CONCEPTUAL ANALYSIS

published: 21 May 2021

doi: 10.3389/fpsyt.2021.658967

Simulation Training in Psychiatry for

Medical Education: A Review
Marie-Aude Piot 1,2,3*, Chris Attoe 4 , Gregoire Billon 4 , Sean Cross 4 , Jan-Joost Rethans 5
and Bruno Falissard 3,6
1
School of Medicine, Faculty of Health, University of Paris, Paris, France, 2 Department of Psychiatry, Institute Mutualiste
Montsouris, Paris, France, 3 Epidemiological and Public Health Research Centre, Villejuif, France, 4 Maudsley Simulation,
South London and Maudsley National Health Service (NHS) Foundation Trust, London, United Kingdom, 5 Skillslab, Faculty of
Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands, 6 Department of Public Health, School of
Medicine, University Paris Saclay, Villejuif, France

Despite recognised benefits of Simulation-Based Education (SBE) in healthcare,

specific adaptations required within psychiatry have slowed its adoption. This article
aims to discuss conceptual and practical features of SBE in psychiatry that may
support or limit its development, so as to encourage clinicians and educators to
consider the implementation of SBE in their practice. SBE took off with the aviation
industry and has been steadily adopted in clinical education, alongside role play
and patient educators, across many medical specialities. Concurrently, healthcare has
shifted towards patient-centred approaches and clinical education has recognised
the importance of reflective learning and teaching centred on learners’ experiences.
SBE is particularly well-suited to promoting a holistic approach to care, reflective
Edited by:
Andres Martin, learning, emotional awareness in interactions and learning, cognitive reframing, and
Yale University, United States co-construction of knowledge. These features present an opportunity to enhance
Reviewed by: education throughout the healthcare workforce, and align particularly well to psychiatric
Doron Amsalem,
Columbia University, United States education, where interpersonal and relational dimensions are at the core of clinical
Mark Hanson, skills. Additionally, SBE provides a strategic opportunity for people with lived experience
University of Toronto, Canada
of mental disorders to be directly involved in clinical education. However, tenacious
*Correspondence:
controversies have questioned the adequacy of SBE in the psychiatric field, possibly
Marie-Aude Piot
[email protected] limiting its adoption. The ability of simulated patients (SPs) to portray complex and
contradictory cognitive, psychological and emotional states has been questioned.
Specialty section:
The validity of SBE to develop a genuine empathetic understanding of patients,
This article was submitted to
Social Psychiatry and Psychiatric to facilitate a comprehensive multiaxial diagnostic formulation, or to develop flexible
Rehabilitation, interpersonal skills has been criticised. Finally, SBE’s relevance to developing complex
a section of the journal
Frontiers in Psychiatry
psychotherapeutic skills is much debated, while issues such as symptom induction
Received: 26 January 2021
in SPs or patients involvement raise ethical dilemmas. These controversies can be
Accepted: 20 April 2021 addressed through adequate evidence, robust learning design, and high standards of
Published: 21 May 2021 practice. Well-designed simulated scenarios can promote a positive consideration of
Citation: mental disorders and complex clinical skills. Shared guidelines and scenario libraries
Piot M-A, Attoe C, Billon G, Cross S,
Rethans J-J and Falissard B (2021) for simulation can be developed, with expert psychiatrists, patients and students
Simulation Training in Psychiatry for involvement, to offer SPs and educators a solid foundation to develop training. Beyond
Medical Education: A Review.
Front. Psychiatry 12:658967.
scenario design, the nuances and complexities in mental healthcare are also duly
doi: 10.3389/fpsyt.2021.658967 acknowledged during the debriefing phases, providing a crucial opportunity to reflect on

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Piot et al. Simulation Training in Psychiatry

complex interpersonal skills or the role of emotions in clinicians’ behaviour. Considered

recruitment and support of SPs by clinical educators can help to maintain psychological
safety and manage ethical issues. The holistic and reflexive nature of SBE aligns to the rich
humanistic tradition nurtured within psychiatry and medicine, presenting the opportunity
to expand the use of SBE to support a range of clinical skills and workforce competencies
required in psychiatry.

Keywords: simulation training, mental health, learning, patient simulation, education medical

INTRODUCTION discuss possible strategies and approaches to address these issues

and capitalise upon the opportunities and broad potential offered
Since the first experimentations with simulators in medicine by SBE in psychiatry.
in the sixties, simulation-based education (SBE) has become a
well-established method to bridge the gap between theory and
practice in medical education, moving from “best secret” to “best HISTORICAL CONTEXT
practice” (1). SBE is now recognised as an effective training
tool to enhance medical error management, patient care and Critical developments on SBE first happened in sectors liable
safety, and health professional team training (2). This training is to a high degree of risk, such as aviation, aeronautics and
defined as “a technique that creates a situation or environment to nuclear safety, to reduce human errors in high stake context.
allow persons to experience a representation of a real event for In healthcare, emergency medicine and intensive care were the
the purpose of practice, learning, evaluation, testing, or to gain first to thoroughly adopt this pedagogical tool. These fields
understanding of systems or human actions” (3). are shaped by a culture of risk management, requiring a high
SBE appears to be a valuable and multidimensional method to degree of technical and procedural control based on rigorous
improve healthcare delivery, deserving further development and teamwork. It became apparent that genuine attempts to minimise
adoption. In psychiatry, despite a strong history of utilising role risks would need to tackle the “human factors” (6). What
play in the teaching of psychotherapy and in nursing education required improvement were “non-technical skills,” including
(4), its development has remained limited. This suggests that personal features (stress, tiredness), cognitive skills (situational
specific considerations and adaptations of SBE might be required awareness, decision making and planning) and social abilities
to allow for its integration into routine mental health education. (communication, teamwork and leadership). The field of human
This article aims to discuss conceptual and practical features factors has had a considerable influence in the development of
of SBE in psychiatry that may support or limit its development, SBE, bringing back the ancient proverb “Errare humanum est” to
so as to encourage clinicians and educators to consider the the forefront of medical education and spurring a growing body
implementation of SBE in their practice. of literature on cognitive bias (7).
We based our argument on two main sources. To document While several countries conducted studies to assess the health
SBE principles and the context of its development, we searched and cost impact of medical errors (8), the American psychologist
for the main historical texts which supported SBE development James Reason developed models to retrospectively analyse errors
and the recognised guidelines to implement SBE based on and enhance work practices. Reason offered a broad perspective,
updated evidence. Then, we focussed on the specific literature including both an analysis of the linear causal chain driving
on SBE in psychiatry, building on a wide systematic review medical error, and a systemic analysis of the context in which
previously carried out, the protocol of which has been reported the error happened. In the aviation industry, this led to the
elsewhere (5). Furthermore, the content of this article reflects development of “Crew Resource Management” training, which
the practical experiences of psychiatrists and multi-professional has remained a robust framework for interprofessional training
teams working in clinical education and SBE for a number in healthcare (9), and contributed to the shift in focus from
of years. individual to collective care and learning.
The article structures the argument through five distinct Another strand leading to the development of SBE can
sections. We first provide the historical context which shaped the be traced back to early experiments to emulate pathological
development of SBE in medicine and psychiatry. Subsequently, states. In 1963, the neurologist Howard Barrow in Los
we outline some key theoretical frameworks underpinning SBE Angeles conducted the first systematic experiments to
in mental health, and practical features of its implementation. portray neurological syndromes through acting, initially
Against this background, we discuss the opportunities simulating multiple sclerosis (10). Here was born a new
and suitability of harnessing SBE more routinely within partner in clinical education: the simulated patient (SP).
psychiatry to improve education, professional development, and Despite early controversies about the cost and feasibility of
clinical practice. We then present some of the controversies using actors to play patients, SPs were rapidly adopted in
surrounding simulated practice in psychiatry, which may limit medical education in the USA as powerful allies in training.
its development and require careful consideration. Finally, we They were made to portray an ever-growing range of physical

