The Differences between Mental Health Professionals

The difference between psychiatrists, psychologists, therapists, counsellors and coaches explained using a physical health analogy: 500 words.

With a plethora of impressively titled mental health professionals out there, it can be difficult to know what they all do and how they differ from each other. The clearest way to explain this is to use a physical health analogy; so, let’s assume you have a problem with your physical conditioning, anything from sub-optimal fitness to a serious injury.

Personal Trainers = Coaches

If you’re simply unhappy with your fitness level, and there’s nothing particularly wrong, then you should consider working with a personal trainer. Perhaps you want help attaining a certain goal, like running a marathon, or just want to get fit.

Coaches are our mental PTs, helping the still functioning individual to function better. They may offer a generalist ‘life coaching’ service, or something more specialist, like executive coaching.

Physiotherapists = Psychologists, Counsellors and Therapists

If you’ve suffered an injury then you’ll want to consult a physiotherapist. They can diagnose your injuries, and guide you through specific exercises that will target those injuries. They will help you to gain insight into possible causes, facilitating improved management in the future.

In mental health, counsellors, therapists and psychologists all provide knowledge-based or behavioural therapies to address some level of dysfunction.

Orthopaedic Surgeons = Psychiatrists

Finally, some injuries warrant a direct biological intervention, so you’ll need to see a doctor. In particular, an orthopaedic surgeon has the most relevant specialist knowledge. Of course, a surgical procedure carries an increased level of risk, but it may be the most potent treatment available.

Psychiatrists are doctors with specialist mental health training, and usually employ biological treatments including medications, the not-as-bad-as-it-sounds Electroconvulsive Therapy (ECT), and more recently developed treatments like Transcranial Magnetic Stimulation (TMS). (Psychosurgery is very rare nowadays.)

Let’s now consider some variations on these basic roles:

  • Psychologists work in various fields, not just mental health. For example, there are neuropsychologists, educational psychologists, organisational psychologists and forensic psychologists to name but a few. Psychologists working in mental health may have engaged in further training on mental health disorders and the therapies used to treat these disorders. In some countries they may hold a specialist designation like ‘Clinical Psychologist’.
  • Doctors often favour the ‘medical model’, that is, using biological treatments to address mental illness; but some will also use psychological therapies. And not only psychiatrists treat mental illness; general practitioners may often prescribe drugs to treat mental ill-health, and of course many GPs are helpful counsellors also.
  • People calling themselves counsellors or psychologists may well provide coaching services.
  • Depending on which country you live in, the various titles used by mental health workers might be regulated by law, and if not, it’s likely there are professional bodies that regulate the standards of their members, so look for these when choosing someone.

*I’ve left out mental health nurses because most people know roughly what nurses do; they care for patients in a hospital, clinic or community setting, and administer treatments, often in consultation with and/or on behalf of doctors. It’s similar in mental health.

A Brilliant Portrait of Schizophrenia

I wrote this book review and posted it on my personal Facebook a couple of years back. To my mind at least the novel in question, Midnight’s Children by Salman Rushdie, very cleverly portrays schizophrenia from the perspective of the sufferer, and so I am re-posting it here: 390 words.

I just finished reading the very dense novel Midnight’s Children by Salman Rushdie (his first, from 1981), and I feel compelled to write about it, so *spoiler alert* for those who are planning to take it on one day. I nearly gave up on this novel because it’s a hard read (much like this review), but roughly mid-way through I became hooked as I realised that rather than being a fantasy novel, Rushdie was in fact weaving a brilliantly intricate and magnificently epic portrait (can you weave a portrait I wonder? – I suppose you can) of schizophrenia in his protagonist, Saleem Sinai. When I briefly looked the book up online this was either not mentioned at all, or was dismissed in favour of accepting the book’s other major motif on face value – that Saleem’s life is linked supernaturally to the fate of the nation of (pre-partition) India, but this seems a very superficial interpretation to me. There are references to a whole range of relevant symptoms, like auditory and olfactory hallucinations, complete absences of emotion and feeling, dissociative amnesia, paranoid delusions and delusions of grandeur, finding connections between everything, tangential thinking, mind reading, the notion of Saleem ‘cracking up’ (in the present day scenes), and perhaps some element of split personality* or at least an alter-ego (Saleem and Shiva). There are also a handful of indirect references to Saleem’s later unkempt appearance and aimless existence which kind of take you by surprise, because in fact it seems from the busyness of his thoughts that he is purposeful and always on the go; and finally there are direct references to potential inconsistencies in the plot made at the very end by Saleem himself, as though to suggest he is on some level aware of problems in his own version of events (but nevertheless remains unperturbed and unwavering in his beliefs). I think it is also far more satisfying to understand the meaning ascribed to the numerous and obscure connections as a grand elaboration on the part of the protagonist himself, rather than a pointless fantasy thought up by the author. It adds a layer of cleverness to the book, but ultimately makes this a very moving story of personal tragedy, one which mirrors the trials and tribulations of the subcontinent over the mid half of the twentieth century.

