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Article #96: Who's Who In The Mental Health Service: GPS, Psychiatrists, Psychologists, CPNS And Allied Therapists

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When a person is experiencing Lithium) are rarely prescribed by
psychological or emotional difficulties GP'swithout consulting a psychiatrist
(hereafter called "mental health first.
problems"), they may well attend their A psychiatrist, as a rule, does not offer
GP. The GP will interview them and based "talking treatments" such as
on the nature and severity of the persons psychotherapy, cognitive therapy or
symptoms may either recommend treatment counselling. The latter may be available
himself or refer the person on to a "in-house" at the GP surgery - some
specialist. There can seem a bewildering surgeries employ a counsellor to whom
array of such specialists, all with they can refer directly.
rather similar titles, and one can wonder Psychologists and allied mental health
as to why they've been referred to one staff typically provide the more
specialist rather than another. In this intensive talking therapies. Some senior
article I give an outline of the mental health nurses and CPNs will have
qualifications, roles and typical working been trained in specific talking
styles of these specialists. This may be therapies. It is to a Psychologist or a
of interest to anyone who is about to, or trained nurse that a psychiatrist will
already seeing, these specialists. refer a patient for talking therapy.
The General Practitioner These therapies are suitable for certain
Although not a mental health specialist, conditions and not for others -
the GP is a common first contact for generally, conditions such as
those with mental health problems. A GP Schizophrenia and psychosis are less
is a doctor who possesses a medical appropriate for these therapies than the
degree (usually a five-year course) and less severe and more common conditions
has completed a one-year such as depression, anxiety,
"pre-registration" period in a general post-traumatic stress disorder, phobia(s)
hospital (six-months on a surgical ward and addictions. In many cases, a patient
and six-months on a medical ward as a will be prescribed both medication and a
"junior house officer"). Following this a talking therapy - thus they may be seen
GP has completed a number of six-month by both a therapist and a psychiatrist
placements in various hospital-based over the course of their treatment.
specialities - typical choices include The Psychologist
obstetrics and gynaecology, paediatrics, A qualified clinical psychologist is
psychiatry and/or general medicine. educated and trained to an impressive
Finally, a year is spent in general degree. In addition to a basic degree in
practice as a "GP registrar" under the Psychology (a three year course) they
supervision of a senior GP. During this will also have completed a PhD ("Doctor
period, most doctors will take of Philosophy" or "Doctorate") - a
examinations to obtain the professional further three-year course involving
qualification of the Royal College of innovative and independent research in
General Practitioners ("Member of the some aspect of psychology. They will also
Royal College of General Practitioners", be formally trained in the assessment and
or MRCGP). Others qualifications, such as treatment of psychological conditions,
diplomas in child health, may also be although with a more "psychological"
obtained. slant than that of psychiatrists.
The GP is thus a doctor with a wide range Psychologists do not prescribe
of skills and experience, able to medication. They are able to offer a wide
recognise and treat a multitude of range of talking therapies to patients,
conditions. Of course the necessity of although they typically specialise and
this wide range of experience places become expert in one particular style of
limits on the depth of knowledge and therapy. The therapies a particular
skills that they can acquire. Therefore, psychologist will offer may vary from a
if a patient's condition is rare or, colleague, but will usually be
complicated, or particularly severe and classifiable under the title of
requiring hospital-based treatment, then Psychotherapy (e.g. Analytic
they will refer that patient on to a Psychotherapy, Transactional Analysis,
specialist. Emotive therapy, Narrative therapy etc)
Focusing on mental health problems it or Cognitive Therapy (e.g. Cognitive
will be noted that whilst the majority of Behavioural Therapy (CBT) or
GP's have completed a six-month placement Neuro-Linguistic Programming (NLP) etc).
in psychiatry, such a placement is not The Community Psychiatric Nurse (CPN)
compulsory for GP's. However, mental These are mental health trained nurses
health problems are a common reason for that work in the community. They will
attending the GP and, subsequently, GP's have completed a two or three year
tend to acquire a lot of experience "on training programme in mental health
the job". nursing - this leads to either a diploma
Most GP's feel able to diagnose and treat or a degree, depending on the specific
the common mental health problems such as course. They are not usually "general
depression and anxiety. The treatments trained", meaning their experience of
will typically consist of prescribing physical illness will be limited.
medication (such as antidepressants or Following completion of the course they
anxiolytics) in the first instance. If will have spent a variable amount of time
these are ineffective, alternative in placements on an inpatient psychiatric
medication may be tried, or they may unit - this time can range from twelve
refer the patient to a specialist. GP's months to several years. They can then
are more likely to refer a patient to a apply to be a CPN - they are required to
specialist immediately if their condition show a good knowledge and significant
is severe, or they are suicidal, or they experience of mental health problems
are experiencing "psychotic" symptoms before being appointed.
such as hallucinations and delusions. CPNs are attached to Community Mental
The Psychiatrist Health Teams and work closely with
This is a fully qualified doctor psychiatrists, psychologists and other
(possessing a medical degree plus one staff. They offer support, advice and
year pre-registration year in general monitoring of patients in the community,
hospital) who has specialised in the usually visiting them at home. They can
diagnosis and treatment of mental health liaise with other mental health staff on
problems. Most psychiatrists commence behalf of the patient and investigate
their psychiatric training immediately other support networks available (such as
following their pre-registration year and the mental health charities).