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Piot et al. Simulation Training in Psychiatry

symptoms and challenges of the doctor-patient relationship, with mental disorders, for example transformative learning
and took part in clinicians’ assessments, with the progressive theory (38).
generalisation of Objective Structured Clinical Examinations Finally, SBE has borrowed beyond the traditional boundaries
(OSCEs; see Table 1). of medical education. Psychodrama exposed mental health
Over the period, SPs were experimentally introduced in workers to the deep transformations instigated by simulations
psychiatric institutions with a more radical aim in mind. In the with the therapist and other patients, beyond one-to-one
famous experiment led by Rosenhan, undercover SPs portraying consultation (39). Significantly, SPs’ performances share
auditory hallucinations provided empirical support to the radical common features with acting and theatre practice. The notion
claims of the anti-psychiatry movement that psychiatric disorders of “state of I am,” as developed by the theatre practitioner
were primarily a social construct perpetuated by its institutions Constantin Stanislavsky, may be relevant for both of these
(26). The undercover SPs remained hospitalised for 7 up to 52 contexts; that is “the point where I begin to feel myself in
days, despite dropping their symptoms following their admission the thick of things, where I begin to coalesce with all the
as in-patients! This experiment highlighted the worryingly circumstances suggested by the playwright” (40). Theatre has
pervasive impact of some diagnostic labels, at times muddling also been brought to medical education to support students’
clinical reasoning in psychiatry, while challenging the relevance empowerment in their learning and professional developments,
of established boundaries between reason and insanity. While as well as a means to question the social transformations of
these challenges might have contributed to the more positivist health systems and the very structure of medical care. It remains
approach to classify mental health disorders in psychiatry, from important for the field of SBE to continue to refine and develop
the third revision of the Diagnostic and Statistical Manual (DSM its pedagogical approach, while making these underpinnings
III, 1980) onwards, Rosenhan’s experiment is a striking example explicit to both educators and learners.
of the power of simulation to trigger deep reflexivity on the
complexity of psychiatric practices.
Several efforts were devoted to improving SP-based pedagogy, Practical Implementation
particularly through the creation of several associations, of which SBE starts with defining the issues to address, the learners’ needs
the Association of Standardized Patient Educators (ASPE) in and specific learning objectives. Scenarios are carefully designed
2001 is the most well-known. ASPE aims to foster advances in to portray either common psychopathological presentations, for
SP-based pedagogy, assessment, research, and scholarship (11). basic training, or increasingly atypical or challenging situations
ASPE became a key player in human simulation, exemplifying for advanced learners (35).
the horizontal and democratic culture of SBE. By gathering both SBE encompasses a diverse array of technologies developed
educators, real patients and SPs to define SP use guidelines, ASPE to recreate clinical situations, from simple role play, to high-
supports patients’ influence in medical education, and ultimately fidelity manikins and human simulated patients, to complex
medical care. virtual reality (VR). Table 1 summarizes SBE techniques,
including a focus on those with a particular relevance
FRAMEWORK to psychiatry.
Single episodes of SBE typically include three practical stages
Theories (Figure 1), with aims and remits varying according to participant
The development of SBE is firmly grounded in several key groups and learning objectives. The first phase is the “pre-
developments of adult learning theories (27). Behaviourism simulation briefing,” or pre-briefing. This is an essential step to
helped to consider how pedagogical conditions support establish the safe learning environment required for SBE and
or limit technical acquisition (28). Cognitivism informed prime learners for the intended learning activities (41). The
instructors on the perception and processing of information, second phase is the simulated scenario itself. It aims to recreate
recognizing further the essential role of emotions, motivation realistic clinical situations to embed participants in with sufficient
and metacognitions in learning (29). The notion of “self- fidelity and alignment to specified learning objectives. The third
efficacy” developed in Bandura’s social cognitive learning stage is the debriefing, where facilitated reflective conversations
theory was especially important for defining the belief aim to convert the simulation experience and reflection into
in one’s capacity to take action as a crucial driver of learning (42). Different debrief models can be used along a
performance (30). The experiential learning theory developed continuum from direct feedback and instructional teaching to
by David Kolb and often summarised in the figure of a more facilitative and reflective approaches (43, 44). There are
learning cycle also deeply influenced SBE (31, 32). Social consensual guidelines on some key features of debriefing in SBE’s
constructionism has strongly influenced SBE, through the instructional design (45): the psychological safety of participants;
notion of subjective and collective construction of meaning, their active involvement; Socratic questioning instead of direct
and the role of community and social context in learning feedback; led by a facilitator with specific training in debriefing;
(33–36). Other approaches, such as Cultural-Historical and who announces and enacts respect for the learners as a
Activity Theory, further emphasised historical and cultural competent human being willing to improve, referred to as the
contexts that shape the group elaboration of meaning (37), basic assumption or principle. Other points remain debated, such
while others still have helped to describe how SBE can as observers’ roles in improving learning (46) or the place of video
challenge participants’ assumptions and beliefs towards patients feedback (44).

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TABLE 1 | Simulation technologies.

Technology Definition Applications, especially in psychiatry

Human simulation: A “methodology that involves human role players interacting with
learners in a wide range of experiential learning and assessment
contexts” (11).
• Role play The patient role-player is “asked to be someone quite different Role-playing are usually reported as appropriate for mental
from themselves and, with little or no preparation, perform in front disorders less difficult to portray by a novice (as typical
of peers and teachers” (12). depression, or some drug abuse disorders) (13).
• Simulated patient “A person who has been carefully coached to simulate an actual Conversely for complex portrayals – such as schizophrenia or
patient so accurately that the simulation cannot be detected by a mania – for novice trainees can create the risk for providing
skilled clinician. In performing the simulation, the SP presents the caricatures or superficial simulations. SPs do enhance the validity
gestalt of the patient being simulated; not just the history, but the of simulations however, including for all other disorders. Digital
body language, the physical findings, and the emotional and libraries of videos for medical education could improve this validity,
personality characteristics as well” (11). as reported in recent articles (14–16).
The most recent and exhaustive guidelines on SP training were
built by the Association of Standardized Patient Educators (ASPE),
upon the principles of safety, quality, professionalism,
accountability and collaboration (11).
• Standardized patients It means highly replicable scenario and SP training-, often used in It is often used in high stakes educational decision – as OSCEs -
high stakes educational decision to improve fidelity, enabling to improve fidelity, enabling equity between the learners (17).
equity between the learners.
Manikin “Full or partial body simulators that can have varying levels of The use of manikins to recreate patients is more devoted to
physiologic function and fidelity” (3). medical specialties where procedural simulation (and its high level
of technic) is the priority, and the reproduction of non-technical
features – as non-verbal signs of emotions- less important.
However in psychiatry, some specific area may benefit from
manikin, such as training discrete procedural skills as
Electroconvulsivo-therapy (18, 19).
Virtual reality: “The use of computer technology to create an interactive Its emerging went with important efforts to make encounters with
three-dimensional world in which the objects have a sense of virtual patients realistic enough to effectively engage learners.
spatial presence” (3) with which an individual can actively interact. Studies suggest that VR have an impact on communication,
teamwork and decision-making (20).
Given the complexity in psychiatry, its use may improve
self-confidence (21), work on assumption and believes toward
patients and focus on clinical reasoning before meeting with a
human SP.
The opportunity to repeat the scenarios as many time as wished
and for some of them, to easily broadcast in personal tables and
smartphone, may recoup the cost of the high initial funding
required to design appropriate VR, while extending infinitely the
dissemination.
• e.g.,: Voice simulation The “use of sounds and voice through an electronic medium to Designed by patients themselves - inside the movement of patient
portray the sounds encountered by a schizophrenic patient” (22). experiential recovery, as Patricia Deegan - this technology enables
the health trainee to experiment in part auditory hallucinations from
a first-person view. Trainees are often missioned to complete
cognitive tasks during the listening, to increase the proximity with
real schizophrenic experiences and their struggles for completing
life challenges. Through improving the identification with patients,
this simulation experience increases the empathy toward people
with schizophrenia (23), while reducing previous assumptions and
believes that often stigmatize person with mental disorders (24).
Objective structured clinical OSCE is composed by series of short stations that the trainee has An exhaustive guide has been developed by the Psychiatric Skills
exams (OSCEs) to complete, each of them focusing on one clinical or other Assessment Project (PSAP) of University of Toronto (17) and
professional task; examination is performed through direct updated since and updated since (25), describing of several steps
observation, checklist, scale, learner presentation or written to implement different psychiatric scenarios in an OSCE.
follow-up exercise (3).

