Standardized patients (SPs) are individuals who are trained to simulate a particular clinical presentation of a patient with a high degree of consistency and realism. SPs have been used to educate and evaluate medical students for more than 20 years. They have commonly been used to teach physical diagnosis skills (+1,+2), evaluate communication skills (+1,+3,+4), and, more recently, to teach ethics and give students exposure to breaking bad news and working with difficult patients (+5). Standardized patients have been widely accepted because they can provide valid, reliable, and highly faithful representations of live patients (+2,+3). They can also be trained to give helpful formative feedback and accurate evaluations of their interviewers (+6). Use of standardized patients is one of the methods recommended by the ACGME for clinical performance assessment (+7). Because these patients are actors trained to portray the cases involved, one does not have the problems with confidentiality, intrusion on the doctor—patient relationship, or problems with issues of coercion and authority that may be found in the use of actual patients.

The use of standardized patients in psychiatry or for psychiatric diagnosis has been more recent, but has been spreading (+8—+10). Standardized patients are used to assess clinical clerks at the end of their third-year (M3) rotations (+11—+13) and are being discussed as a replacement for the live patient interviews currently used in the oral board certification examination for graduates from psychiatric residency training programs (+8). They have been used in psychiatry residency training programs and have been well accepted (+8,+14). Although one study described problems with the emotional realism of the portrayal (+15), this issue has not been reported elsewhere.

The use of simulated psychotherapy patients for the training of residents in psychiatry has been reported only once. Coyle et al. (+9) describe the use of trained psychotherapists (not trained standardized patient actors) portraying a variety of therapy cases in a psychotherapy course. The sessions were done in a group, with two faculty and two resident co-leaders. All residents were present for the sessions, and the sessions could be interrupted for on-the-spot feedback and/or intervention to occur. We could not find reference to any other use of standardized patients in a psychotherapy course to date, despite online searches through MEDLINE, Ovid, Academic Psychiatry, and the psychotherapy literature.

In 2000, one of the authors (D.K.) was asked to create an Introduction to Psychodynamic Psychotherapy course for first-year psychiatry residents, to be given over the 9 weeks preceding their PGY-2 year (April-June). Each weekly session would be 50 minutes long, and the 11 first-year residents would be required to attend the sessions. These first-year residents had seen many patients in an ER or inpatient setting, but would not as yet have seen a single psychodynamic psychotherapy patient. The author knew from previous experience that the most common fear expressed by first-year residents was actually starting a psychodynamic psychotherapy case, since they had had no previous experience. With that in mind, the author created the following course objectives:

We felt that giving the residents the experience of actually interviewing a patient in an initial psychodynamic psychotherapy session would be extremely valuable. Using standardized patients for this session would be ideal because it would give the residents a very realistic experience and allow the class to observe the interview (via videotape). In addition, since these were not actual patients, residents would not have to worry about gaining a patient's consent for a videotaped interview, the logistics (insurance, return appointments), or even whether or not they were "doing the patient any good."

The course topics were laid out as follows:

The course did not have one recommended text, but rather used articles that were relevant, as well as materials from Beitman and Yue (+16).

We used the standardized patients to simulate a one-hour initial psychotherapy session with a resident. The sessions were videotaped at the Clinical Performance Center, in rooms with built-in, unobtrusive cameras and microphones. The sessions were conducted after the 7th week of the course, in preparation for viewing in the 8th and 9th weeks. Standardized patients (SPs) were told the purpose of the interview and were told to come in with a problem, either real or concocted. They could give a completely true history or make it up if they felt uncomfortable or did not want to reveal themselves in this manner. These veteran SPs were given no other instruction, and there was no effort to standardize the scenarios they presented. They were told that if they experienced negative effects of any kind from the initial interview they could speak directly to the course director about it. Residents were told that they could assume that these "patients" had been pre-screened and had been deemed appropriate for psychotherapy. To provide residents with some feedback about the session from the SP's perspective, standardized patients filled out the Stiles and Snow Session Evaluation Questionnaire (+17) after the session. The Stiles and Snow form rates a psychotherapy session on 12 paired-opposites categories: Bad—Good, Safe—Dangerous, Difficult—Easy, Valuable—Worthless, Shallow—Deep, Relaxed—Tense, Unpleasant—Pleasant, Full—Empty, Weak—Powerful, Special—Ordinary, Rough—Smooth, and Comfortable—Uncomfortable. SPs rated each category on a scale from 1 to 7, where the first adjective in the pair was assigned a "1" and the second a "7." SPs did not provide any other feedback, written or oral, to the residents. This instrument was chosen because it is used again later in the curriculum with second-year psychiatry residents and real patients, so we wanted the residents to be familiar with the form and its use as a feedback tool.

