This comprehensive and thoughtful presentation of the value of a psychiatry OSCE by Dr. Hodges and colleagues is based on the use of standardized patients, and it is their use that I have been invited to comment upon. The invitation was tendered because of the knowledge that for many years I had used actor-patients in a seminar on psychotherapeutic skills for psychiatry residents and graduate students. The use of actor-patients in that seminar involved different objectives, and, as a consequence, contrasting my experiences with those described in this paper may assist in clarifying both the advantages and the disadvantages of using standardized patients. First, however, a brief description of the seminar.
Few professions introduce their students to core processes as my generation of psychiatrists was introduced to training in psychotherapy. An almost sole reliance on supervision led to being told to sit with a new patient, "do psychotherapy," and then "we will talk about what happened." Under such ambiguous circumstances, most students took a detailed history. History-taking, however, is a process in which the student takes over the interview by asking a long series of linear questions ("how," "what," "when," and "why" are the predominant foci). This process may lead to the establishment of an early relationship in which the doctor is assumed by the patient to be in charge of the preferred direction of the interview, and the patient to be in the more passive, respondent position. This position is believed to be antithetical to the goals of many forms of psychotherapy.
The goals of the early stages of the seminar were to introduce students to another form of interviewing, one in which the emphasis was on facilitating the patient's narrative flow with as little direction as possible. This intent can be framed as eliciting and entering into the patient's story. It proved useful to delineate this type of interviewing as "exploratory" and the history-taking interview as a "directive inquiry." The basic structures of these two different forms of interviewing were contrasted in both didactic and role-playing exercises. Each form was presented as an essential skill, and the clinical context determined which was to be used. If establishing a diagnosis, for example, was the objective, reliance on the directive inquiry would be increased. If beginning a psychotherapeutic relationship was the intent, emphasis on exploratory techniques would increase.
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Early Training Exercises
In the psychotherapy seminar, a series of experimental exercises preceded interviews with actor-patients. These involved responding first in writing and later verbally to "patient stimuli statements" presented first on audiotapes and then on videotapes. The emphasis was on sensitivity to the affective component of the stimuli statements. Later the students were videotaped during role-playing interviews in which the roles of psychotherapist and patient were enacted. The processes emphasized were those that encourage narrative flow, empathic statements, and reflexive questions designed to open up rather than narrow down patient responses.
Students found that maintaining an exploratory stance was more difficult than they imagined, and they struggled with the tendency to change the process to the more familiar directive inquiry. Often they expressed anxiety about not knowing where the exploratory interview would lead and not feeling comfortably in charge of the direction of the interview. Nevertheless, most students made considerable progress in conducting exploratory interviews during these early exercises.
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The Use of Actor-Patients
Actor-patients were used during the middle segment of the 100-hour seminar. The actor-patients were known to me from earlier work with them for a televised series on family health and dysfunction. They were professionals and were paid the standard scale of the actors' union. One was a middle-aged man, one a middle-aged woman, one a young adult woman, and one a mid-adolescent boy.
Although from time to time their roles were changed, for the most part each actor played the same role through their years of involvement. If one actor was not available during a particular year's seminar, a fifth actor was used.
The actors were given only the briefest of identities. The man was told that he was to portray a business executive who had come to discuss what might be done about his wife's depression and refusal to seek treatment. Behind this theme, however, he had recently been passed over for a promotion and was facing the possibility that his life dream had ended, and, he, too, was struggling with depression. He was not to divulge this underlying theme unless the interview process invited it.
All of the actors' assignments were based on such brief, one-paragraph identities, and they were told to follow the interview process wherever it seemed to lead. This instruction led them to rely on their own more or less at-the-moment responses.
The middle-aged woman was told to portray a person whose husband had just left her for a younger woman and whose children were all living independently. She was depressed, with all the symptoms of a major depression. Primarily she was to portray helplessness and hopelessness and to be having frequent suicidal thoughts, without, however, a suicidal plan.
The young adult woman was to play the role of a graduate student of strong religious orientation—including a staunch pro-life value system—who found herself pregnant by a boyfriend with whom she had already broken up. She was very anxious about what to do about her pregnancy and felt she could not discuss her dilemma with her conservative religious parents.
The mid-adolescent boy had been brought to the interview by his rigid, controlling father and passive mother because they had discovered his drug use. He was to be angry, defiant, and unhappy about seeing a psychiatrist.
The fifth actor was to portray a graduate student in drama who sought help with the ending of a love affair, one of many during recent years. She was told that she was confused and had started thinking about a pattern of affairs with men who proved to be unavailable for a committed relationship.
