So what really is the difference between a psychiatrist and a psychologist?

Greetings all, 

I bet as fellow psychiatrists you are asked this all the time, or maybe not. I always start my session with new patients targeting this to attempt to and debunk any stigma and myths they invariably have about us. The stock standard answer from the new patient is that 'you prescribe drugs, psychologists don't'.

 What a shame that after over a hundred years, post collaborations between Freud and Jung who later parted ways as the genesis of psychiatry and psychology was forming, we still have to explain to patients who we are and what we do. In stark contrast, if a patient presented with a broken leg to an emergency department, they would demand to see a doctor, not an allied health professional fully qualified to assist with rehabilitation. Yet for some reason psychiatry is not recognised as a medical specialty amongst lay people in 2014, and we still need to 'sell' ourselves to those who are referred to us. For those of you reading this and disagree, I suggest you begin your sessions the same way and see what they reveal. Reality ain't pretty. 

There are so many reasons why psychiatry and psychology are two different disciplines that share similarities and should complement each other. Go read a standard text and work it out. In clinical practice, although I incorporate my own mix of pharmacological and psychotherapeutic approaches, I have a niche of psychologists whom I refer to constantly to request their guidance, and deliver their expertise for patients we share. In private practice it is a lovely nurturing model that the public hospital system with all its rhetoric and useless catch phrases never accomplish when they refer to the use of a multidisciplinary team. Where would I have ever learnt about schema focused therapy in my training, yet how many patients have I referred to psychologists for this expert type of therapy that have resumed their lives, better than before with a collaborative approach between psychiatrist, psychologist and GP? Any patient, for which there are so many, with childhood trauma, benefit so beautifully with this approach and I have learnt so much from my psychology colleagues.

But here is the disparity. Last week, I met a psychologist who was keen to work 'collaboratively' with me. After about 10 minutes he was keen to impart his ideas that in about 20 years, psychiatry would be a dying profession, and by then psychologists would be able to prescribe medications. In his eyes, psychiatry was the path of last resort for patients with mental illness, as psychologists were much more expertise when it came to understanding the mind and brain. He had little time for doctors in general and psychiatrists in particular who prescribed medications indiscriminately, and didn't seem to appreciate what psychiatrists could offer. Yet he wanted to work with me and share patients. If I could refer them to him. Gee, thanks, but I chose politely to decline the offer. However, I was left thinking, was his view reality based on his interactions with our specialty or was it skewed? It's easy to argue the latter when defensive. We ain't surgeons, we don't fix almost AMI's and death amongst our patients is taken on as personal failure. Our work is not glamorous, but was he frustrated about our resistance to work together collaboratively, or was he trying to claim our turf bestowed with our medical registration and specialty training?

And then the second disparity. A new patient referred to me and in the throes of engagement with our fortnightly sessions. Towards the end of the second session she felt compelled to talk about her conflict. Not about her life, her family, her chronic illness or her existence. No, her conflict was she didn't see me as a psychiatrist. She asked me to label what was wrong with her and I replied by saying that labels were not always useful, getting to know people was much more helpful. I reassured her that I was still getting to know her and for her to feel comfortable with me. But her feedback was compelling; she stated I acted more like a psychologist as I was more down to earth and easy to talk to. How did she form that opinion? Where did that come from? In her early 20's and without any formal psychiatric history, this was her opinion. 

What is psychiatry getting wrong? Why do we have to constantly defend what we do? Are we going to be obsolete? I welcome you unabashed, candid views...

As always,

Helen

Please tell me this is not happening...

Ok, I haven't worked in the public mental health system since 2009. OK I might be misinformed. But I am hearing more and more from colleagues that a reduction in staffing in public hospitals is leading to increased use of major antipsychotic medications to sedate patients, so they require less intensive support and care. Known as 'chemical restraint', this method is being used over safer methods during the acute period a patient may be agitated and require transportation. Now, anybody who has not witnessed first hand how unwell and distressed patients with acute mental illness can be may find this diffiicult to comprehend. But doctors and nurses are duty bound to ensure they keep patients safe from themselves and others until better. The safest way is to use trained staff to calm patients, proivde one on one support and supervision, in a low stimulus environment. The same goes for patients who are agitated and distressed from head trauma or brain infection as well. Hospitals should be able to rely on teams of trained staff to use their expert skills to contain patients, thus minimising the need to use antipsychotic medications to achieve this.
However, the word on the street is because of staff shortages and more acuity in patients, the use of chemical restraint is becoming more routine in situations where patients need to be transported or contained. Chemical restraint is achieved by injecting medications used for illnesses such as schizophrenia.
So, what happens to patients when they are given cumulative doses of major antipsychotic medications? Well, they may experience respiratory depression, ie unable to breathe effectively, and may end up with pneumonia. They may experience severe side effects of potent medications, particulalrly if already on regular doses of medications. And when chemically sedated, they can't alert anybody that they may be experiencing symptoms of this.
In no way am I blaming the staff who do a superb job working with patients who are very unwell. I am blaming a public health system that looks at dollars, cuts brutally and without consideration, and I feel for the vulnerable patients with acute mental illness that suffer as a result.

