Table 1 provides a brief description of each of the cases written by participants for the simulations. In this results section, we present four themes developed via a symbolic interactionist analysis of the debriefing data, as summarized in Table 2 with example quotations: (1) Reflecting on dyadic challenges: role reversal and individuation; (2) Centering the child, allying with the parent, and treating the family system; (3) Ambivalence in and about the parent-child dyad; and (4) Longitudinal narratives and ambivalence over time.

Table 1 Summaries of the seven simulation cases written by participants Table 2 Themes and illustrative quotations Reflecting on dyadic challenges: role reversal and individuation

Across multiple debriefing discussions, participants noted challenges particular to the parent-child relationships, namely role reversal and the process of separation and individuation. With the exception of one, all the cases depicted difficulties of this nature, suggesting that this was a common dynamic that participants had encountered during their training. Participants reflected on the expectations parents placed on children in the simulated relationships and how roles could become reversed with the child being expected to take on the responsibilities of an adult and manage the parent’s emotions:

[The mother] would get stuck with her own guilt. And then at one point, she said, “Should I just die?” And then [the child] responded, “Well, why are you going to put that on me?” And there was a cross just being thrown on his back (Case 1 C).

The term parentification, or a child being forced to take on the role of an adult in the parent-child relationship (such as a confidante, mediator, or caretaker) came up during multiple debriefing sessions:

The dad was kind of parentifying his daughter because he kept saying really negative things about mom. And she [the daughter] was placed in a situation where she constantly had to be defending mom (Case 2B).

One participant explained how parentification could come in the form of parents asking their children to “help me to help you.” While this may be an understandable response on the part of parents, it could cause the child to “feel responsible for their relationship” (Case 1 A). Along similar lines, a physically or emotionally absent parent who was attempting to re-enter their child’s life can parentify the child by expecting them to “act like an adult” and immediately be ready to rebuild the relationship:

Now I [as the parent] have gotten my act together, I’m better now, I’m not using substances, I’m out of the depression. I’m unfrozen now. And now I’m going to catch up in this relationship (Case 1 A).

Even as the children in the simulated cases were expected to act like adults, the process of individuation and separation during adolescence was a common source of conflict between parents and children. Participants reflected on the shifting nature of dyadic relationships during this period and the emotional experience of parents struggling with their children growing less dependent on their relationship:

At 15, kids begin to have their own opinions, and they get into arguments with their parents as a way to separate. They worry about what’s going to happen when he leaves and moves out in the world, if they will be left all alone (Case 6).

Even when the cases were ostensibly centered on other issues, such as a parent’s gender transition or a son’s exploration of a new faith, participants readily identified the process of individuation as an underlying source of the tension in the dyadic relationship. As participants attempted to bridge the gaps in understanding between the parent and child, they also recognized that creating space in the dyad could be anxiety-provoking and painful for the parent and experienced as threatening their role as a parent and their relationship with their child. Therefore, participants noted the importance of providing a “safe space” to name and process these emotions, for both the parent and the child:

We could explore things around separation, even if it’s very frightening, because we have this safe space [in the clinical encounter] to explore whatever is frightening for both of them (Case 1 C).

In this case, participants noted that separation and individuation not only represented physical or emotional distance, but also the uncertainty of the future and the unknowability of what might become of a parent-child relationship when the child grows up.

Centering the child, allying with the parent, and treating the family system

Participants described the particular emotional and interpersonal work that comes with addressing the unrealistic expectations a parent may place on a child or helping a parent come to terms with the fact that their child is growing up. Such work called for both empathizing with the parents’ struggles and centering the child’s needs. Participants reflected on the complex and shifting nature of the answer to the question “Who is the patient?” in these simulated encounters. Many participants expressed wanting to treat the whole family unit while still trying to ensure that they were prioritizing the child:

Is [the patient] the parents or is it the kid? Oftentimes, I’ve defaulted to the kid (Case 1 C).

Centering the child and their needs often meant helping the parent and child hear each other, which was easier said than done. This required ensuring that the child had an opportunity to be heard and preventing the parent from taking up too much space in the dialogue:

I’m sure grandma is just fragile and trying to hold it together. But she was too big in the room and [the patient] was way too small. He was the one who was hospitalized and wanted to kill himself (Case 5).

Participants described toggling back and forth between viewing the child and the parent as two individuals and as a single dyadic unit. In order to center the child, they had to consider how the child fit into the parent-child relationship, which in turn required trying to understand the parent’s motivations and needs and how that might shape the dyad. Participants emphasized the importance of empathy for the parent, for the sake of the child:

It shifted it from focusing on the logical piece of the story to what’s the emotional meaning behind this need to protect the daughter (Case 4).

