When Might Your Client Need a Psychiatrist?

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.