Funder by the Department of Human Services Auspiced by Our Community

A CONSUMER'S GUIDE TO PSYCHIATRISTS

A psychiatrist is a qualified medical doctor who has obtained additional qualifications to become a specialist in the diagnosis, treatment and prevention of 'mental illness' and emotional problems.

Because of their medical and psychiatric training, psychiatrists are supposed to be able to view illness in an integrated way by taking into consideration the related aspects of body and mind. (However it is a common consumer view that their training is deficient in the area of the social and the cultural.)

Psychiatrists are trained both to recognise and treat the effects of emotional disturbances on the body as well as the effects of physical conditions on the mind. Some are able to do this better than others; that ability is not just to do with their academic credentials.

Psychiatrists claim that this multi-dimensional aspect of their training is important as many emotional disturbances affect various parts of the body and physical illnesses can certainly affect the mind. In principle, a psychiatrist's medical and psychiatric training allows both the physical and emotional to be kept in perspective.

Life with a psychiatrist is much more complex than it may at first appear. What any one of us experiences may be totally different from what another experiences, even when we are seeing the same psychiatrist. This is, in part at least, because so much of what psychiatrists do depends on the individual relationships we create together. This is particularly so with psychiatrists who are more oriented towards psychotherapeutic interventions.


Qualifications & registration

All doctors trained in Australia, including psychiatrists, have a medical degree. In most cases, this is an MBBS (Bachelor of Medicine and Bachelor of Surgery), although doctors trained at Flinders University of South Australia are awarded a BM,BS (Bachelor of Medicine and Bachelor of Surgery), and graduates of the University of Newcastle in New South Wales are awarded an equivalent BMed (Bachelor of Medicine). If they're trained overseas, the qualification may be different again; for example 'MD' (Medical Doctor) in the United States.

Once general medical students have completed their initial training they are required to serve a further year in a public hospital to gain experience. They cannot become fully registered until this internship is completed. Following this, the doctor must serve a further year as a Resident Medical Officer.

In Australia and New Zealand, specialist training for doctors to qualify as psychiatrists is conducted by the Royal Australian and New Zealand College of Psychiatrists (RANZCP). The college's program for post-graduate training in psychiatry takes a minimum of five years. Whilst undertaking this training, doctors are called registrars.

It can be a good idea to check that a potential psychiatrist is a registered doctor. Qualifications and registration are supposed to be prominently displayed in the psychiatrist's rooms. However this is not always done - sometimes psychiatrists who are sensitive to the unhealthy power differential between patient and clinician prefer to put these symbols of power and qualification in a less obvious place.

In any case, public display of qualifications is not always helpful. Some of us feel a bit silly asking to examine these - "Excuse me, may I walk around your office and check your official documents, Doctor?" It's often easier to contact the RANZCP and simply check that everything is bona fide. Call (03) 9640 0646 or email ranzcp@ranzcp.org.

It's important to note that more and more qualifications are not necessarily an indicator of a better clinical experience. For example, we have known some outstanding registrars who have taken a long time to pass their final exams (possibly because they are too busy being good doctors!).


Style of practice

Most psychiatrists use a 'medical model' approach. That is, they develop expertise in the diagnosis and treatment of psychopathology, often using psychiatric drugs (psychiatrists are allowed to prescribe medical drugs). In general, psychiatrists have a primary interest in diagnosis, treatment (in whatever form it takes - sometimes augmented by various forms of psychotherapy using 'talking' and 'behavioural' approaches), and prognosis.

It is OK to ask about the professional interests, experiences, theoretical underpinnings, preferences, fees policy and engagement rules within which a particular psychiatrist works. The psychiatrist does not have to answer but the response will tell us a lot anyway.

Of course, some of us don't want to know all this detail. That's OK too.

If you do want to know more about the style of treatment that your psychiatrist uses, it's useful to have some background first. There are many approaches but for simplicity, this publication introduces three of the most common: psychopharmacology, psychotherapy and behaviour therapies.

Note that many psychiatrists work multi-dimensionally. They may be interested in psychotherapy, may indeed have a specialised interest in this area, and still also use pharmacology. Their practice may be described as 'eclectic'.

