Why Psychiatry over Psychology?

[Salsa45]

I'm trying to decide what I want to do. I'm leaning towards psychiatry. Psychiatry appeals to me because it seems that a psychiatrist has a lot more freedom to treat a patient how they wish than a psychologist. However, I have heard comments about how psychiatry is just a figure-out-the-right-prescription-and-shove-them-out-the-door profession. How much of the psychiatric practice is like this, and what would you consider the pro's cons of being a psychiatrist over a psychologist?

Not counting educational differences-->I can handle the coursework either way and I don't care about the cost of education.

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[Anasazi23]

These are completely different professions in their own right with very different patient approach philosophies and training. Try a search to see some of the previous threads on this very topic, keeping in mind that you'll get different perspectives depending on whether you're in the psychiatry or psychology forum.

Simply put, psychiatry is a branch of medicine. So, it's 4 years of medical school, and 4 years residency + fellowship (optional). It's common misconception is that, as you put it, "find the right rx and push out the door." This is an unfair jab at psychiatry, since all medical specialties are generally paid more for the more patients you see. If a patient only requires a brief medication visit with scheduled follow-up, that's all they might need. In my experience, many, many patients have neither the time, nor the motivation for psychotherapy. An FP "finds the right prescription and pushes out the door," as does a dermatologist, internist, gastroenterologist, and neurologist. So, I'm not sure what, aside from therapy (many psychiatrists choose not to practice much therapy - others practice a great deal of therapy) people would like psychiatrists to do with their patients. The model is medical and disease driven. So, a diagnosis is made, and a treatment administered. Like an internist, dermatologist, or neurologist in practice, you spend a brief amount of time with the patient, and see them for follow-up. If you want to make more money, like any other branch of medicine, you see more patients. If you want to do therapy, you'd be in company of thousands of psychiatrists who practice therapy nationwide. No one will dictate to you how much or how little you can do. It's usually a matter of how much money you'd like to make.

Psychologists specialize in testing and therapy, and go to graduate school, rather than medical school. There is more focus on research as a PhD student, and they operate from a non-medical model in most cases. You can visit the psychology forum for their take on the training.

 

[Thewonderer]

I don't know. I like being able to prescribe medications in addition to doing psychotherapy. But med school and residency are rough. I hated the abuse I took on ob-gyn and surgery. Some surgery residents were really jerks who laugh at making fun of you (the med student) and the pts. So I don't know if it is worth the trouble to go through 4 years of med school and 4 years of residency just to be a psychiatrist.

You can be a social worker or master's level degree holder and still do psychotherapy (like MFT's, etc.). That's really a lot faster than going through 8 years of post-bachelor's training while paying lots of money and taking abuses (it is like paying $35-40k per year of med school tuition so you can wake up at 4am to spend 16-hour-day with the surgeons? there is something wrong with that picture).

 

[whopper]

I went through a similar psychiatry vs psychology debate myself years ago. Chose Psychiatry. I don't regret that decision, though I also think it can vary per person.

I would suggest psychiatry if the person is not afraid of biological & physical sciences, knows ahead of time that very little of the medical school curriculum is behavioral sciences, wants to have medical doctor level knowledge of the connection between physical pathology & mental illness, wants to make more money and is prepared to deal with the reality that for better or worse the industry has become medication driven over psychotherapy driven (not saying its right, just saying the way it is).

I would suggest psychology over psychiatry if the person is not a fan of the biological/physical sciences, is not willing to go through years of intense stufy of subjects like histology & biochemistry, but instead wants to stay within the realm of behavioral science education, is willing to make less money (though its not bad in clinical psychology) and enjoys long interactions with the patient.

There are of course people who are in the middle-e.g. good at the sciences but also want to do psychotherapy. In which case you're going to have to figure this one out on your own.

The 2 fields also differ in approaches. Psychology tends to deal more in statistics & other areas of behavioral sciences such as Sensation & Perception, Behavioral Endocrinology, Abnormal Psychology, Psychobiology.
Medical School tends to deal with the more pure biological sciences. E.g. when I learned Endocrinology in Medschool it was pure endocrinology. There was hardly any psychological/behavioral correlates of the endocrinology we covered. Not surprising since it was taught for all medstudents, including those that did not want to go into Psychiatry.

