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