“Meeting a human, not a medical condition”: a qualitative study of simulated patients’ perceptions of forming a therapeutic alliance with psychiatrists

OBJECTIVE: Increasingly in psychiatric and psychotherapeutic training, simulated patients (SPs) participate in the teaching and evaluation of clinical skills and knowledge. Despite their widespread involvement, doubt remains as to whether a genuine therapeutic alliance can be established with SPs. Further, little is known about the SP's perspective on alliance formation which is an important gap given the correlation between patient perception of alliance and therapeutic success. METHODS: We interviewed three simulated patients about their perception of the bond formed during role plays of standard full-length psychiatric diagnostic assessments. Each SP played their role multiple times yielding sixteen unique interactions and therefore sixteen interviews. SPs watched a complete video recording of each of their role plays. After watching each role play, they rated their interaction with the psychiatrists using the bond subscale of the Working Alliance Inventory (WAI). Following the ratings, each SP was interviewed about the bond formation in each interaction. RESULTS: Despite the simulation, SPs were able to form bonds with psychiatrists across full-length diagnostic assessments. Feeling respected by the psychiatrist, both in the psychiatrist's attempt to understand the problem and in their approaches to finding solutions facilitated bond formation. However, SPs had different preferences as to how respect should be conveyed. When it went well and when it went wrong, bond formation was affected by the same factors in the simulations as is the case in real practice. CONCLUSIONS: Our results suggest that from the point of view of SPs, a therapeutic alliance as reflected by bond formation can be established between psychiatrists and SPs in the context of full-length diagnostic assessments. These findings would be strengthened through replication involving comparison of both the SP and the psychiatrist perspectives.