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FIGURE 1 | The basic three stages process of SBE.

OPPORTUNITIES AND SUITABILITY OF by psychiatric phenomenology as a global perception essential to

SBE IN PSYCHIATRY understand the patient through pattern recognition (50, 51). In
addition, several scenarios can be played successively to portray
Person-centred Care the patient journey through clinical pathways over a period of
The “person-centred medicine” (PCM) movement developed time. SBE can support a diachronic understanding of the patient,
the explicit promotion of the subjectivity of the person with which provides a more comprehensive perspective on the patient
an illness and including the sociocultural environment in care than the snapshot view of a diagnosis or a single presentation.
delivery (47). The World Psychiatric Association supported the Psychiatric SBE can be construed as a learner-centred
development of this approach in psychiatry affirming “the whole approach, further promoting a person-centred approach in
person of the patient in context as the centre and goal of clinical clinical care. The flexibility of SP and trainers allow adaptation
care and health promotion,” within a multidimensional approach of the experience, tailored feedback and reflection to the needs
(including the biological, psychological, sociocultural, spiritual, and characteristics of the learners. By including physical, affective
ethical and artistic dimensions, as well as the users’ views) (48). and cognitive features in the learning process, participants are
Calling for skilled practitioners who can integrate an also considered as a “whole person.” This is particularly relevant
interactional and personalised model of care, PCM challenges when training some essential psychiatric skills, for instance the
traditional educational approaches (49). Authoritarian and empathetic skills that learners should demonstrate towards each
directive teaching, overlooking the learner’s experience, matches other and their patients. Indeed, this can even extend to learning
reductionist and paternalistic models of care overlooking experiences that allow clinicians to reflect on their own health or
the patient’s experience (49). Consequently, PCM requires work-related needs.
an educational approach that promotes an interactive and Finally, SBE offers an increasingly recognised role to real and
dialectical learning environment. Such educational environments expert patients with mental disorders to get involved in clinical
encourage participants to include their personal background and education and have a say in the way they want to be cared
motivations in the learning process, and make the development for. Indeed, SBE can include patients at each step of the SBE
of a reflective understanding a cornerstone to becoming developments, including scenario design, SP training, simulated
a competent and self-aware practitioner. SBE offers several scenarios, and feedback in debriefing.
practical features which align with PCM’s agenda, some of which
are particularly relevant to psychiatry where complex subjective The Nature of Psychiatric Care
and interpersonal processes are at the heart of the delivery of care. SBE is particularly suitable to psychiatric care as evidenced by
By the virtue of its experiential nature, SBE involves the its facilitation of a person-centred approach, the acquisition of
“whole person” of both the learner and the patient. Contrary reflective skills, a common focus on attitudinal change and multi-
to traditional teaching, such as large group lectures set up disciplinary work, and cognitive reframing and co-construction
for knowledge acquisition, SBE allows to work at the same of care. Recently, learner-centred approaches have highlighted
time on the physical, affective, and cognitive features involved current issues encountered by clinicians – such as racial tensions
in the simulated scenario. SBE provides a unique opportunity or transphobia – to co-construct simulations in real time together
to rehearse and enact the complex interpersonal processes with clinicians, trained simulated patients and educators (35,
pertaining to psychiatric care. During the simulated encounter, 36). These factors align to the cognitive and interpersonal skills
the person played by the SP presents themselves “as a whole,” required for psychiatric care and allow education to remain up to
instead of being first considered as a collection of symptoms, as a date with clinical practices and issues encountered.
psychiatric handbook may suggest. These initial perceptions, the Prevailing changes within healthcare further highlight the
“first impressions” with the patient, were previously emphasised opportunity afforded by SBE, such as reduced availability of

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patient contact and bedside teaching in clinical placements due this creates opportunities to gain insights into their work as
to evolutions in psychiatric care delivery, for example ward a team in a dedicated educational space free from clinical
closures, community psychiatric service restructure, specialist demands, supporting creativity and translation of learning into
teams, fewer senior clinicians, and more severe and complex practice. When health workers engage in interprofessional SBE
patients (52). It is then surprising that SBE has remained with unfamiliar colleagues, their individual development and
relatively underdeveloped in the psychiatric field compared to learning from others is complementary across the group. Further,
other specialities, and that psychiatry has not led the development SBE can expose health workers to unusual or uncommon
of SBE in areas with such complex learning outcomes to push the scenarios that they may have had limited opportunity to engage
boundaries of simulated patient scenarios (4). with individually or within teams. This is particularly true for
more inexperienced staff, and for emergency or out-of-hours
Reflective Practice and Attitudinal Change situations, such as managing a mental health crisis (60).
The opportunity to acquire or deepen reflexive skills may
be especially relevant in psychiatry, where health workers Emerging Evidence on Psychiatric SBE
typically need these skills to develop a treatment plan, rather Outcomes of RCTs, non-RCTs, and pre/post-test studies provide
than primarily applying structured guidelines. Likewise, the some evidence on the effectiveness of SBE in psychiatry, collated
opportunity to reflect collectively on the diversity of perceptions in a recent systematic review including 163 studies (13). Two
for the same clinical situation mirrors the way that psychiatric third of studies included attitude outcomes, one-third included
teams collectively build these representations of the patients. skills and knowledge, while behaviours and patients’ benefits
The opportunity to challenge assumptions and beliefs of learners were included in 10% of identified studies. In the 27 RCTs
should be welcomed in psychiatry, prioritising self-awareness and included in meta-analysis, significant differences were found
reflection. Assumptions, beliefs, and attitudes require challenging at immediate post-tests for simulation groups compared with
throughout psychiatric practice and consequently throughout both active and inactive control groups on attitudes, skills,
psychiatric education at all levels for all professionals. knowledge and behaviours of medical doctors and participants.
Indeed, when patients’ presenting complaints are “psychiatric Significant differences were also found at 3-month follow-
behaviour disorders,” a label of “manipulative,” or “borderline ups with large effect sizes for behaviour-based outcomes and
personality,” or with a “history of drug abuse,” patients are small effect sizes for skills-based and patient benefits outcomes.
often met with negative assumptions by practitioners (53). Many Moreover, two third of pre/post-test studies found significant
health students have negative attitudes towards this discipline as differences on attitudes, skills, knowledge and behaviours of
individuals with mental disorders are often feared, stigmatised, participants, alongside around half of the controlled studies.
and stereotyped (54–56). They are often seen as difficult to However, the low number of controlled studies undermine
understand, even hermetic, with students reporting they often the strength of the evidence. Similarly, regarding patients’
don’t know what to say or worrying that they might cause harm benefits, the smaller number of studies and the heterogeneity
by acting in the wrong way, due to the complexity of relational amongst the time-points of assessment make interpretation
skills and attitudes required (57). Even newly qualified doctors difficult. The authors concluded that the number of RCTs was
lack confidence in assessing and managing common psychiatric sufficient for pooling meta-analyses, but not enough to provide
problems more than other conditions (52). For adolescent overwhelming evidence, despite some very high quality research
SPs portraying psychiatric conditions, a study found increased (61). They encourage further research including RCTs, focused
anticipated role discomfort because of stigma related with mental on participants’ behaviours and patient outcomes, longitudinal
disorders (58). evaluations, and even long-term assessment of cost-effectiveness.
Considering dual-process theory on clinical reasoning, these The review highlighted high heterogeneity across studies,
negative feelings are bound to influence the intuitive response including pedagogical conditions (e.g., scenarios, debriefing
of health workers and impact on the reliability of their clinical modalities, length, educational aims, adjuvant pedagogies in
reasoning (53). Conversely, attitudes relating to self-confidence, more than three questers of studies), participant levels (mixing
anxiety, assumptions and beliefs are common outcomes reported medical levels and/or health professions), and the outcomes and
in psychiatric SBE research (13), emphasising the great effort instruments to measure them. While this heterogeneity may limit
ensured by SBE to make psychiatry more accessible to medical the quality of the evidence, it is consistent with the diverse and
students and health workers more globally. This may support complex nature of psychiatry and the multifaceted nature of SBE,
fighting against stigmatisation described more than 40 years ago increasing the external validity of these results.
(59) and still present even among health care workers.
CONTROVERSIES IN PSYCHIATRIC SBE
Multi-disciplinary Team Working
SBE supports the long tradition of multidisciplinary teams Intensity and Requirements of SBE
working in psychiatry required to provide high quality care SBE requires deep, intense involvement and engagement for both
for mental disorders. The ability of SBE to bring together participants and trainers. For participants, performing in front
different professions and specialties to learn together and in of peers can be demanding. Unpredictable simulated scenarios
multi-disciplinary teams reflects how care is and should be can reveal intimate parts of oneself and one’s behaviour, such
delivered (4). When clinical teams engage in SBE together, as spontaneous emotions or reactions that are usually privately