When working with a parent-child dyad, the interviewers had to contend with the reality of the child and the reality of the parent and try to assemble a coherent understanding of these realities that would be meaningful to everyone involved. One case centered on an adolescent struggling in the context of his mother’s gender transition. In this scenario, the mother and the patient viewed the same event (the mother’s transition) as the start of a new life and as the end of a life, respectively. Both realities could be true for the patient and his mother individually but perhaps could not coexist in the same space at the same time. One participant described the complexity of this bereavement and the recognition of the conflicting realities of the transition for the mother and the child:

Maybe just handling the grieving process with [the child] alone so that he can privately name what he lost very explicitly but without bringing that feeling of discomfort to his mother. For them to handle it together in the same room, I think that would be really, really complicated (Case 1 A).

However, participants could still struggle at certain points to center the patient. In a different session utilizing this same family narrative (Case 1B), the script called for a third actor to play the mother’s new female partner. Over the course of the simulated encounter, the dynamics became emotionally charged and chaotic at times, with the SPs at times interrupting and speaking over one another. For many participants, the accounts of the two adults seemed to trump the child’s experience of the situation; participants tended to frame the adolescent male patient as the aggressor in their comments. Yet during the next simulation and debriefing session (Case 2B), which involved similar challenges in a different parent-child relationship and gender constellation, participants generally came to the adolescent female patient’s defense and framed her father as the aggressor. Participants could identify personal histories that could result in prejudging the parent in a clinical scenario:

I come from a place where my dad was not in my life, so I really have a negative connotation towards men in general, and it’s going to be completely real. So it’s almost like guilty until proven innocent for me (Case 2B).

The differing responses to these two scenarios suggested that in spite of one’s best efforts to center the child in the therapeutic relationship, social factors such as gender stereotypes or virtue signaling towards gender minorities could complicate those efforts:

You had these two women, and one a trans woman, who maybe we [the clinicians] see as even more vulnerable or whatever, and we say no, no, no, I can’t push because if I push, maybe I’m a transphobic jerk (Case 2B).

In the previous session featuring the same adolescent patient and his mother (played by the same actors) but without the mother’s partner present, one participant noted the empathy that the interviewer extended to the struggling patient:

When you said to [the child], “When someone transitions, it’s not just them, it’s everybody around them.” That seemed to be like a big moment of opening for him, where he felt seen and allowed him to speak more about his experience (Case 1 A).

When the dynamics were limited to only the patient and the caregiver, participants seemed to empathize with the child more easily. More specifically, the empathy described above did not only seek to identify what the patient was feeling but also created a space for him to experience his emotions, with an understanding that the patient had as much a right to be having a tough time as anyone else. The interviewer’s comment signaled an awareness of the reciprocal nature of the parent-child relationship: In the same way that a significant shift in a child’s life, positive or negative, can be difficult for a parent to process, a child can struggle to adjust when a parent’s life changes radically.

In the debriefing sessions, participants described the work required in the simulated scenarios as simultaneously holding the needs of both the child and the parent. The CCPS model and the use of two patients appeared to allow participants to engage in and reflect upon the particular approaches that dyadic challenges call for. In keeping with a co-constructivist perspective, participants viewed the emotional work of child and adolescent psychiatry as navigating and negotiating two conflicting realities that nevertheless coexist in the same space and time during the clinical encounter.

Ambivalence in and about the parent-child dyad

Across multiple sessions, participants noted patients expressing ambivalence, or conflicting feelings, toward a parent, feeling simultaneously pulled in and pushed away. At times, the ambivalence could cause children and parents to question their relationships with each other, and at other times, it could cause them to question themselves:

Grandma is in such pain about it and feels such hatred towards his father around the death of her beloved daughter. And then [the grandchild] is in the middle of this horrible dilemma: I want the love of my dad. I want somebody that I can identify with, but my grandma, who I love dearly, hates him and thinks he’s evil. Am I evil?” (Case 5).

My gut feeling at that time was acknowledging that mom’s certainty and intensity is coming from a place of intense love and also hurt at what’s happened to her, and that those are the two forces that are driving this certainty, and just to name them (Case 4).

Even as they felt the urge to take sides, participants experienced feelings of ambivalence toward the parents, the patients, and the family dynamics in the simulated cases. They tried to focus more on the aspects of the encounter that were external to themselves as the clinicians, i.e., what the encounter is bringing to me. When faced with challenging patients, they tried to check their baggage at the door and separate themselves from the encounter:

She’s a grandma, she just had her grandson admitted to a psychiatric hospital for the first time. That’s terrible. Go work with that. Try to ignore everything else (Case 5).