Some surgery residents were really jerks who laugh at making fun of you (the med student) and the pts.

I don't think this is as prevalent in the clinical psychology culture. I'm basing this completely on my own anectdotal experience and theories. I've noticed there's a lot of narcicism & type A personalities in the medical field, especially in the more intense fields where doctors are pushed to inhumane hours of work. I think its somewhat of a defense mechanism against the difficulties & stress of the job. This is apparently is lessening & there are now movements in the field to encourage more humane approaches, but I still see it here & there.

pure acting & somewhat unrealistic but it delivers the point.
http://www.youtube.com/watch?v=LqeC3BPYTmE&feature=related

Worse case I had was an Ob-Gyn resident who screamed at the medstudents, blew up in anger several times a day, would often yell expletives (even at patients). The guy was working inhumane hours, well over the 80 hr limit, and was used to do too much scutwork. I felt a mixture of anger & sympathy for the guy.

 

[Anasazi23]

I would suggest psychology over psychiatry if the person is not a fan of the biological/physical sciences, is not willing to go through years of intense stufy of subjects like histology & biochemistry, but instead wants to stay within the realm of behavioral science education, is willing to make less money (though its not bad in clinical psychology) and enjoys long interactions with the patient.

A decent portion of it boils down to this for me. When I was in grad school, I was always in awe of the people that loved those long therapy sessions with patients. I'm just not built like that. I remember feeling jealous of the medical doctors I'd watch that seemed to get a lot done in a relatively short amount of time.

 

[Decepticon]

These are completely different professions in their own right with very different patient approach philosophies and training.

OK.

The model is medical and disease driven. So, a diagnosis is made, and a treatment administered. Like an internist, dermatologist, or neurologist in practice, you spend a brief amount of time with the patient, and see them for follow-up.

Psychologists specialize in testing and therapy, and go to graduate school, rather than medical school. There is more focus on research as a PhD student, and they operate from a non-medical model in most cases. You can visit the psychology forum for their take on the training.

OK, to see if I have understood this correctly:
A psychiatrist has a medical education, a psychologist a graduate education.
A psychiatrist talks to the patient and puts a stamp/brand on the way the patient communicates and appears. A psychologist talks without thinking about similarities between the patient and features described in other patients.
A psychiatrist prescribes medication, a psychologist doesn't
A psychologist does research and holds a Ph.D, a psychiatrist doesn't do research (!)
Psychologists work on a non-medical model, whatever that means. (not prescribing medication? not seeing patients with acute fluctuation of consciousness? not dealing with patients who are very different from most patients?)

 

[michaelrack]

OK.



OK, to see if I have understood this correctly:
A psychiatrist has a medical education, a psychologist a graduate education.
A psychiatrist talks to the patient and puts a stamp/brand on the way the patient communicates and appears. A psychologist talks without thinking about similarities between the patient and features described in other patients.
A psychiatrist prescribes medication, a psychologist doesn't
A psychologist does research and holds a Ph.D, a psychiatrist doesn't do research (!)
Psychologists work on a non-medical model, whatever that means. (not prescribing medication? not seeing patients with acute fluctuation of consciousness? not dealing with patients who are very different from most patients?)

Many psychiatrists do research. I am (sort-of) a psychiatrist, and am currently engaged in research even though I am in private practice. One big difference between the 2 specialties is that psychologists do psychological testing- MMPI, neuropsychological testing, etc, and pscychiatrists in general don't.

 

[Anasazi23]

OK.



OK, to see if I have understood this correctly:
A psychiatrist has a medical education, a psychologist a graduate education.

Right. A psychiatrist goes to medical school, then completes a residency in psychiatry. A psychologist goes to graduate school, then completes an internship and what they call a post-doc. A psychiatrist is an MD or DO. A psychologist is a PhD or PsyD.

A psychiatrist talks to the patient and puts a stamp/brand on the way the patient communicates and appears. A psychologist talks without thinking about similarities between the patient and features described in other patients.

I wouldn't put it quite this way.
Both assess the patient through interviewing, behavioral observation, etc. Psychologists often use psychological testing, psychiatrists rely more on clinical interview and any relevant portions of medical rule-outs.

A psychiatrist prescribes medication, a psychologist doesn't

Yes, since they're (psychiatrists) are physicians, they prescribe medications, order tests and labs, may perform parts of the physical exam, etc.