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shared with the patient or with familiar colleagues. Thus, the students. Thus, a slightly too caricatured portrayal missing some
high cognitive, emotional, and physical load for participants ambivalent and conflicting features may appear authentic to a
while peers and trainers are observing, can generate stress, student, but not to an experienced psychiatrist.
performance anxiety, or fears of being judged. This stress Another risk, if SPs were unable to elicit a learner’s empathy,
could inhibit participants’ interest in SBE and their ability to would be to paradoxically lead to a shallow interaction that
derive learning from all aspects of the training experience. prevents participants from detecting nuances and subtlety in the
Additionally, feedback or collective discussion on features with diagnosis. This may affect the validity of training, while inducing
which the participant is not familiar may be perceived as superficial or even inadequate representations. As a result, there
intrusive or uncomfortable without an appropriately safe and is a specific need for realism and an emotionally engaging
collaborative learning environment. Further, debriefing that aims depiction of patients with mental disorders in psychiatric
to uncover and maybe reframe emotions and cognitions can SBE, to enable learners to develop a real understanding of
cause discomfort due to exposure within the group. However, the patient experience, a comprehensive multiaxial differential
it must be noted that the power and potential of SBE connects diagnosis, and a flexible relationship. However, conversely,
closely with the opportunity to create a learning environment teaching psychotherapeutic and complex interpersonal skills
that facilitates the friendly challenge and constructive discomfort raises other issues regarding emotions. Indeed, there may be a
that allows the generation of deep and complex learning. The difference between an empathic response (of the learner) to an
key to ensuring this opportunity lies with facilitators to prepare actual dramatic character (the SP) compared with the response
and manage interactions with and within the group accordingly, they would have to a future real patient whom the learner will
although SBE literature has struggled to provide clear and support (63). While SPs are trained to arouse emotion, patients
thorough guidance (42, 45). with mental disorders do not plan how they will present to
For trainers too the implementation of SBE may be very the physician. The part of themselves to be uncovered may be
challenging, requiring time and effort to achieve high quality. uncertain, even resistant, as much for themselves as for the
The design of well-suited scenarios and guidance for simulated clinician. The role of the physician is precisely to establish
patients require careful consideration, piloting, and continual an authentic empathic rapport to help the patient to soften
adjustments to tailor to the learners’ needs. The recruitment, conflicted feelings, by “feeling ahead” of the patient and intuiting
training, support, and monitoring of SPs are time-consuming what can’t be linked (63). These essential psychotherapeutic skills
and require continuous work and consideration of the SP as may remain elusive to the SBE set up.
an important member of the training team. Trainers themselves Concurrently, the notion of prototypes of clinical portrays,
must be trained and supported both formally and informally, often used to offer appropriate training to novices, may be
reviewing and encouraging their development and reflection. invalid in psychiatry due to the singular experience of each
Further, the efforts for trainers on the day begin and end well patient with a mental disorder. This issue is also raised by
before and after the training has been completed. Indeed, the recent developments in virtual reality (64, 65), interviewing
time requirements can often lead trainers to opt for shorter a patient with mental disorders in Second Life (66), or an
SBE formats using directive feedback and simpler scenarios. adolescent with PTSD (67), which question even more the
The intensive small group format may also be prohibitive for believability of virtual characters, and their ability to elicit a
systems, settings, and countries where the ratio of trainers to realistic experiences for novice clinicians. Here there is a risk that
participants is low or other resources are lacking beyond time participants learn a reality about patient with mental disorders
and human capacity. Even technologically advanced SBE, such as that is inaccurate, based on portrayals of these experiences
virtual reality, requires considerable time and resource demands rather than real experiences themselves, such as interacting
in creating and testing realistic virtual scenarios. with real patients. This has been described as “hyper-reality”
Consequently, the requirements of SBE for participants, (68), where an excessive use of symbols substitutes the real
trainers, and systems are considerable. This may explain why experience, first highlighted by mass media in the seventies.
role play has been used for a long time in psychiatry. However, Yet, beyond false psychopathological features, the difference
beyond time and cost often mentioned as a barrier to SBE, its between learner/fictional character relationship and the real
implementation in psychiatry has further specific challenges. doctor-patient relationship would enable students to act out good
relationships without being authentically involved (12).
Specific Challenges of SBE in Psychiatry In addition, the choice of mental disorders pictured is often
Some authors still question the ability of SPs to embody a driven by epidemiological considerations, especially for early
complex set of often contradictory cognitive, psychological and career training. This creates the risk of reinforcing stigmatisation
emotional features to support valid learning (12). This raises and stereotypes towards patients. For example, characterizing an
necessary distinction between an authentic – the “impossibility eating disorders patient as a white middle class female. There
to distinguish SPs from patients” (62)– and a valid portrayal. is a constant balance between a realistic portrayal of individual,
Authenticity supports the learner involvement in the learning, social, and epidemiological experience of mental disorder and
since students can report difficulties engaging with the scenario unhelpful stereotyping. This requires the involvement of real
when they perceive the simulation as unrealistic (62). However, patients in education and reflexivity from the trainers and SPs.
the “impossibility to distinguish” refers to the rater’s subjective Moreover, while promising results are reported for SPs
perception, possibly restrained by a limited experience for most in psychiatric OSCE assessment, there is a trade-off between