One result of how personal the clinical encounter could become was that the “clinical gaze” of any two clinicians could differ significantly; in our study, two participants could focus on different aspects of a parent’s or child’s actions and have very different interpretations of the same actions:

I felt that the father was abusive: the thought of him hitting her sister, his response. I thought either it was sexual assault or physical abuse because of [the child’s] body language, it looked like somebody that was physically abused (Case 2B).

Contrary to a lot of people, I felt a lot of pain for the dad. I did feel anger towards the dad, but I’d say a majority of it was I felt really bad and really sorry, and maybe a little pitiful for him. There was this sense of here’s this daughter who’s now living with mom and he feels like mom’s pitting her against him and he wants to build a connection (Case 2B).

In these discussions, ambivalence did not necessarily reflect conflicting realities or cognitive dissonance, but in fact may have offered a truer understanding of the situation than attempting to tidily classify the involved parties:

“Love covers a multitude of sins” (1 Peter, 4:8). Your love for your daughter almost covered how much you were just trying to hold it together for yourself, and your love for your mom was almost covering what you were going through (Case 4).

You can traumatize your kids, even if you love them (Case 2B).

The ambivalence apparent in the parent-child dyads and among the participants suggested that ambivalence may be a common dimension of dyadic relationships. In relationships that involve a power differential, whether it is parent-child or doctor-patient, one person depends on the other and the other is depended upon, and such a dynamic seems inclined toward mixed feelings. If that is indeed the case, then perhaps one needs some amount of ambivalence to see the full picture of the other, the good and bad.

Through examining and accepting their own feelings of ambivalence and uncertainty, participants appeared better poised to understand such feelings as experienced by patients. In case 3, which centered on a transitional-age inpatient with type 1 diabetes being seen by the consult-liaison psychiatry team due to concerns about surreptitious insulin use, participants acknowledged and accepted the uncertainty inherent to clinical work in CAP:

Because I worked a lot with adolescents, it was so important for them just to know that you are scared and that it kind of helped them in some way, just to know that someone was being scared for them in between two meetings (Case 3).

The scenario in the following CCPS session (Case 4) centered on a mother who was convinced that her 15-year-old daughter had been abused by her father, despite the daughter’s insistence that her father has not harmed her. Over the course of the simulation, it became apparent that it was less a case about trying to figure out whether or not the abuse had occurred at some point in time:

We’re not lawyers, we’re not court people, we’re not the police. The historical facts aren’t necessarily the most important thing for us and our purposes; it’s trying to figure out what’s going on between the people now, the relationships, and also assessing the safety (Case 4).

In making peace with these feelings of ambivalence and ambiguity, participants invoked the imperative of clinicians to explore and be curious about a patient’s way of understanding the world, their motivations, and their unmet needs, even if it is deeply troubling:

It’s hard for us to be curious about it, and curiosity is important to be therapeutic. Why is he being racist as a defense? Is it not a defense? And I think his story would’ve fleshed that out (Case 5).

Curiosity offered a way forward when participants came up against the limits of their knowledge and perspective, allowing them to accept those limits:

He could have said, ‘You know, you don’t know anything.’ And I think that, yes, guilty as charged. I, of course, cannot understand. But allow me to be interested. Allow me to be interested in you. And maybe it will allow me to help (Case 6).

Curiosity appeared to function as one antidote to the gap between patient and provider as well as the urge to take sides in a parent-child conflict, allowing for a therapeutic relationship with both parties. Ambivalence appeared to be a necessary precursor to curiosity in this context: regardless of one’s initial feelings about a parent or child, positive or negative, reaching a truth that was meaningful to all involved required accepting some ambivalence and ambiguity, that things may not be more complex than they appeared and that apparently conflicting realities could coexist.

Longitudinal narratives and ambivalence over time

Through the implementation of simulation narratives that carried over across multiple sessions, participants experienced the same simulated family system at two different timepoints in their narrative. We were thus able to examine how participant reflections differed between sessions with the same family and how participants reflected upon the shifting dynamics of the family system. One narrative that was carried over between two sessions (Cases 2 A and 2B, June 2021 and January 2022) involved an adolescent patient who had recently been hospitalized for a suicide attempt and had not been in contact with her father for a few months in the context of her parents’ complicated divorce. In both sessions, participants noted difficulties around helping the daughter be heard due to the charismatic and at times domineering persona of the father:

The dad was hammering at his point and made it difficult sometimes to redirect. That’s why I stepped in and said, “Let’s wait, let [the child] finish,” because she expressed the fear that dad was going to take over. So at that moment, I said I have to be the referee here, and I have to make sure everybody gets their chance to speak (Case 2B).