* Not actually a symptom of schizophrenia, but rather Dissociative Identity Disorder (DID), which is nevertheless at the same pointy end of mental health problems.

Post Traumatic Stress is like an Injury

Post Traumatic Stress Disorder (PTSD) is like an injury, and evidenced based psychological treatments are like rehabilitation exercises for this injury: 429 words.

In my early thirties I decided to get involved with a local soccer team. On my first training run, confident in the knowledge of how fit I used to be, I had a cursory warm up and started kicking the ball around with my new team mates. Within 20 minutes I had torn my calf muscle. I played on for a while that day, numbed by the adrenalin, and not realizing the seriousness of the injury. Afterwards I could still walk slowly, but any sudden movements and running were out of the question. When I later consulted my physiotherapist she said my muscles may never be as strong again, but with the right rehabilitation I could get back on the field.

Post Traumatic Stress Disorder is the mental health condition most like an injury. It can result from single or multiple traumatic events, and places significant limits on normal functioning, although not always right away. Certain experiences will trigger the mental pain of anxiety and anger. Many will try to kill this pain by self-medicating with alcohol and drugs, but this does not repair the damage. The traumatized live in fear of re-injury, and avoid situations they associate with their trauma. But it’s never enough to feel safe, and their lives narrow. Depression may follow.

A debilitating mental injury is a bad break for anyone, but for highly trained members of the military, emergency services and other high-risk occupations, their being confined to the bench can be a shaming experience. We may feel only sympathy for an elite athlete who suffers a career-limiting injury, but those impacted by post-traumatic stress fear being stigmatized as weak and unworthy. Attitudes towards mental illness and injury remain negative compared to their physical counter-parts.

Rehabilitation for physical injury is a gradual process, slowly building the strength and flexibility of muscles, and psychological treatment for PTSD usually proceeds in a similar way. For trauma survivors this involves slowly building confidence – confidence that they can face the memory and reminders of their trauma without suffering harm. Jumping straight in at the deep end is often too much too soon, but to hide away at home will only result in atrophy. Gradually facing fears is necessary if they want to get back on their feet, and then one day take to the field again.

People routinely seek help from physiotherapists, doctors and other health professionals for physical injury. It is my hope that greater awareness of PTSD as a kind of mental injury will make accessing treatment for this debilitating but treatable condition just as routine.

To Beat Depression you have to be a Strongman

A metaphor illustrating an evidenced based treatment for depression called Behavioural Activation: 460 words.

Working with depressed clients has reminded me of the world’s strongest man competitions I used to watch as a child. In one event, competitors would pull heavy vehicles strapped to their waste, and living with depression can feel like we are constantly dragging a heavy weight behind us. Strength alone was not enough to shift these enormous objects – their approach mattered. The Strongmen would lean forward to take the strain, and with their first small steps they would barely move off the mark, despite great strength and determination. In fact, they might sometimes slip backwards, trying too hard without sufficient traction. But with a steady persistence they would inevitably gain forward motion. From here they would build momentum, and gradually lengthen their stride. Before long they were moving at a normal walking pace. It was an impressive feat considering the weight they were pulling. In a similar way to this, it is possible for people to progress in life despite the weight of their depressive illness.

Depression reduces motivation, draining people of energy and instilling a sense of hopelessness and pointlessness. Understandably, people often reduce their activity levels and isolate themselves socially. Unfortunately, these responses strengthen depression by eliminating the few remaining opportunities to be rewarded by life, thereby confirming negative expectations and further reducing motivation in a vicious cycle.

An evidenced based approach to treating depression, Behavioural Activation, targets these maintaining factors. Like the strength athletes in the vehicle-pull event, we can expect a slow and potentially discouraging start. It requires very small steps, and a deliberate and focused approach. Schedule activities that instil a sense of achievement, increase connection to others, or are things you’ve enjoyed in the past. At first these might involve getting out of bed before midday, making a simple meal for a significant other, or going for a coffee at your local café, and regular exercise is recommended. Trying too hard can set us up for a slip backwards, and will probably confirm thoughts of failure. As we begin to build momentum mood can lift, and it will be possible to lengthen our stride by taking on more challenges. Maintaining momentum is important, so keep scheduling a variety of rewarding activities, and commit to doing these despite low motivation. Giving in to a few bad days here and there will not bring us to a grinding halt, but returning to patterns of withdrawal and isolation will, so get back on track when you can. When depression finally lifts it is easy to become complacent, so treatment guidelines recommend a focus on relapse prevention.

We needn’t cower in the shadow of depression. If it’s managed well we can live a meaningful life, and maintaining engagement in life is part of managing a depressive illness.