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the standardisation process required and the validity of the to prevent long-term psychological effects), which may need
psychiatric portrayal (69). Indeed, exams require a strong consideration when allocating resources to SBE.
reliability, both test-retest and inter-rater reliability, in scenarios To address the difficulties of working with trained SPs in
in order to offer equal opportunities in assessment for learners. psychiatry, the opportunity to recruit real patients appears
At the same time, the complexity of psychiatric care sometimes complex too (75): for example, development of a detached
needs a lot of flexibility to be valid in simulated scenarios, style resistant to any acting and rehearsal training; choice to
according a learner’s reaction. It may mean that SPs should describe opinions about treatments instead of depicting pre-
often both reflect the patient they are portraying, and their own treatment symptoms. Most of all, playing personal stories for
personal response to the psychopathology being presented, to a patient with mental disorders (or a story of their own
remain plausible (12). More globally, this raises the underlying mental illness) to improve realism creates a risk of potential
paradox inherent to psychiatric presentations: there is a direct psychological consequences through to mental health crisis,
conflict between a rigidly scripted portrayal and a valid and while for some diseases (such as psychosis), boundaries between
realistic portrayal, which requires flexible adaptation to an thoughts (including delusion) and reality remain blurred.
unfolding interaction. Moreover, possible painful questions raised carelessly during
Furthermore, there are areas of psychopathology where the the debriefing may hurt the real patient, even with training.
fictional nature of the simulation set up might create some Similarly, the opportunity for a real patient to give appropriate
confusion and somehow limit simulation’s educational benefits. feedback may be further debated given individuals’ experience
Pretend mode, false beliefs and the blurring of boundaries of mental disorders, and the difficulties for patients with
between fiction and reality are all common features of simulation mental disorders to adopt enough distance or a metacognitive
practice as well as a number of psychiatric disorders, e.g., position to report a more general experience on their pathology.
“as-if personalities,” malingering, narcissistic disorders. The However, if ethical dilemmas and practical issues are given
practitioner has to uncover the part of the person, which may be due consideration, involving patients with lived experience in
either simulated (consciously or not), factitious, mythomaniac, the design and delivery of simulation training can be a very
delusional, etc. In these cases, with the fictional nature of the rewarding experience for all involved (76).
simulation set-up may confuse the matter further and limits
effective training (63), while learners need a secure well-defined
frame to develop reflective practice. DISCUSSION
Finally, because of the complexity of mental disorder
experience, the ability of SPs to provide feedback on the SBE appears to be particularly well-suited to psychiatry,
phenomenological experience of psychosis, for example, may supporting a holistic person-centred approach, reflective skills
be more complex and unfamiliar than for a SP who portrays acquisition, emotional elaborations, cognitive reframing and
diabetes. A lack of nuance creates the risk to perpetuate stigma, co-construction of care. It also provides an opportunity to
albeit unwillingly, through inappropriate feedback and portrayal involve people with a personal experience of mental disorders in
of illness. clinical education. However, the validity of the SP portrayal, the
Given the above issues of validity and complexity, SP training complexity of psychotherapeutic skills and the specificities of SPs
in psychiatry requires careful consideration, from rigorous require due consideration to be effectively implemented.
recruitment criteria, to comprehensive and diversified training First, considering the issue of realism of psychiatric portrayal,
on the mental health issues at stake, followed by quality assurance we should endorse a heuristic notion of “good enough”
of their performance. Some articles report demanding ways portrayal rather than “perfect depiction.” Indeed, given the wide
to reach appropriate training: combining video of patients variety of singular mental disorders experiences, an excessive
testimonies or doctor-patient interviews, with some immersions essentialisation of symptoms in a unique prototype bares the
into in-patient and ambulatory services, and meeting real risk of a robotic portrayal. However, some adjustments may
patients, in addition to basic SBE training (including learning be necessary to reach appropriate learning. Indeed, this notion
scenario, readings, in-depth explanations with the trainer, and of “prototype” of psychiatric portrayal may be assumed as
several behavioural rehearsals (17, 69). a step to make this specialty more accessible to medical
Moreover, ethical issues are raised by the nature of the students. Moreover, the SP portrayal can be explored during the
roles SPs are required to enact. Phenomena such as role debriefing with facilitators and observers sharing perspectives
adherence, blurring between the role and the person’s real life and from their clinical experience, and by complementary learning
physical exhaustion are reported (70). The results vary according activities after SBE (such as real patients video testimonies,
to different features of the person who depicts the patient: workplace supervision of clinical clerkships, among others).
temperament, gender, age, own history and background (and For example, even a very short social contact-based video
especially psychiatric history, as discussed above). For example, of no more than 90 s can reduce efficiently stigmatisation
stronger identification effects were reported for adolescents who toward patients with a schizophrenia (77). Furthermore, realism
depicted a psychiatric case, because of contagion effects (71, may be fostered by ad hoc resources to train SPs. Videos
72), such as when depicting depression symptoms or suicidal demonstrating good quality portrayals and simulations of people
ideations (73, 74). This warrants a careful monitoring of SPs with mental disorders by SPs, based on expert consensus, could
(careful recruitment; proper de-rolling; and close SP monitoring provide a digital library to support SP training. This should

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Piot et al. Simulation Training in Psychiatry

take into account culturally appropriate portrayals of mental turn contribute to all SBE that deals with complex human
disorder. To reach this consensus and improve the quality interactions in medical education.
and inclusiveness of this library, the group of experts should Similarly, the management of emotions requires dedicated
be multidisciplinary, composed by recognised researchers and consideration in psychiatry, beyond the attention usually given
experienced practitioners, as well as expert real patients, and to emotional responses as part of human factors. Following
medical students. Recent work supports the relevance of skilled simulated scenarios, participants are often encouraged to
video clips of psychiatric SPs depicting psychopathology to teach verbalise the elicited emotions. However, this verbalisation often
mental status exam (14), sex education in child and adolescent aims to defuse the emotions or recognise its negative impact on
psychiatry (15), electroconvulsive therapy (16). Furthermore, to performance, to enable the participants to master technical skills.
prevent a rigid and limited portrayal for each mental disorder, In psychiatric SBE, the identification and elaboration of emotions
this library may include several variations of a given disorder to also aims to regulate emotion so as to improve the participant’s
cover different clinical presentations. Ultimately, the best way for self-confidence in care management. However, emotions are also
educators to promote the pedagogy of SBE as a powerful tool considered as vehicles for meaning and integral to relational
against stigmatisation is to be aware, reflexive and constantly experiences that should be entirely integrated in diagnosis and
collaborating with patients. therapeutic practices. As such they remain an important focus
Secondly, it appears necessary to acknowledge SBE of debriefing conversations beyond the initial reaction phase,
limitations to train in certain interpersonal skills. For supporting the deepening of reflection and self-awareness.
example, the subtle phenomena emerging inside a long- Finally, psychiatric SBE remains an essential opportunity
term and familiar psychotherapeutic relationship might not to put patients at the centre of medical education. This
be adequately grasped by SBE training. However, SBE may embodies the health democracy developments of the past
enable specific training on some specific components of decades while supporting a central credo of the Recovery
psychotherapeutic skills, counselling skills (78) including movement: “nothing about us without us” (80). Patients
some more complex processes such as therapeutic can advise on the co-constructions of appropriate scenarios,
alliance ruptures. using their subjective to supplement professional views, while
Working on complex interpersonal skills requires deliberate guiding the acting of SPs through their holistic experiential
adjustments in the training structure. Indeed, most SBE training lens. Their first-person experience can also broaden the
assumes that simulated scenarios help to identify participants’ reflexivity during debriefing while providing real-life anecdotes
performance gap and explore them through facilitated debriefing which exemplify the importance of words, attention and
to close these gaps by highlighting some of the erroneous authenticity of relationships. Their testimony in addition to the
cognitions leading to these errors. The underlying model of affective load mobilised by simulation can support efficiently
debriefing can be roughly summarised as aiming to enhance students’ empathy developments accordingly. However, patient
clinical performance; in other words a “plus/delta” model of involvement must be arranged, structured, and managed
learning. This remains close to the “metaphor of acquisition,” carefully and supportively. The fear of retraumatising, symptoms
or “the act of gaining knowledge,” which leads most of the induction, or even inability to fully consent (as in an active
literature on learning until the middle of the twentieth century psychotic episode) limit the opportunities for them to be SPs and
(79). This approach was subsumed over the past decades by the for SBE participation more globally. However, there is limited
“metaphor of participation,” suggesting that knowledge building evidence and guidance on this practice in the literature, meriting
is more a result of participation within a group, including further exploration for an area that can have significant benefits.
being inducted to its language and social rules, through a Recent developments within virtual reality or particular uses
continuous and collaborative experience rather than transfer or of manikins and voice simulations might be a way to circumvent
possession of knowledge (79). Yet, in complex interpersonal risks of symptoms induction and re-traumatisation. However,
relationship, such as those within psychiatric care, or also for human simulation, clinical educators must be involved in SP
child abuse, end-of-life, there is rarely a single suitable way recruitment and monitoring to mitigate risks, from the beginning
to behave, in contrast to situations where strong evidence- to the end of the training and beyond. This might require
based guidelines are the rules. Thus, in such complex situations, clinicians to have a dual role as an educator and manager of the
workers often perceive the same clinical situation differently SP pool (including de-rolling after simulations) to retain some
and agree on a “sensible margin” within which the care must clinical insight to assess SPs suitability to remain involved, to
be delivered. Thereby within a constructivist approach, SBE contain symptoms emergence, and to ensure adequate follow-up.
enables for all the participants to observe the same situation, The involvement of real patients in SBE presents a wonderful
and to share their different perspectives on this same situation opportunity to hear real patients’ voice, and should not be
during the debriefing, which enables them to learn from each pre-empted by a paternalistic approach that would like to
other. The structure of debriefing should thus include the protect patients at their own expense. However, each opportunity
principles of both participation and acquisition, supporting to involve patients should not be taken for granted. Any
verbalisation of each participant’s view, then fostering reflexivity patient involvement needs to be managed with due diligence
as a group to collaboratively define appropriate behaviours to individuals’ needs, considering both the patient’s willingness
within appropriate care. Due to its familiarity with such and the clinician’s assessment. Simulated patients are required to
complex interpersonal relationships, psychiatric SBE could in enact a complex performance, balancing fidelity with individual

