A psychiatric advance directive (PAD), also known as a mental health advance directive, is a written document that describes what a person wants to happen if at some time in the future they are judged to be suffering from a mental disorder in such a way that they are deemed unable to decide for themselves or to communicate effectively.
It can inform others about what treatment they want or do not want from psychiatrists or other mental health professionals, and it can identify a person to whom they have given the authority to make decisions on their behalf. A mental health advance directive is one kind of advance health care directive.
Psychiatric advance directives are legal documents used by persons currently enjoying legal capacity to declare their preferences and instructions for future mental health treatment, or to appoint a surrogate decision maker through Health Care Power of Attorney (HCPA), in advance of being targeted by coercive mental health laws, during which they may be stripped of legal capacity to make decisions.
In the United States, although 25 states have now passed legislation in the past decade establishing authority for PADs, there is relatively little public information available to address growing interest in these legal documents. In addition in states without explicit PAD statutes, very similar mental health advance care planning can and does take place under generic HCPA statutes – expanding the audience for PADs to all 50 states (refer to National Resource Centre on Psychiatric Advance Directives).
In addition, states are beginning to recognise legal obligations under the federal Patient Self-Determination Act of 1991, which includes informing all hospital patients that they have a right to prepare advance directives and – with certain caveats – that clinicians are obliged to follow these directives.
Finally, the Joint Commission on the Accreditation of Healthcare Organisations (JCAHO) requires behavioural health facilities to ask patients if they have PADs. The Centres for Medicare and Medicaid Services announced that patients have the right to formulate advance directives and to have hospital staff and practitioners who provide coercive interventions in the hospital comply with these directives. Hospitals out of compliance risk loss of Medicare and Medicaid revenue.
Proponents of these directives believe thy of followed by treatment providers, crisis planning using PADs will help involuntary detainees retain control over their decision making – especially during times when they are labelled incompetent. Additionally, advocates argue that health care agents will be instrumental in providing inpatient clinicians with information that can be central to patients’ treatment, including history of side effects and relevant medical conditions.
Recent data from a NIH-funded study conducted by researchers at Duke University has shown that creating a PAD with a trained facilitator increases therapeutic alliance with clinicians, enhances involuntary patients’ treatment satisfaction and perceived autonomy, and improves treatment decision-making capacity among people labelled with severe mental illness.
Moreover, PADs provide a transportable document – increasingly accessible through electronic directories – to convey information about a detainee’s treatment history, including medical disorders, emergency contact information, and medication side effects. Clinicians often have limited information about citizens detained and labelled as psychiatric patients who present or are coercively presented and labelled as in crisis. Nonetheless, these are the typical settings in which clinicians are called upon to make critical patient-management and treatment decisions, using whatever limited data may be available. With PADs, clinicians could gain immediate access to relevant information about individual cases and thus improve the quality of clinical decision-making – appropriately managing risk to patients and others’ safety while also enhancing patients’ long-term autonomy.
For these reasons, PADs are seen as an innovative and effective way of enhancing values of autonomy and social welfare for detainees labelled with mental illness. Since PADs are among the first laws that are specifically intended to promote autonomy among people detained under mental health laws, wider use of PADs would empower a traditionally disenfranchised group when targeted for coercive psychiatry.
National surveys in the United States indicate that although approximately 70% of people targeted by coercive psychiatry laws would want a PAD if offered assistance in completing one, less than 10% have actually completed a PAD.
Some people detained and forcibly drugged under coercive psychiatry laws report difficulty in understanding advance directives, scepticism about their benefit, and lack of contact with a trusted individual who could serve as proxy decision maker. The sheer complexity of filling out these legal forms, obtaining witnesses, having the documents notarised, and filing the documents in a medical record or registry may pose a formidable barrier.
Recent studies of practitioners of coercive psychiatry’s attitudes about PADs suggest that they are generally supportive of these legal instruments, but have significant concerns about some features of PADs and the feasibility of implementing them in usual coercive intervention settings. Clinicians are concerned about lack of access to PAD documents in a commitment, lack of staff training on PADs, lack of communication between staff across different components of mental health systems, and lack of time to review the advance directive documents.