A psychologist does research and holds a Ph.D, a psychiatrist doesn't do research (!)

Not quite. Many psychologists do research. Many don't. In most cases, psychologists are better qualified to conduct and interpret research, since large part of their training is dedicated to this. Psychiatrists can do research as well. Many work with pharmaceutical companies or are researchers in medical university settings. In general, the medical education process is much less focused on research.

Psychologists work on a non-medical model, whatever that means. (not prescribing medication? not seeing patients with acute fluctuation of consciousness? not dealing with patients who are very different from most patients?)

The medical model is one of accepting pathology as a disease state, which can be treated with a variety of medicaments, including medication. Psychologists tend to view the patient (often called "clients" by psychologists) as a person less with a disease, and more as an ongoing assessment and psychological treatment entity. Others will debate this last part, but it's hard to debate the fact that psychiatrists are much more medical-model oriented than a psychologist would be.

 

[PsychevalIII]

A decent portion of it boils down to this for me. When I was in grad school, I was always in awe of the people that loved those long therapy sessions with patients. I'm just not built like that. I remember feeling jealous of the medical doctors I'd watch that seemed to get a lot done in a relatively short amount of time.

CPT - 90804. 20 minute therapy. Most private insurance will pay a psychologist $60 / unit. 3 units / hour = $180

Ideal for stable pediatric patients with a parent or a C & L Psychology Service.

Regards

 

[Decepticon]

The medical model is one of accepting pathology as a disease state, which can be treated with a variety of medicaments, including medication. Psychologists tend to view the patient (often called "clients" by psychologists) as a person less with a disease, and more as an ongoing assessment and psychological treatment entity. Others will debate this last part, but it's hard to debate the fact that psychiatrists are much more medical-model oriented than a psychologist would be.

Umm.. are you talking about observed differences in what theories people prefer or understanding people have? Is there anything preventing a psychologist from also reasoning by thinking of frontal lobe destruction, transmitter concentrations etc. being a part of the behavior the patient presents with?

 

[Anasazi23]

Umm.. are you talking about observed differences in what theories people prefer or understanding people have? Is there anything preventing a psychologist from also reasoning by thinking of frontal lobe destruction, transmitter concentrations etc. being a part of the behavior the patient presents with?

No there isn't. Corrlelating brain dysfunction, most often in the context of cognitive abnormalities, is what neuropsychologists do, in particular. They measure this through various testing strategies. They may be able to engage in some cognitive remediation to help correct this if possible, but actual treatment is certainly more in the realm of the psychiatrist.

In general more gross anatomical and medically-related psychiatric pathology is the realm of the psychiatrist by definition.

 

[Anasazi23]

CPT - 90804. 20 minute therapy. Most private insurance will pay a psychologist $60 / unit. 3 units / hour = $180

Ideal for stable pediatric patients with a parent or a C & L Psychology Service.

Regards

Yes, we had almost all 20 minute med-check/brief psychotherapy sessions throughout my 3rd and 4th years while I was in outpatient. Even then, I tended to see patients for a shorter amount of time than this. Then in other cases, I'd spend an hour if the case was particularly difficult. I remember specifically a woman I saw every two weeks who was basically nursing a waxing/waning outpatient delirium secondary to end stage Hep C with profound psychosis manifested by strong paranoid delusions and derogatory auditory hallucinations. Wacky husband didn't help matters either.

 

[whopper]

Another difference I wanted to point out is that psychiatrists tend to deal with the cases that justify medication more--and in effect are more severe cases.
e.g. someone trying to jump off a bridge for whatever reason (Depression, psychosis, mania).

Clinical psychologists tend to deal with the patient after the patient has reached a level of stability where talk therapy can help them. Very psychotic patients, screaming and needing restaints often do not fit that category.

I have also noticed the clinical psychologists tend to consider several aspects we psychiatrists do not. We get a medical education--they get a different curriculum which incorporates more use of psychometric testing, epidemiology statistics & non-pathological behavioral sciences (psychiatrists tend to get only behavioral science traininng to treat pathology). For example one psychologist in my department makes cognitive maps based on Hasse Diagrams
http://en.wikipedia.org/wiki/Hasse_diagram

I've never received training on making these maps--he has. His maps are very useful in clinical treatment. The best I can do is make mental projections of what the patient might do, but having it down as a real diagram is better for a treatment team to use & clarifies things very quickly.