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Piot et al. Simulation Training in Psychiatry

learner’s reactions and keeping in mind the session learning Greek philosophers, such as Socrates, and doctors, such as
objectives. These tasks are demanding even for professional Hippocrates, both emphasising the patient as a whole person and
actors, and even more so for patients who may not benefit from the relationship as an essential conduit of care.
the professional distance with their own emotional reactions SBE elicits an intense and personal engagement of the
to the subject matter. Patients should retain some freedom to learners in a setup borrowing from the performing arts. It
withdraw their involvement every time they can have a role in offers opportunities for collective reflexivity and co-construction
SBE. The opportunity to engage patients in clinical education of knowledge that can be compared with community and
should be considered in many creative ways, to contribute to groups processes as described by anthropologists, systemic
diverse learning experiences, but their utilisation in simulated approaches, or in mental health institutions. SBE constitutes a
scenarios requires a very cautious an tentative approach. rich and flexible cultural artefact lending itself to further creative
appropriation, following a diversity of learning needs through
CONCLUSION many contexts and cultures, present and future.
Finally, clinical educators within psychiatry can greatly
SBE is often seen as a high-tech device, through its heritage benefit from and contribute to the field of SBE, with their
rooted in aeronautic or aviation, reflected in its development in clinical experience focusing on intrapersonal, interpersonal, and
technical fields of health care such as anaesthesiology, obstetrics, relational dimensions of care, alongside expert communication
or surgical specialties. This may scare psychiatric educators skills, that can be transferred from clinical work to the
away from this training method. However, SBE relates to core educational setting. We posit that the field of SBE as a whole can
dimensions of clinical interactions as multifaceted experiences benefit from its further implementation and development within
where communication processes have critical effects, which is mental health education, arguing for clinicians and patients to
particularly true in psychiatry. This can support participants engage with this powerful pedagogical tool.
to explore how relationships and communication can have
serious consequences for people’s health and experience of AUTHOR CONTRIBUTIONS
care. Consequently, SBE is not a mere innovation or by-
product of the technological age, but a refined pedagogical All authors contributed to the conceptual analysis. M-AP
approach deeply rooted in a holistic approach as promoted wrote the first draft of the manuscript. The remaining
by the World Psychiatric Association (47) in continuity with authors commented and modified successive drafts. All authors
the medical tradition of a therapeutic praxis, as described by contributed and have approved the final manuscript.

REFERENCES 10. Barrows HS, Abrahamson S. The programmed patient: a technique

for appraising student performance in clinical neurology. Acad Med.
1. Levine AI, DeMaria Jr S, Schwartz AD, Sim AJ. The Comprehensive Textbook (1964) 39:802–5.
of Healthcare Simulation. New York, NY: Springer Science & Business Media 11. Lewis KL, Bohnert CA, Gammon WL, Holzer H, Lyman L, Smith C, et al.
(2013). p. 721. doi: 10.1007/978-1-4614-5993-4 The association of standardized patient educators (ASPE) standards of best
2. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, et practice (SOBP). Adv Sim. (2017) 2:10. doi: 10.1186/s41077-017-0043-4
al. Technology-enhanced simulation for health professions education: 12. McNaughton N, Ravitz P, Wadell A, Hodges B. Psychiatric education and
a systematic review and meta-analysis. JAMA. (2011) 306:978–88. simulation: a review of the literature. Can J Psychiatry. (2008) 53:85–93.
doi: 10.1001/jama.2011.1234 doi: 10.1177/070674370805300203
3. Lopreiato JO, Downing D, Gammon W, Lioce L, Sittner B, Slot V, et al. 13. Piot MA, Dechartres A, Attoe C, Jollant F, Lemogne C, Layat Burn C, et
Healthcare Simulation Dictionary. (2016). Available online at: http://www.ssih. al. Simulation in psychiatry for medical doctors: a systematic review and
org/dictionary (accessed January 25, 2021). meta-analysis. Med Educ. (2020) 54:696–704. doi: 10.1111/medu.14166
4. Attoe C, Kowalski C, Fernando A, Cross S. Integrating mental health 14. Martin A, Jacobs A, Krause R, Amsalem D. The mental status exam:
simulation into routine health-care education. Lancet Psychiatry. (2016) 3:702. an online teaching exercise using video-Based depictions by simulated
doi: 10.1016/S2215-0366(16)30100-6 patients. MedEdPORTAL J Teach Learn Resour. (2020) 16:10947.
5. Piot MA, Dechartres A, Guerrier G, Lemogne C, Layat-Burn C, Falissard doi: 10.15766/mep_2374-8265.10947
B, et al. Effectiveness of simulation in psychiatry for initial and continuing 15. Drozdowicz L, Gordon E, Shapiro D, Jacobson S, Zalpuri I, Stewart
training of healthcare professionals: protocol for a systematic review. BMJ C, et al. Sexual health in child and adolescent psychiatry: multi-site
Open. (2018) 8:e021012. doi: 10.1136/bmjopen-2017-021012 implementation through synchronized videoconferencing of an educational
6. Renouard F, Charrier J-G. Looking for the Weak Link: Initiation to the Human resource using standardized patients. Front Psychiatry. (2020) 11:593101.
Factor. Chatillon: Ewenn (2011). p. 221. doi: 10.3389/fpsyt.2020.593101
7. Reason J. Human Error. New York, NY: Cambridge university press (1990). p. 16. Kitay B, Martin A, Chilton J, Amsalem D, Duvivier R, Goldenberg
320. doi: 10.1017/CBO9781139062367 M. Electroconvulsive therapy: a video-Based educational resource using
8. Donaldson MS, Corrigan JM, Kohn LT. To Err Is Human: Building a Safer standardized patients. Acad Psychiatry J Am Assoc Dir Psychiatr Resid
Health System. Washington DC: National Academies Press (2000). Train Assoc Acad Psychiatry. (2020) 44:531–7. doi: 10.1007/s40596-020-
9. Kowalski C, Attoe C, Ekdawi I, Parry C, Phillips S, Cross S. 01292-z
Interprofessional simulation training to promote working with families 17. Hodges B, Hanson M, McNaughton N, Regehr G. Creating, monitoring,
and networks in mental health services. Acad Psychiatry. (2018) 42:605–12. and improving a psychiatry oSCE. Acad Psychiatry. (2002) 26:134–61.
doi: 10.1007/s40596-017-0840-z doi: 10.1176/appi.ap.26.3.134

