Embracing different languages and local differences: Co-constructive patient simulation strengthens host countries’ clinical training in psychiatry

Table 1 Adapting co-constructive patient simulation to a native language and local setting

Components	Possible adaptations
Actors/standardized patients/SPs	Hire actors through local drama schools or theater programs when no SP programs are available
	Adjust compensation to local market fees (averaging in the US approximately $ 25 per hour per actor, 4-h minimum)
	Consider alternatives to professional actors, e.g., non-professional actors, other mental health professionals who are not part of the same peer group
Delivery via synchronized videoconferencing	Chat feature in Zoom can be useful for a bilingual native speaker to translate key points to any outside guests, particularly during early stages of CCPS development
	Geographic distance can result in wide time zone variance, an added logistic challenge during early planning stages
	Consider that some international and non-academic Zoom accounts can limit session time or number of participants
Facilitation	Transition of leadership as sessions progress: From an outside “guest” to a local “host” facilitator

SPs: Simulated participants; CCPS: Co-constructive patient simulation.

Table 2 Application of co-constructive patient simulation in two Middle Eastern countries

Country	Session	Clinical scenario	Salient quote(s)	Learning objective(s)
Türkiye (online)	1	A 17-year-old young woman overdoses after being denied access to her phone when her deeply religious parents find out she has been having unsupervised contact with boys her age	“We love you, but not more than God. So, if you oppose our faith, we understand if you decide to end your life”	Navigate divergent religious world views in the context of their impact on a family member’s acute psychiatric emergency
	2	A 15-year-old adolescent girl is met with disbelief and anger by her mother when confiding details of long-standing sexual abuse by her brother, the family’s breadwinner and “man of the house”	“She said, ‘his hand might have accidentally touched [my] body,’ and so I might have misunderstood his love for me. Besides, as far as she knows, ‘he has a girlfriend already and so he wouldn’t need me’”	(1) Lead patient to understand that as a clinician you need to contact the authorities (today, as she is still at active risk), and to do so in as collaborative a fashion as possible with her mother; and (2) Ensure the patient’s safety and notify the authorities, while not alienating the child and her family in the process
	3	A 16-year-old gender fluid adolescent struggles with suicidality in the context of rejection by peers and non-acceptance by their family. As a major earthquake affects the country and their immediate family, they blame themselves for the natural disaster	“My grandma kept saying that the earthquake happened because of rebels and godless people like me, that wherever there are degenerates, bad things like this happen”	(1) Appreciate challenges affecting non-binary youth developing in culturally conservative settings; and (2) Explore the roots and psychological function of pathological and survivor guilt
Israel (in person)	1	The mother of a hospitalized adolescent is confronted with the news that, for reasons unknown, her weekend pass and forthcoming discharge are being put on hold. Unbeknownst to the mother is her daughter’s revelation of having been recently assaulted sexually at home, by her brother. As the police investigation proceeds, the physician is forbidden from sharing information with the family	“We gave you our perfect daughter and now you have broken her completely. As if cutting herself was not bad enough, she won’t even come home to us for Shabbat (the Sabbath)”	On being unable to tell the “whole story,” balance the competing demands of sharing limited information with providing sufficient support and not sacrificing the therapeutic alliance along the way
	2	A young widow is informed that her 4-year-old son has autism. Although she had long suspected something was amiss given differences from her normally developing older child, this is the first time she is informed of her “worst fear”	“At such a young age, his father’s death was a tragedy. This news feels like another tragedy, a compounded catastrophe”	(1) Convey a realistic sense of hope, optimism, and a path forward in the face of challenging information; (2) Disentangle losses, and disambiguate permanent, from addressable losses (death, from a chronic diagnosis); and (3) Start mourning the loss of the expected/idealized/anticipated child in order to permit accepting and loving the realities of the actual child
	3	A young father is informed that his 15-old-son’s loud ways, provocative comments, lack of sleep, and concerning behaviors landing him in increasing troubles with family, school, and now the legal system, are neither due to his extroverted personality or possible use of drugs. Rather, the doctor is now certain of a diagnosis of bipolar disorder and is recommending treatment with mood stabilizers	“Is this my doing? Bipolar disorder runs in my family.” “He was always the liveliest, literally the life of the party. How did I not see this coming, this liveliness having a dark side?” “He is now doomed to take medicines forever, isn’t he?”	(1) Consider spontaneous vs more structured ways (e.g., SPIKES28) of sharing difficult news; and (2) Address uncertainty about lifelong questions and prognosis; provide hopefulness without trivializing unknowns or dismissing concerns