In the area of forensic psychiatry for example, several forensic psychiatrists I've worked with don't have much if any experience with psychometric tests to rule out malingering, but several forensic psychologists do have this training.

Several psychiatrists have also mentioned that in treatment teams with both a psychiatrist & a psychologist, that the psychiatrist has higher standing. I however have not seen any documentation that officiates this and every psychologist I worked with as a team member never put me in a situation where one of us had to pull rank to see who was the "leader". My own view is we're all colleagues & should treat each other as such.

Personally, I'm a bit surprised & like some of you, perplexed with how the system exactly defines what the psychogist does vs the psychiatrist. It seems to me its not so much by our-the providers' design but by the design of managed care. Several psychiatry residency programs seem to focus less on psychotherapy these days and several only consider psychologists & "old school" psychiatrists as psychotherapy masters, where as younger psychiatrists are not considered skilled in psychotherapy. I'm not advocating that we as psychiatrists disregard psychotherapy-just that this is what is happening, and if anything we should be aware of it and make sure we get good training in this area.

 

[Therapist4Chnge]

Clinical psychologists tend to deal with the patient after the patient has reached a level of stability where talk therapy can help them. Very psychotic patients, screaming and needing restaints often do not fit that category.

Agreed. Acute stabilization is more of the realm of psychiatry, as medication is almost always required to get the person to a place where they aren't going to be dangerous to themselves or others.

 

[manwhoisthursdy]

Several psychiatrists have also mentioned that in treatment teams with both a psychiatrist & a psychologist, that the psychiatrist has higher standing. I however have not seen any documentation that officiates this and every psychologist I worked with as a team member never put me in a situation where one of us had to pull rank to see who was the "leader". My own view is we're all colleagues & should treat each other as such.

While I definitely agree with the spirit behind this, in practice I have seen that in treatment teams, the psychiatrist (and never the psychologist) does the following:

1. decide that the patient meets (or continues to meet) commitment criteria

2. ultimately decide what groups to put the patient in

3. prescribe/change medications

4. decide when the patient is ready for discharge, and to what type of facility if not to home

5. decide if the patient should have psych testing. Yeah the psychologist will offer opinion as to if and what kind, but in my experience it is the psychiatrist who asks the psychologist, "okay so I want to find this out ... can you use your expertise to help."

6. get updates from nursing and ancillary staff

7. write orders about things other than meds, groups and testing (e.g. diet, or consults/referrals for other specialties, off-site passes, restriction levels, suicide precautions, fall risk precautions, etc. etc.)

I'm sure people have seen different things, but I've seen an environment where, generally, social workers and psychologists are highly valued for their expertise but the psychiatrists coordinate the team members and makes ultimate decisions.

 

[erg923]

1.) "In the area of forensic psychiatry for example, several forensic psychiatrists I've worked with don't have much if any experience with psychometric tests to rule out malingering, but several forensic psychologists do have this training."

To split hairs here.....all clinical forensic psychologists (and all clinical psychologists) are trained in detecting deception from psychometric instruments.

2. "I've never received training on making these maps--he has. His maps are very useful in clinical treatment. The best I can do is make mental projections of what the patient might do, but having it down as a real diagram is better for a treatment team to use & clarifies things very quickly."

I hear psychiatrists say these kinds of things alot, and how all the have is their clinical judgment. I've always wondered if psychiatrists are aware of, or have to read this article and/or study these phenomena during their training. This is mandatory for almost all clinical psychology doctoral students. Its a good read if you like stats. The Minnesota school of thought is both revered and jeered in psychology. But what else would you expect from the birthplace of the MMPI... Although a clinical tool, MMPI codetypes, in their purest forms, are a great example of a statistical prediction model.

Meehl, P. (1954) Clinical Versus Statistical Prediction: A Theoretical Analysis and a Review of the Evidence.

 

[whopper]

I've always wondered if psychiatrists are aware of, or have to read this article and/or study these phenomena during their training.

A reason why we should be working together as a team for the betterment of the patient. I've sat through enough meetings & classes where one discipline slams the other. One side gets training in some areas the other field doesn't get. All of that training can end up helping.