Frontiers in Psychiatry | www.frontiersin.org 10 May 2021 | Volume 12 | Article 658967

Piot et al. Simulation Training in Psychiatry

18. Raysin A, Gillett B, Carmody J, Goel N, McAfee S, Jacob T. From 41. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning
information to simulation: improving competency in eCT training in simulation: the role of the presimulation briefing. Sim Health. (2014)
using high-Fidelity simulation. Acad Psychiatry. (2018) 42:653–8. 9:339–49. doi: 10.1097/SIH.0000000000000047
doi: 10.1007/s40596-017-0859-1 42. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning.
19. Rabheru K, Wiens A, Ramprasad B, Bourgon L, Antochi R, Hamstra SJ. Sim Health. (2007) 2:115–25. doi: 10.1097/SIH.0b013e3180315539
Comparison of traditional didactic seminar to high-fidelity simulation for 43. Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng A. More than one way
teaching electroconvulsive therapy technique to psychiatry trainees. J ECT. to debrief: a critical review of healthcare simulation debriefing methods. Sim
(2013) 29:291–6. doi: 10.1097/YCT.0b013e318290f9fb Health. (2016) 11:209–17. doi: 10.1097/SIH.0000000000000148
20. Peddle M, Bearman M, Nestel D. Virtual patients and nontechnical skills in 44. Cheng A, Eppich W, Grant V, Sherbino J, Zendejas B, Cook DA. Debriefing
undergraduate health professional education: an integrative review. Clin Sim for technology-enhanced simulation: a systematic review and meta-analysis.
Nurs. (2016) 12:400–10. doi: 10.1016/j.ecns.2016.04.004 Med Educ. (2014) 48:657–66. doi: 10.1111/medu.12432
21. Pantziaras I, Fors U, Ekblad S. Innovative training with virtual patients 45. Kolbe M, Grande B, Spahn DR. Briefing and debriefing during simulation-
in transcultural psychiatry: the impact on resident psychiatrists’ based training and beyond: content, structure, attitude and setting. Best Pract
confidence. PLoS ONE. (2015) 10:e0119754. doi: 10.1371/journal.pone. Res Clin Anaest. (2015) 29:87–96. doi: 10.1016/j.bpa.2015.01.002
0119754 46. O’Regan S, Molloy E, Watterson L, Nestel D. Observer roles that optimise
22. Williams B, Reddy P, Marshall S, Beovich B, McKarney L. Simulation learning in healthcare simulation education: a systematic review. Adv Sim.
and mental health outcomes: a scoping review. Adv Simul. (2017) 2:2. (2016) 1:4. doi: 10.1186/s41077-015-0004-8
doi: 10.1186/s41077-016-0035-9 47. Mezzich JE, Botbol M, Christodoulou GN, Cloninger CR, Salloum
23. Bunn W, Terpstra J. Cultivating empathy for the mentally ill using IM. Introduction to person-centered psychiatry. In: Mezzich JE.
simulated auditory hallucinations. Acad Psychiatry. (2009) 33:457–60. Person Centered Psychiatry. Swizerland: Soringer (2016). p. 1–15.
doi: 10.1176/appi.ap.33.6.457 doi: 10.1007/978-3-319-39724-5_1
24. Galletly C, Burton C. Improving medical student attitudes towards 48. Mezzich JE. Psychiatry for the person: articulating medicine’s science and
people with schizophrenia. Aust N Z J Psychiatry. (2011) 45:473–6. humanism. World Psychiatry. (2007) 6:65.
doi: 10.3109/00048674.2011.541419 49. Ramalho R, Montenegro R, Djordjevic V, Bras M, Christodoulou N. Person-
25. Hodges BD, Hollenberg E, McNaughton N, Hanson MD, Regehr G. The centered psychiatric education. In: Mezzich JE. Person Centered Psychiatry.
psychiatry OSCE: a 20-year retrospective. Acad Psychiatry. (2014) 38:26–34. Swizerland: Soringer. (2016). P. 539–549. doi: 10.1007/978-3-319-39724-5_39
doi: 10.1007/s40596-013-0012-8 50. Quintin J, Thiboutot C. Great Figures of Existential Psychopathology. Montreal:
26. Rosenhan DL. On being sane in insane places. Science. (1973) 179:250–8. Liber (2020).
doi: 10.1126/science.179.4070.250 51. Martin B, Piot M-A. Phenomenological approah of schizophrenia.
27. Taylor DC, Hamdy H. Adult learning theories: implications for learning L’Information Psychiatr. (2011) 87:781–90. doi: 10.3917/inpsy.8710.0781
and teaching in medical education: aMEE guide no. 83. Med Teach. (2013) 52. Abed R, Teodorczuk A. Danger ahead: challenges in undergraduate psychiatry
35:e1561–72. doi: 10.3109/0142159X.2013.828153 teaching and implications for community psychiatry. Br J Psychiatry. (2015)
28. Bernard J-L, Reyes P. Learning in medicine (first part). Pedag Med. (2001) 206:89–90. doi: 10.1192/bjp.bp.114.146852
2:163–9. doi: 10.1051/pmed:2001031 53. Pelaccia T, Tardif J, Triby E, Charlin B. An analysis of clinical reasoning
29. Jouquan J, Romanus C, Vierset V, Jaffrelot G, Parent F. Supporting active through a recent and comprehensive approach: the dual-process theory. Med
education as support to reflective practice and to deep learning. In: Parent Educ Online. (2011) 16:5890–9. doi: 10.3402/meo.v16i0.5890
F, Jouquan J, editors. Thinking Training for Healthcare Worker. An Integrative 54. Robinson-Smith G, Bradley PK, Meakim C. Evaluating the use of standardized
Perspective. Bruxelles: De Boeck (2013). p. 245–284. patients in undergraduate psychiatric nursing experiences. Clin Sim Nurs.
30. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. (2009) 5:e203–e11. doi: 10.1016/j.ecns.2009.07.001
Psychol Rev. (1977) 84:191. doi: 10.1037/0033-295X.84.2.191 55. Stuart GW. Principles and Practice of Psychiatric Nursing-e-Book. Mosby:
31. Husebø SE, O’Regan S, Nestel D. Reflective practice and its role in Elsevier Health Sciences (2014). p. 832.
simulation. Clin Sim Nurs. (2015) 11:368–75. doi: 10.1016/j.ecns.2015. 56. Lehr ST, Kaplan B. A mental health simulation experience for
04.005 baccalaureate student nurses. Clin Sim Nurs. (2013) 9:e425–31.
32. Kolb D. Experiential Learning. Englewood cliffs: Prentice Hall (1984). p. 256. doi: 10.1016/j.ecns.2012.12.003
33. Vygotsky LS, Cole M, John-Steiner V, Scribner S, Souberman E. The 57. Ogard-Repal A, De Presno AK, Fossum M. Simulation with standardized
development of higher psychological processes. Mind Soc. (1978) 1–91. patients to prepare undergraduate nursing students for mental health clinical
34. Wenger E. Communities of Practice: Learning, Meaning, and practice: an integrative literature review. Nurs Educ Today. (2018) 66:149–57.
Identity. New York, NY: Cambridge University Press (1999). doi: 10.1016/j.nedt.2018.04.018
doi: 10.1017/CBO9780511803932 58. Hanson MD, Johnson S, Niec A, Pietrantonio AM, High B, MacMillan H, et
35. Martin A, Weller I, Amsalem D, Duvivier R, Jaarsma D, de Carvalho al. Does mental illness stigma contribute to adolescent standardized patients’
Filho MA. Co-constructive patient simulation: a learner-centered method to discomfort with simulations of mental illness and adverse psychosocial
enhance communication and reflection skills. Simul Health J Soc Simul Health. experiences? Acad Psychiatry. (2008) 32:98–103. doi: 10.1176/appi.ap.32.2.98
(2020) 2. doi: 10.1097/SIH.0000000000000528 59. Goffman E. Stigma and social identity. In: Raiwater L. Deviance & Liberty:
36. Martin A, Weller I, Amsalem D, Adigun A, Jaarsma D, Duvivier R, et Social Problems and Public Policy. New York, NY: Routledge (1974). p. 446.
al. From learning psychiatry to becoming psychiatrists: a qualitative study 60. Ortega Vega M, Williams L, Saunders A, Iannelli H, Cross S, Attoe C.
of co-constructive patient simulation. Front Psychiatry. (2020) 11:616239. Simulation training programme to improve the integrated response of
doi: 10.3389/fpsyt.2020.616239 teams in mental health crisis care. BMJ STEL. (2020) 7:bmjstel-2020-000641.
37. Eppich W, Cheng A. How cultural-historical activity theory can inform doi: 10.1136/bmjstel-2020-000641
interprofessional team debriefings. Clin Sim Nurs. (2015) 11:383–9. 61. Sanci L, Chondros P, Sawyer S, Pirkis J, Ozer E, Hegarty K, et al.
doi: 10.1016/j.ecns.2015.05.012 Responding to young people’s health risks in primary care: a cluster
38. Parker B, Myrick F. Transformative learning as a context for randomised trial of training clinicians in screening and motivational
human patient simulation. J Nurs Educ. (2010) 49:326–32. interviewing. PLoS ONE. (2015) 10:e0137581. doi: 10.1371/journal.pone.
doi: 10.3928/01484834-20100224-02 0137581
39. Moreno JL. The role concept, a bridge between psychiatry and sociology. Am 62. Wuendrich MS, Nissen C, Feige B, Philipsen AS, Voderholzer U. Portrayal
J Psychiatry. (1961) 118:518–23. doi: 10.1176/ajp.118.6.518 of psychiatric disorders: are simulated patients authentic? Acad Psych. (2012)
40. Smith CM, Gephardt EG, Nestel D. Applying the theory of stanislavski 36:501–2. doi: 10.1176/appi.ap.11090163
to simulation: stepping into role. Clin Sim Nurs. (2015) 11:361–7. 63. Brenner AM. Uses and limitations of simulated patients in psychiatric
doi: 10.1016/j.ecns.2015.04.001 education. Acad Psychiatry. (2009) 33:112–9. doi: 10.1176/appi.ap.33.2.112