Psychopharmacology

Psychopharmacology (which describes the practice of psychiatrists who have a primary interest in brain chemistry and pharmaceutical drugs) is a major area of practice for psychiatrists.

Sometimes individual psychiatrists who fit into this category develop a particular speciality; for example, 'polyphamacology [administration of many drugs together] for Bipolar Affective Disorder'.

Psychiatrists who have a primary interest in psychopharmacology are likely to be interested in that set of illnesses that are known to have a strong chemical aetiology (or background). The sorts of diagnoses that might be of interest would include bipolar affective disorder, the schizophrenias, schizoaffective disorder and also some of the depression and anxiety disorders which are 'clearly biochemical'.

It is possible that we may be referred to these sorts of specialists for specific advice that our own psychiatrists believe will prove useful. However, compared with other treatment styles, pharmacologically oriented psychiatrists tend to see us less frequently, maybe once a month, and for less time, maybe just 15-20 minutes at a time. Their interest might predominantly be in how we are reacting to the medical drugs.

The practice of pharmacologically oriented psychiatrists, and their interest in those of us who seem to have diagnoses at the biological end of the 'illness' scale, does not mean we have lived singularly uncomplicated lives and that psychosis, for example, just landed on us like a biochemical bolt from the blue. There are many of us who still need or desire a skilled psychiatrist or clinical psychologist interested in 'talking therapies'.

It's important to note that we can make choices about our 'treatment'. A clinician who's good with medical drugs is perfect for some people. Some of us have tried the talking therapies, found them of limited use and just want our medications monitored.

Psychoanalysis

'Talking therapies' are diverse. Some are formalised into very structured, deliberate patterns of interaction between doctor and 'patient', incorporating practices that have been tested over time.

Some of the more structured therapeutic approaches are very predictable in terms of the relationship, may have 'contracts' that patients have to agree to before therapy is commenced, and may have rules about things like interaction between visits.

These sorts of therapies come in different forms but they include perhaps the most famous, psychoanalysis, which was developed by Sigmund Freud and is maintained in structure from Freud's original paradigm. If we sign up to undertake therapy which is psychoanalytical in origin it is probable that we'd visit the psychiatrist up to three times a week.

There are two common problems that many of us encounter with psychoanalysis. The first is the cost - Medicare will not subsidise such frequent visits. The second problem is that some of us will fall over completely trying to analyse ourselves! It sometimes becomes so overwhelming that the rest of our life disappears or becomes secondary to the analysis. Not surprisingly, this can be harmful for your mental health.

Notwithstanding these two not insignificant problems, many consumers have reported that there are some very good psychoanalytical practitioners who have been very helpful.

Supportive psychotherapy

Psychoanalysis is not the only 'talking therapy' approach; in fact, there are dozens of variants.

Psychotherapy is another approach. This is all about learning new things, reflecting, analysing and practicing, both for the 'patient' and the psychiatrist. In fact, we actually do very little of the work in the session with the psychiatrist. It all happens in the shower and in bed, the toilet, or car (or anywhere where there is head space time) during the hours and days between sessions.

There are many sub-sets of supportive psychotherapy but what they have in common is a reliance on healing through the relationship the patient has with the doctor. The relationship is paramount. This relationship is born out of regular visits, often weekly, to the psychiatrist, which usually last for about 50 minutes. If consultations total less than 50 a year, they are generally covered by Medicare.

Psychotherapy is very different from other forms of medicine and it does have its ups and downs but for many of us it works. Because the relationship is so important, it's crucial that the psychiatrist we see for this type of therapy is the right person for us.

Many consumers think that all psychotherapy is expensive gobbledygook and see 'talking therapies' in general as a waste of time and a waste of their taxes. Many consumers also heavily criticise psychopharmacology and its relationship to 'Big Pharma' (Big Pharma is the consumer terminology for the pharmaceutical industry which some consumers believe is a huge multinational industry which poisons people, rips off taxpayers and which has far too much say in health policy. Naturally, not all consumers believe this). There is no doubt that consumers have a wide range of political and personal beliefs and therapeutic preferences. No one view is more 'worthy' than another.