Additionally, participants between the two sessions had different views on re-establishing the relationship between the estranged father and daughter and what such a reunion would mean for each:

She said, “He’s my dad, of course I want him in my life.“ That was an inflection point where I thought, “Got you,“ because that’s what I wanted to get to, they’re both here, it’s clear they want each other in their lives (Case 2B).

I also wonder what kid doesn’t want a relationship in theory with their parents? It doesn’t mean it’s necessarily going to be helpful. I think every kid desires a relationship with their parent, even if they were being abused by their parent (Case 2 A).

In a similar vein, the issue of power in participants differed in their approach to power breakdown, in this case between the parent and child. Whereas in one session, many participants cast the daughter as a victim, a participant in another session subverted the idea of what constitutes power in this context:

My parents were divorced when I was in middle school. There’s this weird thing when you’re a teenager and you have divorced parents where you actually have a lot of power in terms of where you decide to go. Normally, kids, when they’re teenagers, can’t just ghost a parent for six months. I think the kids are given that choice, and we, as clinicians, often support it (Case 2 A).

For the other longitudinal case, the initial session was in April 2021 with follow-up sessions in November 2021 and June 2022 (Cases 1 A, 1B, and 1 C). This narrative focused on an adolescent experiencing challenges at home and at school in the context of his mother’s recent gender transition. All three sessions depicted the same family system with the same actors at two different timepoints, with Case 1B also including the mother’s new partner, as described above.

Between Cases 1B and 1 C, participants noted the changes in the children and their parents between sessions and how it a created a more dynamic simulated family system:

We don’t know what’s going on exactly, but things just don’t feel right. Whereas last time we could easily pin like okay these two are yelling at each other, everybody’s yelling at each other. And this was just walking into a room and you feel the depression without exactly knowing why the depression (Case 1 C).

Between Cases 1 A and 1 C, interviewers and participants in each session used a similar schema (a child experiencing bullying due to a parent’s minority status) to understand the conflict. However, the emotional meaning and valence given to these interpretations were very distinct and at least in part refracted through personal experiences. During Case 1 A, one observing participant framed the situation in terms of bullying to make sense of it:

He could have had a low-income parent or a parent who is unemployed, or any other situation where kids bully others, because the parents are a minority. He’s dealing with the difficulties of kids who have parents from a minority group (Case 1 A).

Notably, in Case 1B, which continued this patient narrative, bullying was not a point of emphasis. This session involved the patient, his mother, and her new female partner. The dynamics between the male adolescent patient and the two adult women seemed to cause interviewers and observers to be less likely to frame the patient as a victim. In the first and third sessions of this narrative, which included only the patient and his mother, it became evident relatively quickly that the patient’s fights at school in response to peers making negative comments about his mother being transgender. In the first and third sessions, while recognizing the behavior as inappropriate, participants felt that it was rooted in a desire to defend his mother and who she is. However, in the second session, when this aspect of the fights at school came to light, it was framed as bad behavior and expression of the patient’s anger toward his mother and not as him being “clearly protective of his mom,” as one participant put in the first session (Case 1 A). In the third session, a synthesis of the two views emerged, recognizing that both realities could be simultaneously true:

Participant 1: [The patient] might be like, “Mom has nothing to do with this. This is the kids at school.” And so we’re trying to treat two different things as the same thing there. So that makes it even more complicated.

Participant 2: Or mom does have to do with it. But it’s just that she’s causing the bullying. It’s not her fault. He doesn’t necessarily blame her for it. But he probably still feels some resentment towards her for it (Case 1 C).

The longitudinal nature of this case brought to the surface the ambivalence surrounding the patient’s experience of his mother’s transition. Here, the issue of bullying was presented in turns as a way to provide a framework for understanding the patient’s experience and then as a potentially insurmountable challenge. It seemed that both were simultaneously true; as a clinician, one could not necessarily stop the bullying from occurring. But one can address and acknowledge it in the moment and give a name to that experience:

It also brought up a lot of personal memories of being bullied when people found out my dad was a bus driver in middle school. No one could give me any advice about what to do about that because my dad’s not going to stop being a bus driver (Case 1 C).

Often you can’t stop the bad things that happen in the world as a therapist. But I think our job is to help people cope. It’s not your fault. Or exploring why you would think it’s your fault. And some patients need to hear that or be able to have that space (Case 1 C).

Longitudinal narratives in these CCPS sessions provided the opportunity to revisit the patients and their families and to see them with fresh eyes and hear their stories anew. With each new episode of the family narrative, themes recurred but took different forms in different contexts. These multiple valences of meaning became apparent over time in a manner that would be challenging to convey in a single installment of the narrative.