interviewing strategies to make the patient comfortable

Identifying necessary diagnostic procedures

Obtaining helpful background information


Interpersonal skills


Eliciting complete history

Conducting mental status examination

Making differential diagnosis

Developing comprehensive treatment plan


Therapeutic communication


Working with patients who accuse provider of stealing/lying to them

Diffusing patient’s agitation

Caring for patients who feel sense of entitlement to specific care


Using patient-centered communication techniques


Building rapport during short interview

Detecting mental health issues during Post-Deployment Health Reassessment


Beginning to pick up latent meaning of verbal messages


Beginning to pick up nonverbal messages

Understanding the effect of the patient on the therapist and vice versa

Conducting sensitive initial psychotherapeutic interview

Virtual patient

Interviewing techniques


Knowledge of signs and symptoms of conduct disorder

Computer program

Questioning process


Attitude (convergent, ambiguous, divergent)

Of particular interest in psychiatry is the teaching of the mental status examination (MSE) [79]. Often considered the equivalent of a physical examination for psychiatry, MSE training has incorporated simulation by having a large group of medical students observe a lecturer perform an MSE on a SP [7] and having groups of medical students conduct MSEs on SPs simulating various mental health diagnoses [8]. Overall, students liked both approaches, with 93.9% of the lecture group responding that using an SP was a useful tool to teach the MSE [7] and 98% of the students conducting group interviews reporting that they enjoyed the session and learned from it [8].

On a systems level, simulation using SPs has been used to train mental health teams and improve leadership skills in designing treatment plans. As part of a larger initiative to improve interdisciplinary teamwork and patient care, participants viewed videotapes of an SP being interviewed by a clinician. They also had access to “mock” charts, intake assessment information, admitting notes, and results of laboratory tests. The overall helpfulness of these simulated treatment planning sessions were rated as “good” or “excellent” by almost 75% of participants [33]. In another novel treatment team activity, a virtual online case unfolded in real time over the course of a week, facilitating an electronic-based discussion between students and faculty [34].

Teaching clinicians to be empathic is another unique application for simulation [17, 18, 20, 35, 36]. It is known that stereotyping of and bias against individuals with mental illnesses can hinder a clinician’s ability to respond empathetically [17]. This is especially problematic as mental health clinicians learn to use their empathic response to a patient as part of the diagnostic process [3]. As psychotic symptoms are often stereotyped and stigmatized, several interventions have focused on exposing participants to simulated hallucinations, often based on the hallucinations of real patients. Techniques include using MP3 players to play audio recordings [20], participating in elaborate role-plays where participants have different perceptions of a situation [37], and even the construction of a virtual hospital ward in the commercial virtual world system Second Life [25]. Such interventions have been used with mental health professionals [20], nursing students [17, 18], undergraduates [35], correctional officers [36], and the general public [25].

Simulation also provides the opportunity to foster skills that, while important for mental health education, are not specific to the profession. These include critical thinking, communication [14, 22], decision-making [19], self-efficacy, confidence, cultural competency [19, 28], clinical reasoning [23], and general interviewing skills [21]. Conversely, techniques such as virtual reality (VR) have been used to train professionals in other disciplines who are entering mental health settings [19].


Simulation is particularly suited to assess competencies that necessitate a clinician-patient interaction [38] and are difficult to observe or interpret consistently within a clinical setting. This is often the case in mental health, which features sensitive or private conversations and varied clinical presentations that would be difficult to compare across learners [39]. Simulations can be used for formative (low-stakes) assessments for which trainees receive feedback and remediation, as well as summative (high-stakes) assessments that determine competencies and lead to certification or licensing [21, 39]. As with any testing modality, simulations need to be designed with clear outcomes that distinguish between low, medium, and high performers [39].

For similar ethical reasons to those discussed for interventions in mental health, there are advantages to using simulation rather than real patients for formative assessment to test the effectiveness of an educational intervention. This is particularly important for studies that want to compare competence in a trained group to an untrained control group. While the total number of simulations used in mental health is limited, SPs have been used to assess whether interventions teaching cognitive behavioral therapy improved social worker [40] and general practitioner [41] competence in using these skills. Both studies videotaped the SP encounters and rated them using the Cognitive Therapy Scale, finding in both cases that the intervention group performed significantly better than the control group. SPs have also been used to assess pediatric resident’s use of Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria to diagnose adolescent depression [42]. Outcomes of training in relevant skills, such as assessment of contextual factors [43], have also been ascertained using SPs. Performance with an SP during the Objective Structured Clinical Examination (OSCE) has been used as an outcome measure, examining the effect of communication skills training [44] as well as the completion of a psychiatry clerkship [45]. In both studies, the group that had participated in the intervention performed significantly better with SPs than the group that had not.

