inside-head-psychiatrist-therapist

“I’m going to see a shrink for therapy” – what does that actually mean? Who are you going to see and for what? What is the difference between a psychiatrist, a psychologist and a therapist? Who would win in a Psychiatrist v Therapist fight?

Freudian Script is going to demystify the difference between a psychiatrist v therapist and what exactly folks mean by “therapy”.

What is a psychiatrist?
A psychiatrist is a medical doctor who specialises in mental health. In the UK, this means going to medical school, doing at least a couple of years in different medical and surgical jobs, then specialising in psychiatry. Psychiatrists are members of the Royal College of Psychiatrists.

You would visit a psychiatrist particularly for diagnosis, medication and monitoring. You may also visit them for therapy, but I will get into that later.

What is a psychologist?
A clinical psychologist is someone who has trained in psychology, usually to the PhD level (which means they are also called doctor!), and specialise in different psychological therapies. They can specialise in a particular therapy – for example, cognitive-behavioural therapy. These professionals take the lead on psychological therapy, or talking therapy.

You would visit a psychologist for a specific type of talking therapy, usually for a time-limited period. This is equivalent to taking a course of medication or undergoing a surgical procedure as a treatment for what ails you.

What is a therapist?
A therapist is anyone who feels like calling themselves a therapist. No, really. Some therapists are registered with professional bodies, which means you know what you’re getting, but otherwise it’s a free-for-all.

Therapists do not need to be psychiatrists or psychologists. They can also be “counsellors” – which also doesn’t really tell you what qualifications or therapy they are actually peddling.

Don’t get me wrong – therapists can be highly-trained and effective practitioners, but the term can be used and abused by anyone with an office.

But when you say “I’m seeing a therapist”…
However, common things are common. When someone is “in therapy” or “seeing a therapist”, they are usually talking about psychodynamic psychotherapy, psychoanalytical psychotherapy or psychoanalysis – i.e. adapted from the Freudian model.

So, it’s all about fancying your mother…?
While Sigmund Freud had some very interesting ideas about young children and their impressions of their parents, a lot of his work is nothing to do with that (though both childhood and sex feature frequently in his work).

The theoretical background focusses on how a person’s internal world relates to the external world, particularly how we re-enact patterns we learned as children in our adult lives and how these are a source of conflict to us. It is a deep and fascinating set of theories, but I won’t go into the details – suffice it to say, this is the underpinning of what is commonly called “therapy” or “psychotherapy”.

And psychiatrists do this?
This is where I start busting some Hollywood myths. Not all psychiatrists practice psychotherapy. In fact, in the UK, most psychiatrists do not regularly practice psychotherapy at all. It is a sub-speciality of psychiatry, like cardiology is a sub-speciality of medicine and orthopaedics is a sub-speciality of surgery.

But not all psychotherapists are psychiatrists. You do not need a medical degree to be a psychotherapist. However, to be a licensed psychoanalyst, you have to be trained in the modality.

Psychotherapy v psychological therapy
Let me re-emphasise here the difference between psychotherapy and psychological therapy. Psychotherapy is an exploration of the subconscious with the general aim of bringing it to conscious awareness, so it can be used in the present. Psychological therapy is a goal-orientated talking therapy for a specific problem – i.e. depression, spider phobia, failing relationship. It is usually time-limited to a few weeks, whereas psychotherapy and psychoanalysis can go on for years. “Brief psychotherapy” can last for a year!

Who visits a psychotherapist?
Anyone can visit a psychotherapist. In the National Health Service, it is reserved for people with long-standing emotional difficulties, particularly severe enough to be considered a personality disorder. In the private sector, however, anyone can sign themselves up for a bit of analysis. And this is the version we often see in Hollywood – anyone and everyone has a therapist.

What’s it like in a psychotherapy session?
Psychotherapy sessions last 50 minutes, no more, no less. They take place at the same time and in the same place at regular, precise intervals. This is part of the therapy – a consistent space that contains. They take place at a minimum of once per week, but in very intense therapy, they can happen every day.

freud-couch-psychiatrist-therapist
Sigmund Freud’s original couch

Some therapists use a couch, in the classical Freudian style. Not being able to see the therapist’s face is meant to create a more intense experience and progress therapy faster. Most now use a chair, a more natural setting that more people warm to easily.

In the first meeting – the so-called “business meeting” – the therapist takes the lead and explains the rules of consistency. At every session after, the client takes the lead. They speak first and they speak last. They talk about whatever they want, like Freud’s original free association. The role of the therapist is to ask curiously and point out any patterns they see, drawing the client’s attention to the unconscious.