I sat through an interesting court case where the forensic psychiatrist argued on the defense basing it on his clinical skill, but basing none of his opinion on psychometric testing. The prosecution used a forensic psychologist who employed several psychometric tests that pointed to malingering.

Very different schools of thought. Too bad I never found out judge's decision.

Meehl, P. (1954) Clinical Versus Statistical Prediction: A Theoretical Analysis and a Review of the Evidence.

Know of any more recent articles covering this? I'm very interested to see which would hold superiority in court.

 

[erg923]

The point of me bring this up (clinical vs: statistical prediction) is that this issue is very very relevant for psychiatrists since they do so much clinical decision making regarding criminal recidivism, behavior, treatment outcomes, etc. And I cant really understand why your profession would not educate its residents in these critical issues. Both professions have been resistat to adopt this well documented phenomena that clinical decision making is much less accurate than we think, and would like to believe. There has been little need for modification of the meta-analysis presented in Meehl's 1954 paper, because 1.) not much research is done on it within clinical decision making 2). No one has produced a clinical decision model, that is superior to actuarial methods. One of his former students, also at Minnesota, William Grove, Ph.D., wrote a review and update article in 2005. This is a decent synopsis, and explains others arguments against it. But yes your right, very different kinds of training in the 2 fields and both can compliment the other when they work together.

http://www.psych.umn.edu/faculty/grove/112clinicalversusstatisticalprediction.pdf

 

[manwhoisthursdy]

Regarding the whole psychometric testing in a forensic setting thing: I just finished a forensic psychiatry elective, and regularly saw that evaluating psychiatrists got tests (like the TOMM) from psychologists, which they then incorporated, along with social work assessments and all sorts of other information (I had one attending who ordered a head CT as part of his evaluation to assess the likelihood of serious mental sequelae of head injury) into the evaluation.

An advantage that the forensic psychiatrist may have: familiarity with the course of illness when a defendant has not been meds around the time of an offense, or when meds may have affected a defendents behavior during the offense (e.g. the Ambien defense), or when medical illness complicates the issue, or when you need to answer the question "is inpatient psychiatric treatment likely to restore competence to stand trial or not?"

 

[erg923]

Yes, good deal. A good evaluation always uses multiple sources of info. And if what you mean by "mental sequalea" is cognitive deficits, I hope that the attending ordered a neuropsychological evaluational from a neuropsychologist as well. A CT in no way would tell you if some one had cognitive deficits. The literature is clear that plenty of patients with unremarkable imaging can have loads cognitive problems. Conversely, I have seen brains in postmortem exams of patients who's brains were very atrophied but manifested relative little cognitive problems when alive. Plus, I would think that he would need some way to quantify the deficits if he suspected them anyway.

 

[manwhoisthursdy]

Yes, good deal. A good evaluation always uses multiple sources of info. And if what you mean by "mental sequalea" is cognitive deficits, I hope that the attending ordered a neuropsychological evaluational from a neuropsychologist. as well. A CT in no way would tell you if some one had cognitive deficits. Plus, you would need some way to quantify them if he suspected them anyway.

By mental sequelae, I meant to include cognitive deficits but also, "does the CT show damage which might add weight to the possibility that the defendant has poor impulse control secondary to the injury." (Which might affect "capacity to conform conduct to the requirements of the law," which is relevant to South Carolina's Guilty But Mentally Ill statute. I don't know about other states.) My understanding is this is much much harder to quantify than cognition, hence the CT.

But yes, I was taught that neuropsych testing, is an important part of any evaluation in which cognitive deficits may have affect the outcome of the evaluation and when they are not obvious. (Sometimes you can just tell, by interview, that a defendant is very intelligent and knowledgeable about their legal situation ... but you know what I mean ... testing for the harder cases.)

 

[erg923]

Ah..I see what your saying. Yes, CT would be good to have to increase evidence of that. Although with a lack of neuropsych testing all you can say is "he has damage to frontal regions which could possibly cause impulse control problems.: With both however, you can can say, "client demonstrate difficulties with impulse control on these tests X, Y, Z. These deficits are consistent with frontal damage, as can be seen in this CT scan."

Many executive function tests can capture difficulties with inhibition or impulsiveness (stroop, Wisconsin card sorting) as can collateral questionnaires or personality measures (behavioral dyscontrol scale, FrSBE) as well as careful behavioral observations during testing.