There are several challenges inherent in using real patients for assessment of trainees. First, a sample of real patients is not always representative, and presentations cannot be selected systematically. As a result, trainees may not see enough patients during an exam to provide a fair assessment of their skills. Additionally, there are concerns that chronically mentally ill patients may not have the capacity to consent to participation [12, 46]. By providing greater consistency in level of difficulty and type of patient response, simulation can fill the assessment requirements of (1) stability of competence over time for the same trainee and (2) fairness and consistency across different SPs [46, 47]. In general, simulation is superior to “role-­playing” for assessment. Conflicts of interest and breaches of confidentiality can occur when a ­student portrays a patient for another student during a high-stakes examination [21].

Summative performance assessments are required at many levels of mental health training. One performance assessment paradigm that frequently uses simulation is the OSCE, reviewed in depth by McNaughton and colleagues (see also Chap.​ 13) [21]. OSCEs are used at multiple levels of mental health education, most notably as part of the United States Medical Licensing Examination Step 2: Clinical Skills (USMLE Step 2CS) exam which has been designed to assess competence in various clinical encounters [46]. These exams typically contain “stations” in which trainees interact with SPs, some of which focus on mental health condition [21]. Examination benchmarks focus on students’ abilities to detect nuances of communication as well as interpersonal cues [38]. Some focus on a specific competency, such as assessing and managing suicide risk [48].

In some cases, the SPs provide ratings that constitute a component of a trainee’s score on the assessment [39]. Some researchers indicate that SPs have the greatest reliability when rating more than 30 items [39]. One study found SPs’ ratings of trainee performance of a psychiatric interview to correlate with clinical evaluators’ assessments of these videotaped interactions, as well as with trainees’ performance on a written differential diagnosis and mental health treatment plan [49]. Another found only moderate agreement between SPs and physician examiners regarding trainee communication skills [50]. This discrepancy has led some to caution against using SPs to assess complex interpersonal skills, particularly empathy [3].

In addition to OSCEs, SPs have been used to assess other competence in clinical mental health skills. For example, to assess the competence of mental health and addiction workers in the technique of motivational interviewing, one study videotaped interactions with SPs [47]. This technique was shown to have good test-retest reliability, as participants’ performance scores stayed constant when they interacted with SPs weeks apart. In addition, SPs have been trained to simulate depression, enabling them to visit doctors’ offices incognito to provide an assessment of doctors’ diagnosis and management of depression [51, 52].

While SPs are frequently used to perform in or score assessments, virtual techniques have been used as well [5356]. A web-based platform designed for psychiatry, the computer simulation assessment tool (CSAT) (Fig. 36.1), allows trainees to act as clinicians in a clinical encounter with a virtual SP, in a manner similar to that described by Srinivasan and colleagues [39]. After choosing an action, participants are directed to a video clip. The website also features branching capabilities based on the trainee actions. At the end of the simulation, the CSAT tool provides immediate targeted remediation based on the trainee’s performance during the encounter. This tool has been used to assess psychiatry residents’ competency in obtaining informed ­consent to initiate medication treatment for a patient with depression [53]. Virtual patients have also been used to assess competency in determining a differential diagnosis [54]. Another virtual technique, known as the objective structured video exam (OSVE), involves trainees watching a video vignette of an interview and completing an answer sheet detailing their observations, knowledge, and recommendations regarding key communication skills [55, 56]. OSVEs have been used with trainees at varying levels of education, including undergraduates [57], first-year medical students [55], and third-year medical students [56], and for diverse processes, including to gauge the effectiveness of communication skills training [57] or as part of a training curriculum [56]. Unlike the OSCE, the OSVE is designed to elucidate “covert cognitive scripts underlying overt communication behavior” [56]. While several different video vignettes were used, inter-rater reliability was high [5557] and one study found high ­correlation with examiner ratings of trainees’ performance in the OSCE (though not with standardized patient ratings of trainees’ OSCE performance) [55].


Fig. 36.1
Screenshot of computer simulation assessment tool (CSAT)

Other Applications of Simulation in Mental Health

Therapeutic Simulation for Mental Health Patient Care

Unlike other fields of medicine, simulation in mental health has been used extensively with patients, both as a treatment modality and a tool for diagnosis and assessment (see Table 36.3 for summary). Knowledge of these applications is particularly informative for educators who may wish to alter or build upon existing patient care modalities for later use as training tools.

Table 36.3
Uses of virtual reality in mental health patient care

Use in patient care

Clinical area





[59, 60]

[61 b, 62 b, 63]



[64, 65]

Anxiety, PTSD



[67, 68]





Active duty military





Skill training


Social skills


Autism, fetal alcohol syndrome

Safety skills



Job interview



Social skills




Spatial memory



Cognitive performance


Mentally disordered offenders

Risk assessment



Medication management








aThese citations are not meant to be comprehensive

bIndicates meta-analysis

Treatment and Skill Building

VR has been used in mental health treatment since the 1990s, often as a tool for exposure therapy [86]. The use of VR to augment exposure therapy is ideal for disorders that interfere seriously with the normal functioning of a patient’s life (fear of dogs); are more expensive, unsafe, or impossible to use in vivo exposure (fear of flying, heights, or driving) [87, 88]; and are time sensitive [63]. Further, knowing that the simulation can be paused during a session may make the treatment less aversive, increasing the number of patients seeking treatment and decreasing attrition rates [87].