Residents also received feedback during the viewing of their videotapes in class. The author (D.K.) pre-viewed all the tapes and selected a 5-minute segment from each resident's tape based on its illustration of teaching points. Overall, one-third of the segments were from the beginning parts of sessions, one-third from the middle, and one-third from the end. They generally demonstrated positive aspects of the interaction so as to give residents a positive first experience with this method of teaching.

The class reviewed the tapes in the last two sessions of the course. Each resident's tape segment was played for approximately 5 consecutive minutes, and then the group discussed what it had seen. The author commented on residents' abilities to pick up verbal and nonverbal messages, pitfalls experienced as seen in the tapes, and other relevant issues demonstrated in the interaction. All comments were for formative purposes only; no evaluations were given. Residents were given their own tape at the end of the session and were encouraged to play it for the psychotherapy supervisor they would begin to see as PGY-2 residents the next month. They were also encouraged to view the tape by themselves.

Comments about the use of SPs in this course were solicited from both the standardized patients and the residents. Immediately after the exercise, standardized patients completed a questionnaire that asked about their response to the interview process. Residents' reactions were gathered in several ways and on several occasions. First, a focus group was held at the end of the seminar so that residents could discuss their thoughts about the course directly. Second, a standardized course evaluation form was administered to them several weeks after the end of the course. Finally, residents were queried 6 weeks and again 6 months after the experience to find out if they had reviewed their videotapes and if they found the experience of interviewing the SP useful when they actually began to see psychotherapy patients.

The cost to hire standardized patients was $16 per hour per patient. Five different standardized patients were used for the 11 residents. (One patient saw three residents, and each of the other four patients saw two residents each.) Patients spent one hour of time with the residents and one hour of time filling out paperwork and other miscellaneous activities (checking in, etc.). Total cost was therefore $32×11=$352.

Resident response to the use of standardized patients was very positive. In the focus group, discussion residents noted that although they were extremely nervous while interviewing the standardized patients and were nervous about being videotaped, the experience nonetheless allowed them to have some practice before their encounter with a real psychotherapy patient. All considered the experience valuable, and most felt prepared to go on to work with a real psychotherapy patient. Many of the residents commented that they had learned a lot by watching themselves on tape because they picked up mannerisms (leg swinging, body posture) that were occurring without their conscious awareness.

The course evaluation ratings also reflected the residents' positive attitudes about the experience. On a scale of 1 (poor) to 5 (outstanding), the average rating for the course was a 4.8. The question about the use of standardized patients in particular in this course elicited an average score of 5.0. In the comments section, residents specifically mentioned the videotaped use of standardized patient interviews as a feature that was "outstanding" and/or that should be retained in the course. There were no negative comments about the standardized patients in any of the evaluations.

When polled by e-mail several weeks after the course, all residents responding (8 of the 11) noted that they either had played or intended to play their standardized patient videotape for their psychotherapy supervisor. All 8 responding also noted that they either had watched or intended to watch the videotape in its entirety on their own as well.

Six months after the course, all 11 residents had shown their videotape to their respective supervisors, and all felt that this provided an additional and valuable learning opportunity. In addition, the residents continued to feel that the experience had been helpful. Residents stated that they had felt more confident and less stressed when beginning psychotherapy with a real patient as a result of the standardized patient interaction.

Standardized patients' responses to their work have been reported elsewhere (+18), and we were curious to know what reactions this particular standardized patient experience engendered. Standardized patients were asked how the experience was for them as actors, and how it was for them as individuals. On the question of acting, only one noted that he had indeed acted during the sessions. This person noted that it was a good acting challenge, since it was "a challenge to talk about issues I have some distance from, but still try to have them be hard things to talk about or be things I am talking about for the first time." Two of the remaining four noted that this experience did not make a difference for them as actors, since they were being themselves, not someone else. The remaining two noted that though they were not acting in the case (i.e., they were being themselves and talking about real issues), the issue of acting was a big topic of discussion in the session.

