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