 

[Therapist4Chnge]

Ah..I see what your saying. Yes, CT would be good to have to increase evidence of that. Although with a lack of neuropsych testing all you can say is "he has damage to frontal regions which could possibly cause impulse control problems."

These are the kind of things that make the lawyers for your side cringe....as any weakness can be exploited by the other side. ("Why didn't you use the XYZ assessment, etc")

I know people who do this for a living (and have for decades), and they always say that you need to be VERY careful with what you say and how you say it, which is why there are good experts....and then everyone else.

 

[whopper]

And I cant really understand why your profession would not educate its residents in these critical issues.

Don't ask me why this is happening. I don't know. Its frustrating when for example the gold standard book of psychiatry--Kaplan & Sadock even mentions a psychometric test that should be used for a particular situation and the psychiatrist won't do it becuase they don't know how to do it.

Yes I have seen psychiatrists occasionally incorporate psychometric tests but in general its something it seems we don't do much.

I've read the AAPL's booklet on competence to stand trial, and it has a section on the use of psychometric tests. It mentions that while psychometric tests are extremely useful, they do not have to be used so long as the forensic psychiatrist does a thorough interview that also incorporates collateral information.

That answer didn't quite satisfy my curiosity on the subject. If I were for example a judge and I was told that psychometric testing was far more accurate than clinical interviewing, I'd consider the results of a psychometric test in addition to an interview to be a far more effective means of detecting what's really going on vs a simple interview.

I asked the forensic psychiatrist I was working with during an elective about this (he was the guy that testified the interview data, a forensic psychologist on the opposing team presented interview data in addition to psychometric tests results). That psychiatrist just gave a 1 sentence answer to the effect of -well I don't know how to use these tests so I'm just going to not go into that territory-.

I guess this is something I'll have to wait until my forensic fellowship starts to get some better answers on this topic.

 

[erg923]

Agreed, although I didn't mean to imply psychiatrist should be trained in psyhometrics, as this remains our territory. I really meant that I cant understand why psychiatry isn't better educated or at least be aware of clinical versus statistical equation modeling, and the limited accuracy of "clinical judgment" when compared to linear equation models for the same behavior in question. The attached article in my previous post provides a great synopsis of this and and is less obtuse than Meehl (1954).

 

[Anasazi23]

Agreed, although I didn't mean to imply psychiatrist should be trained in psyhometrics, as this remains our territory. I really meant that I cant understand why psychiatry isn't better educated or at least be aware of clinical versus statistical equation modeling, and the limited accuracy of "clinical judgment" when compared to linear equation models for the same behavior in question. The attached article in my previous post provides a great synopsis of this and and is less obtuse than Meehl (1954).

You might be pigeonholing what forensic psychiatrists do. Predictive estimates of violence has been studied extensively. Volumes exist on Risk Management. Neither psychologists nor psychiatrists are great predictors, and psychometric testing fails to take into account other variables that factor into such prediction. A good portion of patients invalidate psychologic measures with unsophisticated attempts to present in a certain manner. I'm not saying that psychological testing is not valuable to the process...quite the contrary. But to discount the clinical interview or fail to take into account predictive variables based on diagnosis and history is also a mistake.

 

[Therapist4Chnge]

A really interesting area of forensic work is competency to stand trial work, though that tends to be more in the psychology domain (because of the psychometric testing), though it varies by state and some places have strong preferences for one group or the other to complete the assessment.

 

[manwhoisthursdy]

Neither psychologists nor psychiatrists are great predictors

I think it's interesting (and funny) that the Supreme Court has not justified expert testimony on dangerousness because it's at all considered "accurate." The Court has simply said that given the situation we find ourselves in, psychiatric testimony is now an integral part of the legal process, and if dangerousness is to be discussed, psychiatric testimony cannot be excluded since there is *no reason to believe psychiatrists are less capable of assessing dangerousness than any ordinary person*. (The court has also said that indigent defendants be provided a psychiatrist to argue, among other things, against dangerousness ... again not because it's accurate but simply because expert testimony strongly influences a jury and it's a violation of due process if the state can use psychiatric testimony and the defendant can't afford it.)

I'm not saying that's the extent of it clinically, but that's the legal situation ... I wish I could remember which landmark case ... Barefoot v. Estelle or Ake v. Oklahoma maybe.