Patients' responses to how the experience was for them as individuals were also positive. One noted that he "got more satisfaction out of 2 of the 3 encounters than I had ever had with my regular therapist (whom I stopped seeing)." He noted that he thought this had something to do with the residents "asking the right questions—probing (gently) into areas that I didn't think had to do with why I said I was here. Ironically all 3 sessions pretty much ended up dealing with the same issues, even though I started with different reasons for being there." He wondered if these residents were seeing patients currently. Another standardized patient noted that she did learn something about herself, and that she had gained some focus and perspective in both sessions. A third standardized patient noted that "it was good, but I also felt like I had talked through many of these problems before with friends or with myself." She wondered if it would have made a difference if the doctors were not taped, since at times it seemed as if they were aware of the camera. A fourth standardized patient noted that overall it was a positive experience, but she too, noted the residents' nerves in front of the camera, and felt that she had not really learned anything new about herself. A fifth standardized patient noted that although it was a good session, he felt afterwards that perhaps he would be better suited to a male therapist, which was a surprise to him. (Both of his interviewers had been female.)

In this pilot study, standardized patients provided a reasonably realistic simulation of an initial psychotherapy session. Beginning psychiatry residents were able to use this nonthreatening setting to practice applying the knowledge, attitudes, and skills gained in their introductory course, to observe their own behavior, and to gain some appreciation of their effect on the patient. In our current psychodynamic psychotherapy setting it is usual to provide audiotapes for the supervisor's listening, but it is extremely rare to videotape sessions, because of logistic difficulties and patient and resident reluctance. The videotapes produced by the standardized patient encounter are thus a uniquely valuable source of information about the residents' actual behavior in the context of a psychotherapy session. Reviewing the videotapes on their own and/or with their individual supervisors provided additional learning opportunities for the residents, and all of the residents in this study have already taken advantage of this opportunity. The early introduction of a videotaped session into the residents' curriculum thus may help desensitize the residents and reduce some of their resistance to videotaping actual psychotherapy sessions for review.

The interactions between the residents and the standardized patients in this study are best thought of as simulations rather than standardized encounters. No effort was made to standardize the experience across residents. Because the feedback in these cases was formative only, we were not concerned about the case specificity issues that arise when using SPs for high-stakes evaluations (+19).

Each veteran SP presented a story that was as real, or as simulated, as he or she wished; only one of the five SPs stated that he'd "acted" rather than presented his own story. This may have contributed to the success of the simulation, since the SPs were able to react spontaneously and genuinely, rather than being constrained by a script. Similarly, SPs were able to rate the sessions genuinely, on the basis of their subjective reaction to the process of the session. True standardization of cases based on scripts might increase the difficulty of the portrayal and preclude the use of the Stiles and Snow form for feedback. On the other hand, standardization would afford more control over the challenges presented and would allow residents to see a variety of possible responses to the same situation.

Some of the standardized patients used in our course had had prior psychotherapy of their own. This may have contributed to their comfort levels in these initial psychodynamic psychotherapy sessions, or it may have sensitized them to particular issues when it came time to rate the residents on the questionnaire. Although the Stiles and Snow ratings are difficult to interpret—is a pleasant, comfortable session necessarily an effective one?—and their reliability in this particular context is questionable, the ratings did provide the residents with a gross measure of how their behavior affected their patient across several dimensions. Similarly, although the SPs' narrative comments are open to many interpretations, they do not raise any concern that the SPs were distressed by this teaching exercise. It would be interesting to learn whether psychotherapy-naive standardized patients experience and/or rate the sessions differently from those who have prior experience with psychotherapy as actual patients.

Our successful trial run using SPs in an introductory psychotherapy course for residents suggests that standardized patients can play an important role in psychotherapy education for psychiatry residents. The use of standardized patients could be expanded in several ways. For example, standardized patients could be trained to recognize the essential features and common pitfalls of an initial psychotherapy interview so that they could give more specific, relevant, and reliable written comments and/or verbal feedback to the residents involved. In addition, the use of standardized psychotherapy cases illustrating common problems such as acting out, transference, intrusive questions, or seductive behavior would allow residents to have an experience with these anxiety-provoking situations in a simulated setting before they occur in their practice. Finally, performance in standardized scenarios could be used as an additional source of data for the assessment of resident competency in the psychotherapy domain.