In a survey conducted of 600 psychiatrists, psychologists, and social workers showed that the vast majority thought advance care planning for crises would help improve patients’ overall mental health care. Further, the more clinicians knew about PAD laws, the more favourable were their attitudes toward these practices. For instance, while most psychiatrists, social workers, and psychologists surveyed believed PADs would be helpful to people detained and targeted for forced drugging and electroshock when labelled with severe mental illnesses, clinicians with more legal knowledge about PAD laws were more likely to endorse PADs as a beneficial part of patients’ treatment planning.
However, many clinicians reported NOT knowing enough about how PADs work and specifically indicated they lacked resources to readily help patients fill out PADs. Thus, if clinicians knew more about advance directives and had ready assistance for creating PADs, they said they would be much more likely to help their clients develop crisis plans.
It thus has become clear that the potential significance of PADs is becoming widely recognized among those targeted for coercive psychiatry, survivors of coercive psychiatry, influential policy makers, clinicians, family members, and patient advocacy groups but that significantly more concerted efforts at dissemination were needed. The community of stakeholders interested in PADs and the broader concept of self-directed care are in need of online resource and gathering place for exchange of views and information.
As a result, in the United States, a collaboration between the Bazelon Centre for Mental Health Law and Duke University has led to creation of the MacArthur Foundation-funded National Resource Center on Psychiatric Advance Directives, the only web portal exclusively devoted to developing a learning community to help people targeted for coercive psychiatry, their families, and clinicians prepare for, and ultimately prevent, coercive psychiatry interventions. The NRC-PAD includes basic information, frequently asked questions, educational webcasts, web blog, most recent research, legal analyses, and state-by-state information on PADs and patient-centred crisis planning. The NRC-PAD website thus includes easy step-by-step information to help those targeted for forced drugging, family, and clinicians complete PADs that mirror the provisions in the PAD statutes.
Clinical Psychology (Topics in Applied Psychology).
Author(s): Graham Davey, Nick Lake, and Adrian Whittington (Editors).
Edition: Second (2nd).
Type(s): Hardcover, Paperback and Kindle.
Clinical Psychology, Second Edition offers a comprehensive and an up-to-date introduction to the field. Written by clinical practitioners and researchers, as well as service users who add their personal stories, the book provides a broad and balanced view of contemporary clinical psychology.
This new edition has been extensively revised throughout and includes a new section on working with people with disabilities and physical health problems. It also includes a new chapter on career choices, and help and advice on how to move forward into clinical psychology training.
The book starts by explaining the core elements of what a clinical psychologist does and the principles of clinical practice, as well as outlining the role of the clinical psychologist within a healthcare team. It goes on to cover issues involved with working with children and families, adult mental health problems, working with people with disabilities and physical health problems, and the use of neuropsychology. The final part of the book explores current professional issues in clinical psychology, the history and future of clinical psychology, and career options.
The integrated and interactive approach, combined with the comprehensive coverage, make this book the ideal companion for undergraduate courses in clinical psychology, and anyone interested in a career in this field. It will also be of interest to anyone who wants to learn more about the work of a clinical psychologist, including other healthcare professionals.
Clinical Psychology for Trainees: Foundations of Science-Informed Practice.
Author(s): Andrew C. Page and Werner G.K. Stritzke.
Edition: Second (2nd).
Publisher: Cambridge University Press.
Type(s): Paperback and Kindle.
Thoroughly revised, and fully updated for DSM-5, the new edition of this practice-focused book guides clinical psychology trainees through a field which is rapidly evolving. Through real-world exploration of the scientist-practitioner model, the book helps readers to develop the core competencies required in an increasingly interdisciplinary healthcare environment. New chapters cover brief interventions, routine monitoring of treatment progress, and managing alliance ruptures. Practical skills such as interviewing, diagnosis, assessment, treatment and case management are discussed with emphasis on the question ‘how would a scientist-practitioner think and act?’ By demonstrating how an evidence-base can influence every decision that a clinical psychologist makes, the book equips trainees to deliver the accountable, efficient, effective client-centred service which is demanded of professionals in the modern integrated care setting. Essential reading for all those enrolled in, or contemplating, postgraduate studies in clinical psychology.
Author(s): Helen Beinart, Paul Kennedy, and Susan Llewelyn (Editors).
Edition: First (1st).
Type(s): Paperback and eBook.
Academic, clinical and research aspects are offered in collaboration with clinical practitioners, who provide the clinical experience to foster the development of competencies in Health and Social Care.
