Midweek Medicine: what’s a shrink?

I’ve been asked to explain the difference between a psychiatrist and a psychologist. Well, I’m a psychiatrist, and I’m not a psychologist

Seriously, this is a question that comes up a lot – surprisingly so, for psychiatrists (and I’m sure for psychologists as well), as it seems obvious to us. But that’s only because we’re one or the other, and we work with each other all the time – so of course it seems obvious. Clearly it’s actually not though (and indeed why would it be?), so I’ll have a go at elucidating it.

Take psychiatrists (please! ) … we’re doctors, for a start, and psychiatry is a medical specialty like neurology or endocrinology, for example (and they’re probably the two specialties closest to us, really). We go through medical school, and basic general house-officer jobs (like on Scrubs … just like on Scrubs … seriously ) before entering specialist training in psychiatry. Consequently our overall approach is one of applied science, where we apply the scientific method (which I might go into for this Friday’s philosophy post … hurries off to reschedule the post just started for Friday …) to clinical problems. These problems have been broadened, widened, and consequently diluted near to the point of meaningless, and called “mental health” rather than psychiatry, but that’s a rant for another day …

We deal really with psychiatric illness (and whatever else the gummint dictates we must: see my recent post on the folly of risk assessment), rather than general unhappiness, disquiet, seeking … By psychiatric illness I mean major disruptions to the functioning of the mind, with consequent detrimental effects on behavioural, occupational/academic, social, and relational function. Broadly we can divide these into affective (mood) and anxiety disorders (e.g. bipolar disorder, major depressive disorder, social phobia), psychotic disorders (e.g. schizophrenia, delusional disorder), personality disorders (yet another rant for another day), and substance-related disorders (abuse, dependence, substance induced mood/psychotic disorders) – though our wonderful HMO-driven “cookbook”, the DSM (Diagnostic and Statistical Manual of Mental Disorders) gets fatter every edition, with all sorts of different dis-somethings.

We look at any of these disorders through a bio-psycho-social framework. Contrary to the (idiotic) accusation levelled repeatedly at us, we do not adhere to a rigid, biological “medical model”. We include the various aspects of the person when making our assessment:

• Perturbations in the biology (we’re not yet at the level of diagnostic blood tests or scans, but things like family history are informative here, and to some degree probably the nature of the illness as presented – though the latter might not always be strictly evidence-based at this point, but rather expert opinion)
• Psychological disruptions, past and present. We take into account the environment and events that have shaped a person’s character and interactions with the world, and the meaning of various events, and how they contribute to the presentation – as well as how they are likely to affect engagement with treatment, choice of treatment modalities, and so on.
• Problems outside the person: family, job/school, money … this list could go on as long as you’d like, pretty much.

We put those all together to create an understanding of the particular individual presenting to us, including a formal psychiatric diagnosis, and develop a treatment plan, which will similarly be bio-psycho-social in nature, in order to address the varied aspects of the person and his or her disorder. This can involve medication as part of addressing the biology, but also things like exercise, and bright light. We also address the psychological and social aspects of disorders in our planned management, but depending on our own experience, sub-specialty training, and practice, we might do it ourselves, or (more often, especially in public service) engage others: social workers, occupational therapists, psychotherapists (please, please, can we stop talking about “counsellors” and “counselling”?) and psychologists. However, we have to understand all those aspects and how they affect the person, if we are to develop a useful formulation, diagnosis, and management plan.

A psychologist trains not as a doctor, but in psychology – which might be under the Arts or Sciences faculty in a university (or both; I think at Auckland Uni when I was there not studying psychology, you could do either a BA or BSc in psychology). They can stop after the undergraduate psychology degree or follow that with clinical training to become a clinical psychologist. As the name implies, these guys specialise in the psychological aspects of mental problems (and no, that’s not a redundant statement ). They probably include the social dimension moreso than the biological, and are more about a psychological formulation, than making a formal psychiatric diagnosis. Compared with psychiatrists, they will also have more to offer – and will tend to be more involved – with problematic aspects of mental life not related to major mental illness: things that lie more within normal experience, but cause distress. So, they have particular expertise in the psychological treatment (with what can be referred to as “talking treatments”) of some aspects of major mental illness (even sone aspects of psychosis; I don’t want to suggest that they don’t have a role in the hard stuff -in fact the easy stuff will likely improve whoever does whatever, and it’s when things are hard and complex that we all need to work together), and wider aspects of unhappiness, dissatisfaction, desire for personal growth, and things that a psychologist could talk about better than I.

In summary: whereas a psychiatrist will (should) generally develop a broader picture of a person’s problems and management than a psychologist, and will particularly be an expert diagnostician, and expert in the biological aspects of management, psychologists will generally develop a deeper appreciation of the psychological aspects of the person, and be expert in addressing those aspects in psychotherapy.

I hope that makes sense of the major differences between psychiatrists an psychologists – though we’re both sometimes referred to as shrinks (head-shrinkers). And as a final disclaimer, I will emphasise that I’m a psychiatrist, not a psychologist, so what I say about psychologists is based on my awareness (such as it is) of their training, my experience working wirh various psychologists over the years, knowledge of their roles in those services.

Heh – every time I type psychologist on my iPhone keyboard I miss and get “paychologist” … Freudian slip?

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Tags: bio-psycho-social, biopsychosocial, medical, medicine, psychiatry, psychologist, shrink