Frontiers in Psychiatry | www.frontiersin.org 11 May 2021 | Volume 12 | Article 658967

Piot et al. Simulation Training in Psychiatry

64. Albright G, Bryan C, Adam C, McMillan J, Shockley K. Using virtual patient of depression and suicidal ideation. Acad Med. (2007) 82:S61–4.
simulations to prepare primary health care professionals to conduct substance doi: 10.1097/ACM.0b013e31813ffedd
use and mental health screening and brief intervention. J Am Psych Nurs 75. Krahn LE, Bostwick JM, Sutor B, Olsen MW. The challenge of empathy:
Assoc. (2018) 24:247–59. doi: 10.1177/1078390317719321 a pilot study of the use of standardized patients to teach introductory
65. Ekblad S, Mollica RF, Fors U, Pantziaras I, Lavelle J. Educational potential of psychopathology to medical students. Acad Psychiatry. (2002) 26:26–30.
a virtual patient system for caring for traumatized patients in primary care. doi: 10.1176/appi.ap.26.1.26
BMC Med Educ. (2013) 13:110. doi: 10.1186/1472-6920-13-110 76. Attoe C, Billon G, Riches S, Marshall-Tate K, Wheildon J, Cross S. Actors
66. Shultz E, Pandya M, Mehta N. Technology and teaching: suicide risk with intellectual disabilities in mental health simulation training. J Men Health
assessment. Med Educ. (2013) 47:1132–3. doi: 10.1111/medu.12322 Train Educ Pract. (2017) 12:272–8. doi: 10.1108/JMHTEP-04-2017-0024
67. Kenny P, Parsons TD, Gratch J, Rizzo AA. Evaluation of justina: a virtual 77. Amsalem D, Yang LH, Jankowski S, Lieff SA, Markowitz JC, Dixon LB.
patient with pTSD. International workshop on intelligent virtual agents. Reducing stigma toward individuals with schizophrenia using a brief video:
In: Prendinger H, Lester J, Ishizuka M, editors. Intelligent Virtual Agents. a Randomized controlled trial of young adults. Schizophr Bull. (2021) 47:7–14.
IVA 2008 Lecture Notes in Computer Science; 5208. Berlin, Heidelberg: doi: 10.1093/schbul/sbaa114
Springer (2008). 78. Fernandez-Liria A, Rodriguez-Vega B, Ortiz-Sanchez D, Baldor Tubet
68. Baudrillard J, Foss P. The precession of simulacra. New York, NY: Semiotext I, Gonzalez-Juarez C. Effectiveness of a structured training program
(1983). p. 5. in psychotherapeutic skills used in clinical interviews for psychiatry
69. Shirazi M, Sadeghi M, Emami A, Kashani AS, Parikh S, Alaeddini F, et al. and clinical psychology residents. Psychother Res. (2010) 20:113–21.
Training and validation of standardized patients for unannounced assessment doi: 10.1080/10503300903131907
of physicians’ management of depression. Acad Psychiatry. (2011) 35:382–7. 79. Sfard A. On two metaphors for learning and the dangers of choosing just one.
doi: 10.1176/appi.ap.35.6.382 Educ Res. (1998) 27:4–13. doi: 10.3102/0013189X027002004
70. Woodward CA, Gliva-McConvey G. The effect of simulating 80. Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework
on standardized patients. Acad Med. (1995) 70:418–20. for personal recovery in mental health: systematic review and narrative
doi: 10.1097/00001888-199505000-00020 synthesis. Br J Psychiatry. (2011) 199:445–52. doi: 10.1192/bjp.bp.110.083733
71. Woodward CA, Gliva-McConvey G. Children as standardized patients:
initial assessment of effects. Teach Learn Med. (1995) 7:188–91. Conflict of Interest: The authors declare that the research was conducted in the
doi: 10.1080/10401339509539739 absence of any commercial or financial relationships that could be construed as a
72. Spencer J, Dales J. Meeting the needs of simulated patients and potential conflict of interest.
caring for the person behind them? Med Educ. (2006) 40:3–5.
doi: 10.1111/j.1365-2929.2005.02375.x Copyright © 2021 Piot, Attoe, Billon, Cross, Rethans and Falissard. This is an open-
73. Hanson M, Tiberius R, Hodges B, Mackay S, McNaughton N, access article distributed under the terms of the Creative Commons Attribution
Dickens S, et al. Implications of suicide contagion for the selection License (CC BY). The use, distribution or reproduction in other forums is permitted,
of adolescent standardized patients. Acad Med. (2002) 77:S100–102. provided the original author(s) and the copyright owner(s) are credited and that the
doi: 10.1097/00001888-200210001-00031 original publication in this journal is cited, in accordance with accepted academic
74. Hanson MD, Niec A, Pietrantonio AM, Johnson S, Young M, High B, practice. No use, distribution or reproduction is permitted which does not comply
et al. Effects associated with adolescent standardized patient simulation with these terms.

Frontiers in Psychiatry | www.frontiersin.org 12 May 2021 | Volume 12 | Article 658967