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When Might Your Client Need a Psychiatrist?

Counselling and therapy trainings rarely cover psychiatry in much depth. So what happens when the two fields overlap in practice? As an NHS psychiatrist trained in person-centred counselling, and the author of a new book about psychiatry for counsellors, Dr Rachel Freeth is often asked how therapists can gauge whether a psychiatric referral is in their client’s best interest. As she explains here, there are no easy answers – but understanding the factors at play in such a decision is a good place to start.


If there is one key learning point about psychiatry and who might need a psychiatrist, it is that there are few absolutes. Yet there are instances when therapists need to consider whether their client needs a referral to a psychiatrist or mental health team. So even if there are few absolutes, guidance will certainly be helpful. 

It is likely that this issue will become even sharper over the coming months. In the wake of the Covid-19 pandemic, there are warnings about an ‘epidemic’ of depression and anxiety. In my role as a psychiatrist, I am bracing myself for an increased clinical workload.  

Huge numbers of people, young and old, are being traumatised by the social and psychological impact of the coronavirus. Many will turn to statutory healthcare services, often initially consulting their GP. Others will seek counselling or psychotherapy independently. But how do we know what kind of help will be beneficial – whether, for example, a person will benefit most from psychiatric drugs, CBT or person-centred counselling? 

As a counsellor as well as a psychiatrist, I have regularly considered when a person might need a psychiatrist and when psychotherapy or some other form of help might be more beneficial. This is actually pretty complex to think about. It means being able to take into account such factors as: 

How mental distress in general is conceptualised: is it a medical condition that might require medical treatment? Or a normal and understandable response to psychosocial stress and trauma? Or both? 

The particular form (or nature) and severity of distress – for example, severe low mood, mania or psychosis that may require specialist assessment and expertise. 

Whether the mental distress is of a nature or degree that places the person at risk of harm through suicide, self-injury or self-neglect, or poses risk to others, and when intervention is necessary in the interests of health and safety.   

Whether psychiatric drugs might play a useful role, and the various short-and long-term effects of drugs – physiological and psychological, helpful and harmful. 

What kind of help a person wants and can work with – whether from a more medical model and diagnostic framework (as tends to be the main operating framework of statutory healthcare services), or someone to listen attentively to their story, help them make sense of their experience, or perhaps support them to grieve. 

What actual help is available, accessible and affordable. 

What concerns me is that many people are referred to mental health services either because it is assumed that they need a medical (psychiatric) form of help, without seriously exploring and questioning the many consequences of this, or because of a lack of alternatives. In my place of work, many people will be referred into services because they are not able to access individual therapy – particularly of a non-medical model kind – unless they have the means to pay for it. 

There are times when seeing a psychiatrist or other mental health professional may be in a person’s interests. But when and how to judge whether and when these situations apply will not necessarily be obvious or easy. Clearly this has implications for training and continuing professional development on a range of issues such as the nature and role of psychiatric diagnosis, psychiatric drugs, the medical model, assessing and tolerating risk, mental capacity, an understanding of how different values and ethical positions influence our clinical practice and decision-making, and, crucially, understanding the limitations and potential harms of psychiatry. These are just some of the areas I cover in my new book. 

Psychiatry and Mental Health: A guide for counsellors and psychotherapists, by Rachel Freeth, is published by PCCS Books.  


Rachel Freeth

Rachel Freeth has worked as an NHS psychiatrist for nearly 25 years, during which time she has worked in a variety of different mental health settings. She currently works as a community psychiatrist in Herefordshire, England. Rachel also trained in person-centred counselling in the late 1990s and has most recently worked as a counsellor in the voluntary sector.

For a number of years she has been delivering workshops on subjects related to psychiatry and mental health, many of which are designed for counsellors and psychotherapists. Both through delivering training and writing she aims to bridge the different worlds of psychiatry and counselling. See for further details of her publications, including her first book Humanising Psychiatry and Mental Health Care: The challenge of the person-centred approach (2007). Oxford: Radcliffe Publishing. She lives with her partner in Gloucestershire.