Provides a clear, authoritative and lively introduction to the practice of clinical psychology.
Explains succinctly the range of competencies which a psychologist is expected to possess, and how these can be applied in a variety of contexts.
Key issues covered include awareness of the social context, the need for responsive and flexible practice, and respect for diversity.
Examples and principles are provided which demonstrate the clinical psychologist in action, and explain why and how they work as they do.
Clinical Psychology, Research and Practice: An Introductory Text.
Author(s): Paul Bennett.
Edition: Fourth (4th).
Publisher: Open University Press.
Type(s): Paperback and Kindle.
Extensively updated, this popular and accessibly written textbook outlines the latest research and therapeutic approaches within clinical psychology, alongside important developments in clinical practice. The book introduces and evaluates the conceptual models of mental health problems and their treatment, including second and third wave therapies.
Each disorder is considered from a psychological, social and biological perspective and different intervention types are thoroughly investigated.
Key updates to this edition include:
The development of case formulations for conditions within each chapter.
An articulation and use of modern theories of psychopathology, including sections on the transdiagnostic approach, meta-cognitive therapy, and acceptance and commitment therapy.
An introduction to emerging mental health issues, such as internet gaming disorder.
Challenging ‘stop and think’ boxes that encourage readers to address topical issues raised in each chapter, such as societal responses to topics as varied as psychopathy, paedophilia and the Black Lives Matter movement.
New vocabulary collated into key terms boxes for easy reference.
Becoming a Clinical Psychologist: Everything You Need to Know.
Author(s): Steven Mayers and Amanda Mwale.
Edition: First (1st).
Type(s): Hardcover, Paperback, and Kindle.
Becoming a Clinical Psychologist: Everything You Need to Know brings together all the information you need to pursue a career in this competitive field.
This essential guide includes up-to-date information and guidance about a career in clinical psychology and gaining a place on clinical psychology training in the UK. It answers the questions all aspiring psychologists need to know, such as:
What is clinical psychology?
What is it like to train and work as a clinical psychologist?
How to make the most of your work and research experience.
How to prepare for clinical psychology applications and interviews.
Is clinical psychology the right career for me?
By cutting through all the jargon, and providing detailed interviews with trained and trainee clinical psychologists, Becoming a Clinical Psychologist will provide psychology graduates or undergrads considering a career in this area with all the tools they need.
Borderline Personality Disorder: An Evidence-Based Guide For Generalist Mental Health Professionals.
Author(s): Anthony W. Bateman (author) and Roy Krawitz (contrbutor).
Edition: First (1st), Illustrated Edition.
Publisher: Oxford University Press.
Type(s): Paperback and Kindle.
Over the past two decades considerable progress has been made in developing specialist psychosocial treatments for borderline personality disorder (BPD), yet the majority of people with BPD receive treatment within generalist mental health services, rather than specialist treatment centres.
This is a book for general mental health professionals who treat people with BPD. It offers practical guidance on how to help people with BPD with advice based on research evidence. After a discussion of the symptoms of BPD, the authors review all the generalist treatment interventions that have resulted in good outcomes in randomised controlled trials, when compared with specialist treatments, and summarise the effective components of these interventions. The treatment strategies are organised into a structured approach called Structured Clinical Management (SCM), which can be delivered by general mental health professionals without extensive additional training.
The heart of the book outlines the principles underpinning SCM and offers a step-by-step guide to the clinical intervention. Practitioners can learn the interventions easily and develop more confidence in treating people with BPD. In addition, a chapter is devoted to how to help families – an issue commonly neglected when treating patients with BPD. Finally the authors discuss the top 10 strategies for delivering treatment and outline how the general mental health clinician can deliver these strategies competently.
Essentials of Child Psychopathology (Part of Essentials of Behavioural Science).
Author(s): Linda Wilmhurst.
Edition: First (1st).
The only concise, comprehensive overview of child psychopathology covering theory, assessment, and treatment as well as issues and trends
Essentials of Child Psychopathology provides students and professionals with a comprehensive overview of critical conceptual issues in child and adolescent psychopathology. The text covers the major theories, assessment practices, issues, and trends in this important field. Author Linda Wilmshurst also includes chapters on specific disorders prevalent among this age group and covers special topics such as diversity, abuse, and divorce.
