What is a psychiatrist?

As a psychiatrist, I have often been asked the questions, “What is a psychiatrist, and what do they do?” “What is the difference between a psychiatrist and a psychologist?” and, “Why should I see a psychiatrist instead of a therapist?” The most straightforward answer to the first question is that a psychiatrist is a medical doctor that specializes in the diagnosis and treatment of mental illnesses. A psychiatrist must complete four years of medical school, then spend an additional four years of specialized training in an approved residency program in general psychiatry. Some psychiatrists go on to further specialize in the subspecialties of child and adolescent psychiatry; geriatric psychiatry; substance abuse and addiction treatment; consult liaison psychiatry, which usually involves consultations about psychiatric issues on medical floors of hospitals; or forensic psychiatry, which concerns the overlap of mental illness and the law. A new and growing area of psychiatry is interventional psychiatry. That subspecialty involves use of device-driven techniques such as electroconvulsive therapy, transcranial magnetic stimulation, deep brain stimulation and other high-tech methods that alter brain activity through electromagnetic means.

The roles of psychiatrists, psychologists, and therapists are complimentary and often overlap. The current understanding of mental illness, held by virtually all branches of mental health care, is based on the bio-psycho-social model. That is, that mental illness is partly biological and reflects abnormalities in the chemistry and function of the brain. However, mental illness can also rise out of psychological trauma, misinformation and maladaptive behaviors we bring with us from childhood or develop on the way. Finally, as social animals dependent on the resources, protection and good will of general society, the stresses, traumas and misfortunes of cultural conflict, racism, sexism, religious bigotry and economic tribulations add their own layers of distress. One component may contribute to illness more than the others in each individual. Each must be considered, but one form of  expertise may offer a particular individual more help than the others.

All licensed mental health care providers, whether a psychiatrist, psychologist or social worker, are capable of establishing a diagnosis. Because of their medical training, psychiatrists are uniquely well equipped to recognize and pursue the biological components of mental illness. Moreover, many primarily medical conditions can exacerbate or mimic mental illnesses, and it is the psychiatrist’s job to identify and treat those conditions or to refer the patient to another medical specialist. Treatment often entails laboratory testing, and in some cases addressing hormonal or nutritional deficiencies. There may also be genetic predispositions that must be recognized and compensated for. While psychological issues, traumas and learned maladaptive behaviors can lead to mental disturbances, they can also cause physiological stresses that in turn can generate  abnormalities of brain chemistry. These abnormalities often need to be stabilized by a psychiatrist before the underlying psychological contributions can be successfully addressed. The psychiatrist generally treats these biological aspects of mental illness with medications. If the condition has no obvious basis in the recent events in a person’s life and includes a lot of physical symptoms, such as changes in sleep, appetite and energy, then a psychiatrist may be a good initial choice. If a person has done well on medication in the past, or has family members who have suffered a similar set of symptoms and responded well to medication, a psychiatrist may again be a good choice. Certain conditions, such as schizophrenia, bipolar mania or severe ADHD, almost always require medication and the skills of a psychiatrist.

If a person is having difficulties with a specific aspect of their life—something they can put their finger on that is causing them persisting distress—it is often prudent to seek help from a psychologist or other psychotherapists who can point out errors in thinking and offer alternatives to failing behavioral patterns. In general, mental illnesses that arise primarily out of psychological trauma, misconceptions about one’s self and other people or maladaptation to life’s demand, are often best treated with psychotherapy. All psychiatrists receive training in psychotherapy during their four years of residency, and many are quite skilled in providing it. However, the current realities of medical economics make it more common for psychotherapy to be delivered by a psychologist or therapist, such as a licensed clinical social worker. Given the fact that psychologists and other therapists focus almost entirely on psychotherapy, they often have a higher level of experience, confidence and skill in offering it as treatment.

There are also different schools and approaches to psychotherapy, ranging from cognitive behavioral therapy to interpersonal psychotherapy to psychoanalysis. Although much has been written about the unique merits of each approach, often the type of therapy is less important than the strength, competence and empathy of the individual therapist.

Although one patient may respond best to medication, and another to psychotherapy, in more severe cases, a combination of medication and psychotherapy is often necessary. Even if a condition arises almost entirely from biological aberrations, the suffering, losses, and disappointments that arise from such illness may still need to be discussed, put into perspective, and learned from with the help of a skilled therapist.