To date, VR has been used as an exposure tool for fears of flying (see Fig. 36.2) [64, 65], driving [67, 68], and spiders, as well as addiction [58], social phobia, posttraumatic stress disorder (PTSD) [66, 6976], and other forms of anxiety [6163]. For example, exposing patients with fear of heights to a series of virtual environments including a virtual glass elevator, an ­outdoor balcony, and a footbridge helped patients decrease their anxiety using exposure-response prevention techniques [63]. VR exposure has been used for PTSD [66] both with civilian [69] and military populations [7076]. With PTSD, in vivo exposure is often impossible, and patients may have difficulty imagining, visualizing, or describing the traumatic experience [63]. Follow-up studies suggest that this type of virtual exposure has sustained long-term positive effects [87].


Fig. 36.2
Virtual environment used in exposure therapy for fear of flying

Simulation has provided the opportunity for mental health patients to practice and learn specific skills. VR has been used to simulate environments such as virtual cafes and virtual supermarkets for patients with autism, enabling them to practice social skills. These patients learn to use the VR equipment quickly and have shown performance improvements both within the VR environment and in real life. Advantages to VR for this training include the removal of confusing or competing stimuli, the ability to manipulate time (the clinician can pause the simulation to discuss important points), and the ability to allow subjects to learn while playing. In some cases, the clinician can also be an avatar in the virtual environment [89]. VR has also been used to facilitate social skills training for patients with schizophrenia [80]. One particular social skill, the job interview, is critical for patients with severe mental illness who wish to return to the workforce. Preliminary data from a job interview simulation study suggest that patients found the tool easy to use, realistic, and helpful [79]. VR has also been used to teach fire and street safety to children with fetal alcohol syndrome and autism spectrum disorder [78]. The program Second Life has been used to provide experiential learning to patients regarding their illness and facilitate group sessions in which patients learn psychology-based skills such as the relaxation response (Fig. 36.3) [90].


Fig. 36.3
Training patients in relaxation techniques using Second Life

While most uses of simulation for treatment and skill building directly involve a clinician, simulation has also been used to form peer-run virtual support groups for patients with mental illnesses [91]. In another example, virtual clinicians (referred to as embodied conversational agents) complete daily check-ins with patients. Data from the check-ins, including the patient’s mood state and patient adherence, are then referred back to the real-world treatment team [91].

Assessment and Diagnosis

In addition to treatment and skill building, simulation has aided in the assessment of patients with mental health disorders. One group developed a 15-min virtual reality cognitive performance assessment test, which demonstrated good convergent and discriminant validity when compared with a traditional (1.5-h) neuropsychological test battery [24]. Using a virtual town (a surrogate for spatial memory), investigators could distinguish between patients with depression and controls, a level of sensitivity not found in a neuropsychological test battery [81]. Based on performance profiles in a virtual maze (a surrogate for working memory), investigators were able to distinguish between patients with schizophrenia and controls [84]. In another study of patients with schizophrenia, adherence to a simulated medication regimen in a virtual apartment had significant agreement with a validated measure of medication management skills [83].

Simulation is also beginning to find use in forensic psychiatry. A computer-based simulation tool has been used with mentally disordered offenders who committed violent crimes, enabling them to choose actions and observe the consequences of those actions (Fig. 36.4). While it is currently in the pilot phase, it holds potential as a risk assessment tool [82].


Fig. 36.4
Screenshot of computer-based simulation used with mentally disordered offenders

Simulation in Mental Health Research

Within the mental health field, simulation has become a powerful research tool. It has provided the opportunity to deepen understanding of mental health disorders as well as the clinicians who treat them.

A great deal of VR research with mental health patients has focused on addiction disorders and the concept of cue reactivity [9299]. Using VR for this type of research allows patients to be exposed to more complex stimuli, creating a more realistic substance use environment and creating opportunities for future use in treatment [92]. VR techniques have also been used in tandem with functional neuroimaging to determine areas of differential activation associated with cue reactivity within these immersive environments [98].

Simulation can provide the opportunity to evaluate adaptive and functional abilities in diagnostic domains beyond addiction. One study assessed the driving ability of patients with schizophrenia prior to discharge from inpatient treatment, finding overall poor performance as well as significant differences based on treatment type [85]. Another study assessed spatial learning performance in patients with schizophrenia using a virtual 8-arm radial maze [100]. Finally, VR has been used as an outcome measure to assess the effectiveness of treatment interventions for patients with social phobia [101].

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May 30, 2017 | Posted by in Uncategorized | Comments Off on Simulation in Psychiatry

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