Fame is not a vaccine for depression

This week has been confronting for most who watch popular or social media. We have woken to the news that celebrity olympian, Ian Thorpe, has declared he is being treated for depression and other conditions, and whether due to depression or not, the world has lost Philip Seymour Hoffman, who, most importantly, was a father of 3 young children. In a society so accustomed to perceive we know people we have never met, to 'follow' and to 'like' complete strangers we seem to be affronted that we are not aware celebrities are in pain or struggling. How many of my patients tell me they would not consider informing friends they are seeing a psychiatrist, let alone reveal they are depressed, anxious and perhaps entertaining suicidal thoughts? If they don't feel comfortable, then how can we expect those in the spotlight can until it is way too late?
Is it living in the spotlight that makes those vulnerable to mental illness fall victim to it? Or is it that they are just like everybody else, with the same chances of developing what are common disorders such as anxiety and depression? And surely, as a society we must remember we don't really know anybody very well, particularly those we like to think we know because we follow them.

Ahhhh, families...

It must be January. Not because it's so hot, the tennis is on, and the traffic is slightly better in Melbourne at the moment. Because my patients tell me so. Because they have endured Christmas, and now feel the pain. They have spent time with their families, and this hasn't always been a great thing.
Why do we feel compelled to 'celebrate' with those who push our buttons and trigger our vulnerabilities? It's common for some patients to strengthen throughout the year, resolve to rise above  dysfunctional dynamics, be confident in their decisions, only to undo this on 25 December. They feel obligated, emotional blackmail is unleashed and they spend time with those they avoid for 364 days of the year. The in-law, the grandparent, the cousin, somebody who has caused pain in the past is bestowed way too much power, and all is unleashed as if it was yesterday.
Somebody once told me that Psychiatrists invented Christmas to ensure there was plenty of work to do in a slow, cold European winter. More than just a joke. Time to roll up my sleeves and offer some healing for the next few months.

Goodbye 2013

2013 began with a tragedy that turned into a miracle. I still suffer the results of the tragedy and don't for a minute think of the miracle. I was holidaying in a swanky resort in Waikiki with my son, trying to recover from a very busy year working as a busy shrink and driving new workshop creation for CPD Formulations. For some reason, I was meant to be in the pool at the moment a Japanese couple decided it would be fine to let their 3 year old toddler explore without supervision. I made the news, 5 Jan 2013, 'Waikiki drowning in resort pool'. Within a few muscle straining strides I grabbed a 3 year old stranger I just happened to come across while playing with my son, just as this unmanned tourist was about to head to the bottom of a resort pool manned by staff who did not know how to administer CPR. And the pool had no fence, much less no visibility, that is, no visibility of the bottom. When I reached him he looked dead, and as I cradled him in my arms and bolted to the side, I lost track of my son who I was ultimately responsible for. I presume my son got out of the pool sensing danger, and retreated to some sort of safety.

 For a few excruciating minutes I forgot I was a Doctor and shrieked like a grieving mother, holding this little unattended stranger foaming at the mouth with no signs of life, and I could not find my boy. I placed him down by the side of the pool presuming that somebody, somebody, would take over, so I could see if my charge was out of the water and find out what he had witnessed. Within seconds, that felt like hours, and play out still in my nightmares I realised nobody knew what to do.

I have nightmares a year later, I have anxiety and I cannot bring myself to contact the resort for an apology. I guess that lay people think that Doctors don't suffer if placed in situations like this. If I was faced with this while on duty I would be hyper-vigilant, and more capable of dealing with the gravity of the situation, but at 10am that Sunday morning, I had 'clocked off' and more in tune with catching my son off the water slide.

One year on, I remain angry and in no way see myself as hero even though I have given this unknown child a second chance at life. I don't say this lightly, he was not breathing and heading head first to the bottom of a pool with no visibility, and no parents to watch him. His mother was in their room somewhere else and his father was sleeping on a deckchair.

What I am most angry about;
1. The parents that put myself and my son in that position
2. The same parents that did not even say 'thank you' for saving their son's life
3. The attitude of the citizens of US who are more terrified of being sued than administering first aid
4. To the hotel, the airline and the insurance company who would not help us come home away from the tragedy
5. To the police officer who tried to console my traumatised son by giving him his gun to play with
6. To any parent that expects others to take over the care and responsibility they should bestow.

What I am most grateful for;
1. My son, family and friends who kept me together until I could get home
2. To the burly Aussie life saver who got up as a tourist like me and helped me deliver the sloppiest CPR which somehow worked
3. To those at Royal Children's Hospital, Melbourne,who helped with debriefing when I finally got home.

What I know:
1. I am glad I live in a country where we have a respectful fear for water
2. I am a doctor who can save lives no matter what my peers think about psychiatrists being 'real doctors'
3. It will be a long time before I head to the US or stay at that hotel chain again.

Here's to a better start to this year, and wherever you are, unknown toddler, hope you are well and happy,

H