As part of the Essentials of Behavioral Science series, this book provides information mental health professionals need in order to practice knowledgeably, efficiently, and ethically in today’s behavioral healthcare environment. Each concise chapter features numerous callout boxes highlighting key concepts, bulleted points, and extensive illustrative material, as well as “Test Yourself” questions that help you gauge and reinforce your grasp of the information covered.
Essentials of Child Psychopathology is the only available resource to condense the wide-ranging topics of the field into a concise, accessible format for handy and quick reference. An excellent review guide, Essentials of Child Psychopathology is an invaluable tool for learning as well as a convenient reference for established mental health professionals.
Other titles in the Essentials of Behavioral Science series:
Essentials of Statistics for the Social and Behavioural Sciences.
Depressive symptoms in residents of a tertiary training hospital in Malaysia: The prevalence and associated factors.
The mental wellbeing of doctors is becoming an increasing concern in the world today.
In Malaysia, residency is a challenging period in a doctor’s life, with many changes professionally and possibly in their personal lives as well.
This study aims to determine the prevalence of depressive symptoms and the socio-demographic correlates among residents in a tertiary training hospital in Malaysia.
It is a cross sectional study and all residents were approached to participate in the study.
The instruments used were a socio-demographic questionnaire and the Patient Health Questionnaire 9 (PHQ-9).
Chi-square test was used to explore the association between the socio-demographic correlates, and those that were found to have significant associations were further tested using multivariate logistic regression.
The prevalence of depression among residents was 25.1 %. Longer working hours, missing meals, and working in Department of Surgery and Department of Anaesthesia was significantly positively associated while having protected study time, CME/lectures, leisure/hobbies and exercise were negatively associated with depression.
The Department of Rehabilitation Medicine had a significantly negative association with depression. After logistic regression, longer working hours and a lack of protected study time was significantly associated with depression in the respective departments.
In summary, the prevalence of depression among residents is high and is associated with longer working hours, missing meals and a lack of protected study time are significantly associated with depression.
Remedial steps should be taken to improve the mental health among residents.
Nair, N., Ng, C.G. & Sulaiman, A.H. (2021) Depressive symptoms in residents of a tertiary training hospital in Malaysia: The prevalence and associated factors. Asian Journal of Psychiatry. doi: 10.1016/j.ajp.2021.102548. Online ahead of print.
A mental health professional is a health care practitioner or social and human services provider who offers services for the purpose of improving an individual’s mental health or to treat mental disorders.
This broad category was developed as a name for community personnel who worked in the new community mental health agencies begun in the 1970s to assist individuals moving from state hospitals, to prevent admissions, and to provide support in homes, jobs, education, and community. These individuals (i.e. state office personnel, private sector personnel, and non-profit, and now voluntary sector personnel) were the forefront brigade to develop the community programmes, which today may be referred to by names such as supported housing, psychiatric rehabilitation, supported or transitional employment, sheltered workshops, supported education, daily living skills, affirmative industries, dual diagnosis treatment, individual and family psychoeducation, adult day care, foster care, family services and mental health counselling.
Psychiatrists also are working in clinical fields with psychologists including in sociobehavioural, neurological, person-centred and clinical approaches (often office-based), and studies of the “brain disease” (which came from the community fields and community management and are taught at the MA to PhD level in education). For example, Nat Raskin (at Northwestern University Medical School) who worked with the illustrious Carl Rogers, published on person-centred approaches and therapy in 2004. The term counsellors often refers to office-based professionals who offer therapy sessions to their clients, operated by organisations such as pastoral counselling (which may or may not work with long term services clients) and family counsellors. Mental health counsellors may refer to counsellors working in residential services in the field of mental health in community programmes.
As Community Professionals
As Dr. William Anthony, father of psychiatric rehabilitation, described, psychiatric nurses (RNMH, RMN, CPN), clinical psychologists (PsyD or PhD), clinical social workers (MSW or MSSW), mental health counselors (MA or MS), professional counselors, pharmacists, as well as many other professionals are often educated in “psychiatric fields” or conversely, educated in a generic community approach (e.g. human services programmes or health and human services in 2013). However, his primary concern is education that leads to a willingness to work with “long-term services and supports” community support in the community to lead to better life quality for the individual, the families and the community.
