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