Cognitive and behavioural therapies

This set of therapeutical approaches divides consumers perhaps more than any other. Some people get a lot out of them and others absolutely hate them.

This style of therapy includes cognitive behavioural therapy, dialectical behavioural therapy, or any one of the new behavioural therapies that are emerging. Behavioural therapies differ from pharmacological and psychotherapeutic approaches. They are complex and multifarious; however, as a crude idea they tend to be:

Some consumers sing the praises of cognitive and behavioural therapies. People say they know what they're getting, the boundaries are very clear, they see improvement for themselves, and group work provides a very useful learning 'replay experience', even when it's not so pleasant. They say that progress notes and constant feedback helps, as does praise for their effort and the gains they make. Many like the fact that the whole parcel is short and they can aim for something in the short term.

On the other hand, many consumers dislike cognitive and behavioural approaches. People who have an aversion to this approach are often those who like playing with ideas - they don't like what they experience as a straight-jacketed, dictatorial approach and they object to what they experience as patronism by doctors. They are often creative thinkers who feel stuck in a jar in this type of setting, with every approach they make to be themselves seemingly forbidden.

This division depends on many things but one of them, we think, has to do with whether we are concrete or abstract thinkers.


Practice differences

Apart from broad social and cultural determinants and particular preferred treatment methods, psychiatrists also have individual practice priorities, habits, communication skills, likes and dislikes. They have a 'worldview'.

Some psychiatrists take loads of notes, some take none. Some charge the recommended fee whilst others are quite expensive. Some talk about themselves and others don't. Some have a messy office and squeaky chairs; others have spotless offices.

There is no right or wrong about all this but it's important to back our own judgment and if things don't feel like a good 'fit' it's better to extricate ourselves from an unhelpful relationship early.


The art and science of psychiatry

No psychiatrist is belief-neutral and no psychiatrist sits outside the larger social forces of our society. Gender, culture, ethnicity, social class and sexual preference are all factors that affect the clinician's practice - the decisions they make and the actions they take.

Of all the clinical groups working in the area of mental health, psychiatrists have the greatest power to assert their social values and beliefs on to others. This is because the institution of psychiatry is such a powerful social force.

Despite attempts to promote the science of psychiatry, many psychiatrists (and many of us) recognise that much happens which is - at its best - closer to art, and, at its worse, conjecture.


The relationship

Transparency needs to be an aim of the psychiatrist. At the same time we (consumers) need to remember that the psychiatrist's room is not a confessional - we don't have to tell our psychiatrist everything. There is nothing like the power of a secret well kept!

At the same time, for many of us who 'keep' private psychiatrists there is great relief in knowing that someone is being paid to listen - mostly respectfully - to what we have to say.

Provided we have enough money to support this habit it can be very healing to have someone to talk to. It's also a good way to unburden oneself on someone who is paid to take it. Having these conversations with family and friends just isn't on for many of us. It's also a way we can show that we are taking responsibility for our own 'stuffed up lives' (well, hopefully not absolutely stuffed up!) and only dumping on someone who can't be hurt (at least, that's what we tell ourselves).

However, how do we know when it's become too easy, too much of a luxury? Many of us have frequent or not so frequent pangs of guilt for using up professional time that we don't deserve: "Will she ever say, 'enough is enough, you're cured, go away'? How will we react when that day happens?" We may wonder about the hidden fears we have about 'going it alone'.

Many of us wonder whether we've become 'institutionalised' in a sociological sense - becoming dependent on regular visits.

The amount of ourselves caught up in this relationship can be huge, but this is often not reciprocated, leaving us feeling guilty for allowing ourselves to become dependent. Remember, this is about your whole life but it is only the psychiatrist's job. Dependency in this scenario is not of our making.

The relationship between a psychiatrist and a mental health consumer is a big topic, and discussed further in the help sheet titled Understanding Clinical Relationships.

Fees are another big issue when it comes to private psychiatrists - see the help sheet titled How money (or lack of it) affects a consumer's choices for more on this.