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Why should you obtain a diagnosis in cooperation with a psychiatrist, psychologist and psychotherapist?

A diagnosis, i.e. the recognition of an illness, is the basis for the choice of treatment or a referral to another centre. Often, it also turns out to be the starting point for a change in the way a patient thinks about himself/herself, his/her prospects for treatment, or even planning his/her future life. Alleged consequences of a psychiatric diagnosis may include a conviction, often mistaken, that the patient is not responsible for his/her actions, unable to marry, at risk of passing the disorder onto his/her offspring, likely to be dismissed from work and many more. 

One of the most painful experiences for patients (and future patients) is the unfortunate Internet diagnosis consisting of a Google search for extreme opinions and random descriptions leading to, for example, a false belief in the incurability of personality disorders, greater or exclusive effectiveness of one therapy type or medication to treat the condition. Such situations are often a product of trust in one-sided or simply dishonest advertising or a belief that some outdated views, unfounded ideologies, personal beliefs or various frustrations of the Internet users can be considered a scientific truth. 

The only correct way to carry out a full diagnosis is an in-person examination (even during the Covid-19 pandemic it is highly doubtful that such an assessment can be carried out via such an application as Skype or by telephone) by a competent person. 

At this point, it is necessary to clarify the concept of competence, especially in view of the common confusion between three or even more related professions – primarily those of a psychiatrist, psychologist, psychotherapist and nurse and, additionally, an addiction therapist, social skill trainer, recovery assistant, coach, mediator, counsellor, etc. The process of diagnosis is performed by representatives of the first three professional groups, with the greatest participation of physicians - psychiatrists. From time to time, there are proposals to limit diagnosing to doctors only (including psychiatrists, of course) and consider such terms as a medical diagnosis and psychiatric diagnosis as different from a psychological diagnosis and psychotherapeutic diagnosis. These are, of course, legitimate postulates, but at the same time they indicate competence differences, which I will try to explain later in this text.

Additional complications are caused by the fact that some professionals work in two or more of these areas and have two or more qualifications - most psychiatrists working in the field of psychotherapy are or want to become certified psychotherapists, too, while many psychologists working at state-funded centres are also certified psychotherapists. In addition, practitioners sometimes are responsible for a wider or narrower range of tasks, which increases their competences, for example in the areas of pharmacotherapy for the elderly, couples’ psychotherapy, outpatient treatment for adolescents or expert opinions for the court or insurance purposes. These narrower specialisations are not reflected by professional titles or designations, but they may be helpful when you need to choose a person who will diagnose you. 

A psychiatrist is a physician by training, which allows him to perform a preliminary diagnosis, the so-called differential diagnosis to determine whether the patient’s complaints are psychogenic (caused by mental factors) or based on biological grounds, for example, neurological, internal medical or surgical, which may even require an urgent diagnosis in an emergency department or a surgical intervention (for example, the removal of a brain tumour). Moreover, a psychiatrist as a physician is the only one authorized to issue a sick leave (in which he/she may be assisted by an authorized assistant) and he/she is usually responsible for the pharmacotherapy using psychiatric drugs, too. This can also be (although relatively rarely)  the responsibility of a neurologist, GP or a physician of other speciality. The psychiatrist (and any physician), unlike other professions mentioned above, can also refer the patient to many additional tests and consultations.

A psychologist is perceived by many patients as ‘safer’ and ‘non-stigmatising’, unlike the psychiatrist; contact with him/her does not necessarily mean a record documenting a mental disorder is entered into the psychiatric health care system. Unfortunately, the psychologist, especially if he or she is not a specialist in clinical psychology (which requires several years of postgraduate education completed with a difficult state examination), may not have adequate knowledge to carry out a full differential diagnosis. 

A psychotherapist can see patients independently, without a referral, however, as a person who is not a psychiatrist, psychologist, educator or even a philosopher, but just an MA programme graduate, he/she may not have sufficient knowledge and should not treat people with incompletely diagnosed somatic or conversion disorders on his/her own. He/she should consult a psychiatrist or sometimes physicians of other specialisations, e.g. primary care or neurology.

The author of this text takes the liberty of expressing his personal conviction that the safest and most beneficial way for a patient who suspects he/she may have a mental disorder and need psychotherapy or pharmacotherapy is to begin the diagnosing process by consulting a psychiatrist, preferably a specialist in the field of the patient’s alleged disorder. After discussing indications with the physician, the diagnosis may be expanded to include a psychological and/or psychotherapeutic diagnosis aimed at a broader recognition of the conditions and difficulties of an individual patient and, finally, his/her preparation for psychotherapy.

Reference literature:

Jerzy Aleksandrowicz, Psychoterapia. Poradnik dla pacjentów. Wydawnictwo Uniwersytetu Jagiellońskiego. Kraków, 2004. ISBN 978-83-233-1890-3

About the author

Jerzy A. Sobański, MD-PhD – psychiatrist and psychotherapist, assistant professor at the Faculty of Psychotherapy of the Jagiellonian University Medical College. For two decades he has been teaching psychotherapy to students of medical and postgraduate programmes. He has authored publications on the psychopathology of anxiety disorders and the effectiveness of psychotherapy. He is deputy chief-of staff of the bimonthly ‘Psychiatria Polska’ and secretary of the Edititorial and Publishing Committee of the Polish Psychiatric Association. He earned his doctoral degree in medical sciences from the Medical Faculty of the Jagiellonian University Medical College.