so have limited experience in other areas Some CPNs will be formally trained in one
of physical illness (although some have or more "talking therapies", usually a
trained as GP's and then switched to cognitive therapy such as CBT (see
psychiatry at a later date). Psychiatric "Allied Therapists" below).
training typically consists of a "Allied" Therapists
three-year "basic" training followed by a Many "talking therapies" are offered by
three year "specialist training". During non-psychologists - for example, mental
basic training, the doctor (as a "Senior health nurses and mental health
House Officer" or SHO) undertakes occupational therapists, can undertake a
six-month placements in a variety of training course in a cognitive therapy
psychiatric specialities taken from a like CBT. After successful completion of
list such as; General Adult Psychiatry, the course, the nurse will be qualified
Old Age Psychiatry (Psychogeriatrics), and able to offer CBT to patients. The
Child and Family Psychiatry, Forensic length and intensity of these courses can
Psychiatry (the diagnosis and treatment vary dramatically, depending on the type
of mentally ill offenders), Learning of therapy and the establishment
Disabilities and the Psychiatry of providing the course. Some are intensive,
Addictions. During basic training, the full-time one or two week courses; others
doctor takes examinations to obtain the are part-time and can extend over months
professional qualification of the Royal and years. Perhaps a typical course will
College of Psychiatrists ("Member of the be one or two days a week for two to
Royal College of Psychiatrists" or three months. Formal educational
MRCPsych). qualifications are not necessary to
After obtaining this qualification, the undertake these courses, and they are
doctor undertakes a further three-year open to "lay" people with little or no
specialist-training placement as a experience of the NHS mental health
"Specialist Registrar" or SpR. At this services. Of course this is not
point the doctor chooses which area of necessarily a problem - it may even be
psychiatry to specialise in - General considered a positive point!
Adult Psychiatry, Old Age Psychiatry etc Some of those therapists thus qualified
- and his placements are selected will offer their skills as part of their
appropriately. There are no further work in the NHS - for instance, a nurse,
examinations, and following successful CPN or occupational therapist may offer
completion of this three-year period, the cognitive therapy to a patient that has
doctor receives a "Certificate of been referred by a psychiatrist.
Completion of Specialist Training" or Unfortunately this is relatively rare at
CCST. He can now be appointed as a the moment, presumably due to the
Consultant Psychiatrist. reluctance of the NHS to pay for such
The above is a typical career path for a training for their staff. As a result
psychiatrist. However, there are an these therapies are more accessible on a
increasing number of job titles out with private basis.
the SHO-SpR-Consultant rubric. These Summary
include such titles as "Staff Grade An individual with psychological
Psychiatrist" and "Associate Specialist difficulties will normally attend their
in Psychiatry". The doctors with these GP in the first instance. The GP will
titles have varying qualifications and usually have encountered similar problems
degrees of experience. Some may possess with other patients and can offer a
the MRCPsych but not the CCST (typically, diagnosis and appropriate treatment. If
these are the Associate Specialists); the condition is unusual or particularly
others may possess neither or only part severe, the GP can refer the patient to a
of the MRCPsych (many Staff Grades). psychiatrist. The psychiatrist is able to
Psychiatrists of any level or job title access a wider range of treatments
will have significant experience in the (medications and hospital care) and can,
diagnosis and treatment of people with if necessary, recruit other mental health
mental health difficulties, and all professionals to help the patient. This
(unless themselves a consultant) will be system perhaps works best with the
supervised by a consultant. severely mentally ill such as those with
Psychiatrists have particular skill in psychotic symptoms or who are suicidal.
the diagnosis of mental health problems, The Mental Health Services in the NHS are
and will generally be able to provide a generally less well suited to those with
more detailed diagnosis (i.e. what the psychological problems of a less severe
condition is) and prognosis (i.e. how the nature - the moderately depressed, the
condition changes over time and responds anxious, the phobic etc. The availability
to treatment) than a GP. The psychiatrist of "talking therapies" is limited in the
is also in a better position to access NHS, with long waiting lists or even no
other mental health specialists (such as provision at all in some areas. This
Psychologists and Community Psychiatric appears to be due both to the cost of
Nurses or CPNs) when needed. They also training staff appropriately and the
have access to inpatient and day patient time-intensive nature of these therapies.
services for those with severe mental For those with such conditions, the main
health problems. option is to seek help outside the NHS.
The mainstay of treatment by a There are some voluntary organisations
psychiatrist is, like with GP's, that offer free counselling for specific
medication. However, they will be more problems such as bereavement or marital
experienced and confident in prescribing relationship difficulties, but more
from the entire range of psychiatric intensive therapies (such as CBT or NLP)
medications - some medications (such as are typically fee based. Your GP or local
the antipsychotic Clozapine) are only Community Mental Health Team may be able
available under psychiatric supervision to recommend a local private therapist.
and others (such as the mood-stabiliser






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