The interviews were 20 to 30 minutes long and were videotaped. The videotapes of interviews with each patient were played sequentially to the group, with each resident assigned an observational task. These tasks included 1) observing the affective component of the interview with particular attention to the interviewer's empathic responses; 2) noting the patient's narrative themes and suggesting a tentative formulation; 3) observing the patterns of nonverbal behaviors of both interviewer and patient; 4) noting patient behaviors that suggested the use of various defense mechanisms; and 5) noting the evidence of an interviewer's anxiety and how she or he appeared to manage that anxiety. In addition, the actor-patient recorded his or her feelings about the interview, and these audio recordings were played to the group following discussion of the residents' observations.
In observing 5 to 8 different residents' interviews with the same actor-patient, it was easily observed that there were wide variations in the quality of the interviews. Some were seen as skillful explorations; others were less so; and a few were dismal failures to connect. It also became apparent that each resident did better with some actor-patients and less well with others. These differences led to discussions of countertransference and its impact on the interview process. The variations also led to an appreciation of how different the actor-patent appeared to be with different interviewers, and the idea of an interactional interpretive perspective was introduced.
A second observation is that the interviews, their videotaping, and presentation to the group were the source of considerable anxiety for most residents. It was important for the seminar leader to set the tone of pointing out errors, missed opportunities, and the like in the context of support and the idea of the inevitability of errors. Many residents reported years later that the group process was an important part of their learning.
The actor-patients all reported positive experiences and appeared to invest heavily in their roles as participants in the seminar. They were disappointed if a road booking interfered with their participation during a particular year.
On some occasions the actor-patient would report that a particular interview had led him or her into a meaningful personal exploration and new learning had occurred. There were no reports of negative consequences, and years later, on chance meetings, they continued to comment positively about their seminar experiences.
Another learning experience for the residents involved the occasional need to ask a series of focused and linear questions (e.g., when the patient reports symptoms of a major depression with or without suicidal thoughts) in the context of an exploratory interview. They were told that it was better to wait until the exploratory interview was near completion and then acknowledge the change with a bridging comment like, "Now I need to switch to a series of direct questions." This approach was preferable to trying to mix the two forms of interviewing as the interview progressed, and it was believed to minimize confusion in the patient's mind about the nature of the doctor-patient relationship being established.
The different use of actor-patients in the Introduction to Psychotherapy seminar reinforces the finding of Dr. Hodges and colleagues that actor-patients can be valuable participants in the education of students. What seems essential is that the goals of the interview process be clear. If, as with this seminar, the goal is to introduce students to a form of interviewing that is consistent with many forms of psychotherapy, then a major reliance on a directive interview format is not indicated. If one wishes to establish a collaborative alliance, then assuming the clearly more powerful position suggested by directive techniques ("I ask the questions and you provide the answers") is apt to be counterproductive. This means that students must become competent and comfortable with two basic interview formats and know when each is indicated. Students are thus introduced to the idea that how one talks with people establishes the basic structure of the relationship. Students may come to a beginning understanding of the roles of power, metaphorical distance-regulation (how closely to work with the patient's subjective reality), and other important relationship variables.
In some ways the various objectives of using actor-patients in this seminar are less easily separated than are the more concrete objectives of various OSCE stations. This can be understood as making for a more complex learning task for students. If I am correct in these assumptions, the implication is that actor-patients can be used in a variety of ways across a continuum of complexity.
A second implication is that actor-patients can be used not only to evaluate student skills (as in the OSCE) but as important adjuncts in a process of new learning. The clear differences in outcome of different students' interviews with the same actor-patient and with each student's interviews with different actor-patients is understood as a beginning step in understanding many of the ways in which therapists' characteristics contribute to the outcome of clinical encounters. This kind of learning can be a beginning of greater self-awareness in the usually difficult area of assessing one's impact on important relationships.
In order to achieve the goals of the seminar, the actor-patients could not be too scripted in their responses. Although keeping their assigned identities in mind, they had to rely on their spontaneous responses—and these often involved both past and current life circumstances. Indeed, the more the actor-patients thought the interviewer facilitated the exploration of their personal experiences, the more positively they evaluated the interview. From this perspective, learning the skills of exploratory interviewing can be understood as an effort to learn what is different about patients who may share the same descriptive diagnoses.
The ethical issue raised by Dr. Hodges and colleagues regarding the potential impact on actor-patients of participating in such studies is illuminated by the observations growing out of their use in the Introduction to Psychotherapy seminar. In this format the actor-patients frequently explored personal material and did so without apparent harm. On the contrary, they appeared to value such experiences. It does suggest, however, that actor-patients need to be screened in order to protect those who may be vulnerable to harmful effects.
In summary, the observations from the use of actor-patients in a different and, in some ways, more complex educational task than the OSCE assessment adds support to the helpful role they can play in teaching students a variety of clinical skills.