Anyone who has ever watched a film in which a therapist appears will no doubt be surprised by this description. Hollywood psychotherapy is very therapist-led, though the ubiquitous “how do you feel about that?” is fairly common!

harleen-quinzel-psychiatrist-therapist

Also, though I cringe that I should have to point this out, therapists do not sleep with their clients. That is how therapists lose their job and their accreditation. You cannot be impartial with someone if you are swapping bodily fluids. Also, therapists do not generally “go insane” from being therapists. Else we would have no therapists. I’m looking at you, Harleen Quinzel.

What is Hollywood’s obsession with therapists?
My theory: cheap exposition. You want to know how your arsehole character really feels? Have him open up to his therapist. Your strong, tough guy shares some painful childhood experience that made him the loner he is today – you get vulnerability, you get an explanation for his behaviour, and he gets a “get out of jail free” card for his next arsehole action. See: Christian Grey.

Real therapy does not work that way. Sure, there are “eureka” moments but most of it is slow, gradual awakening over months and years. However, that does not fit into a 90-minute film or the episode-of-the-week where a burned-out cop is ordered to see a therapist before he returns to active duty.

Write Better Therapy
So, what do I want to see? How about folks that are in therapy just-because? What about more complex explanations for why folks have difficulties? How about some therapists who actually practice a recognisable form of psychotherapy and don’t sleep with their clients? My demands are modest, I assure you.

How do you feel about that?

5 Comments

  • This was a particularly interesting read for me because I’d been under the impression from the academic staff at university that everybody had ditched Freudian analysis these days. If I recall correctly, they turned away from the theories because they couldn’t be disproven (Karl Popper’s falsifiability principles in science is the relevant bit of reading here), and psychologists were keen to have it recognised as a respectable science. It still surprises me that rational people look upon this sort of thing without any scepticism.

    Another topic that springs to mind, discussed around psychiatrists vs clinical psychologists, is the prescription pad. Psychologists have been shouting for years now that a fully trained clinical psychologist should have the ability to prescribe useful drugs to aid/complement any therapy they’re providing to a patient… but the doctors have been childishly opposing anybody else being allowed to prescribe anything. (They’ve always opposed anybody else getting prescriptive powers.) I’ve always felt it doesn’t put our health system in a good light. Particularly when the gatekeeper to referrals on mental health in the NHS, is your GP: – possibly the least qualified member of the NHS (in terms of training) to be able to spot and diagnose mental health issues. Does the debate still rage on this? Or am I completely out of touch?

    • Psychoanalysis and psychodynamic psychotherapy do have an evidence base. Freud’s theories had been expanded upon and revisited in the intervening years. When you realise that he was working from a base of absolutely nothing, his theories are astonishing in their breadth and understanding for the time. The reality is that, as much as we don’t want to believe it, our childhoods and early relationships do have a huge influence over our adult reality. We learn our patterns of behaviour as children. This has been subsequently talked about in attachment theory and systemic/couples therapy.

      However, psychoanalysis isn’t for everyone or everything. In France, they only practice psychoanalysis – there is no CBT, etc. That makes no sense. However, I think psychoanalysis has its place in the therapeutic menu.

      As for prescribing… Perhaps I am one of those childish doctors, but I think prescribing powers are better held with doctors for mental health as opposed to psychologists. I think therapeutic psychological work shouldn’t necessarily include medication monitoring – I think it can get in the way of the therapeutic relationship. Also, safe prescribing doesn’t just involve the ability to hold a pen – there’s a reason doctors go to medical school. However, psychologists in my team often make a recommendation for considering medication, because they feel it would aid therapy, and that client is then reviewed by a doctor for only that purpose. As for GPs, they should be able to prescribe basic psychiatric medications just as they prescribe blood pressure tablets and asthma inhalers. If it’s more complicated than that, that’s where a psychiatrist comes in.

      • Yep, a huge area this all links into. Though it’s interesting how the range of therapy has begun evolving on its own. All the different approaches trying to mix and match to a certain degree.

        Though one question remains… why do you stare daggers at Harley? You’re jealous of her pet hyenas aren’t you?

        • I love Harley. I have a little knitted Harley and Joker!

          knitted Harley and Joker

          But she is a girl with issues and a lesson to us all that dating your murderous patients is a big no-no.

Leave a Reply

Your email address will not be published. Required fields are marked *