“What’s the difference between psychiatrists and psychologists?” Most in the know will respond that psychiatrists prescribe medicine. There is a difference, though, between observing that psychiatrists can offer medication, and knowing whether this is our usual form of treatment.
Psychiatrists are full-fledged medical doctors in education, degree, and training, with the most advanced medical knowledge of all mental health providers. It is no surprise, then, that we are uniquely situated to provide indicated medical, pharmacological, and somatic treatments for our patients. It is our responsibility to know when non-psychiatric medical problems, such as neurological, endocrinologic, or infectious diseases, are presenting with or contributing to mental health symptoms, and to accurately diagnose and treat them.
The public perception of psychiatry, as might be expected, is that we do have a more medical focus than our nonmedical colleagues, and it is noticed that our interventions are often effective. We have developed very clear and reliable indications of when and how to provide medical treatment for mental health diagnoses.
George Engel, though, reminded the medical profession in 1977 that illness and disease take place not only in isolated organs, but also in psychological and cultural milieus that influence symptoms and treatment. He coined the term biopsychosocial model to remind us to investigate broad contributions to disease, its course, and paths to improvement. His template invites consideration of genetic susceptibility and expression, personality, stress, and biological and socioeconomic environments. We therefore strive to avoid the either/or of bio/psycho/social causes and influences, becoming pluralistic, and truly addressing all three at every step.
During our training, psychiatrists must become competent in supportive psychotherapy, an essential element in all healthy doctor-patient relationships. This intervention is akin to counseling: talking about recognized problems without making interpretations about a patient’s unconscious or expecting these conversations to directly alter their symptoms. This kind and helpful approach to patient care may involve reassurance, clear validation, advice, psychoeducation, and facilitating access to community support and electronic resources, when appropriate. It also includes helping patients develop coping skills to enhance self-control and self-management while they await symptom resolution.
All psychiatrists can and should provide this supportive psychotherapy, and recent studies show that half of psychiatrists also provide the more technical and life changing psychotherapies to their patients. Every psychiatrist can demonstrate, at minimum, competence in a range of psychotherapeutic approaches: psychodynamic (based on psychoanalysis), behavioral, cognitive behavioral (CBT), couples, family, and group therapies. Many of us also develop skills in other forms, such as formal psychoanalysis, eye movement desensitization and reprocessing (EMDR), cognitive processing therapy (CPT), cognitive therapy, and dialectical behavior therapy (DBT), to name a few.
It is true that patient preference will help guide the choice of treatment. Patients who seek psychotherapy today are most often paying for their own cost of treatment, older, and members of certain ethnic and geographic groups. The public also correctly believes that psychiatrists play a major role in providing care to patients with the more serious mental health problems, including schizophrenia and bipolar disorder. Many forms of psychotherapy, other than supportive, are not appropriate for treating some of these these serious mental illnesses (SMI), while medication or somatic treatment can often provide the greatest symptom relief and best prognosis.
As a result, psychiatrists are usually observed providing medical care, often with psychiatric medications, but not as often seen offering psychotherapy. Our co-professionals, including psychologists, social workers, and addiction counselors, are also available to provide many of these same psychotherapies, which may be sought by patients as often as prescribed by professionals. Similarly, family practitioners and primary care internists actually prescribe far more antidepressants than psychiatrists do.
As a smaller professional group, psychiatrists provide medical care and psychotherapy as indicated, but we are not the most common providers of either (outside of helping patients who have SMI, whom large segments of the population do not observe, recognize, or acknowledge). While many non-psychiatric physicians mistakenly believe that we have turned our backs on medicine, and our nonmedical psychotherapeutic colleagues think we only practice medicine, the reality is that neither is true. To practice psychiatry, and provide the most value to our patients, psychiatrists must know all the medicine, all the psychology, and a great deal of sociology. Our method and results are evident when we are uniquely able to combine knowledge and skills from all three to help a single patient.
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