The community support framework in the US of the 1970s is taken-for-granted as the base for new treatment developments (e.g. eating disorders, drug addiction programmes) which tend to be free-standing clinics for specific “disorders”. Typically, the term “mental health professional” does not refer to other categorical disability areas, such as intellectual and developmental disability (which trains its own professionals and maintains its own journals, and US state systems and institutions). Psychiatric rehabilitation has also been reintroduced into the transfer to behavioural health care systems.
As Certified and Licensed (Across Institutions and Communities)
These professionals often deal with the same illnesses, disorders, conditions, and issues (though may separate on-site locations, such as hospital or community for the same clientele); however, their scope of practice differs and more particularly, their positions and roles in the fields of mental health services and systems. The most significant difference between mental health professionals are the laws regarding required education and training across the various professions. However, the most significant change has been the Supreme Court Olmstead Decision on the most integrated setting which should further reduce state hospital utilisation; yet with new professionals seeking right for community treatment orders and rights to administer medications (original community programmes, residents taught to self-administer medications, 1970s).
In 2013, new mental health practitioners are licensed or certified in the community (e.g., PhD, education in private clinical practice) by states, degrees and certifications are offered in fields such as psychiatric rehabilitation (MS, PhD), BA psychology (liberal arts, experimental/clinical/existential/community) to MA licensing is now more popular, BA (to PhD) mid-level programme management, qualified civil service professionals, and social workers remain the mainstay of community admissions procedures (licensed by state, often generic training) in the US. Surprisingly, state direction has moved from psychiatry or clinical psychology to community leadership and professionalisation of community services management.
Entry level recruitment and training remain a primary concern (since the 1970s, then often competing with fast food positions), and the US Direct Support Workforce includes an emphasis on also training of psychiatric aides, behavioural aides, and addictions aides to work in homes and communities. The Centres for Medicaid and Medicare have new provisions for “self-direction” in services and new options are in place for individual plans for better life outcomes. Community programs are increasingly using health care financing, such as Medicaid, and Mental Health Parity is now law in the US.
Currently, psychologists may prescribe in US five states: Iowa, Idaho, Illinois, New Mexico, and Louisiana, as well as in the Public Health Service, the Indian Health Service, the US military, and Guam.
Includes licensed dual inclusion educators, behaviour analyst, substance abuse and behavioural disorders, “inclusion educator”.
Treatment Diversity and Community Mental Health
Mental health professionals exist to improve the mental health of individuals, couples, families and the community-at-large (In this generic use, mental health is available to the entire population, similar to the use by mental health associations). Because mental health covers a wide range of elements, the scope of practice greatly varies between professionals. Some professionals may enhance relationships while others treat specific mental disorders and illness; still, others work on population-based health promotion or prevention activities. Often, as with the case of psychiatrists and psychologists, the scope of practice may overlap often due to common hiring and promotion practices by employers.
As indicated earlier, community mental health professionals have been involved in the beginning and operating community programmes which include ongoing efforts to improve life outcomes, originally through long term services and supports (LTSS). Termed functional or competency-based programmes, this service also stressed decision making and self-determination or empowerment as critical aspects. Community mental health professionals may also serve children who have different needs, as do families, including family therapy, financial assistance and support services. Community mental health professionals serve people of all ages from young children with autism, to children with emotional (or behavioural) needs, to grandma who has Alzheimer’s or dementia and is living at home after dad passes away.
Most qualified mental health professionals will refer a patient or client to another professional if the specific type of treatment needed is outside of their scope of practice. The main community concern is “zero rejection” from community services for individuals who have been termed “hard to serve” in the population (think schizophrenia or dual diagnosis) or who have additional needs such as mobility and sensory impairments. Additionally, many mental health professionals may sometimes work together using a variety of treatment options such as concurrent psychiatric medication and psychotherapy and supported housing. Additionally, specific mental health professionals may be utilised based upon their cultural and religious background or experience, as part of a theory of both alternative medicines and of the nature of helping and ethnicity.
Primary care providers, such as internists, paediatricians, and family physicians, may provide initial components of mental health diagnosis and treatment for children and adults; however, family physicians in some states refuse to even prescribe a psychotropic medication deferring to separately funded “medication management” services. Community programmes in the categorical field of mental health were designed (1970s) to have a personal family physician for every client in their programmes, except for institutional settings and nursing facilities which have only one or two for a large facility.
In particular, family physicians are trained during residency in interviewing and diagnostic skills, and may be quite skilled in managing conditions such as attention deficit hyperactivity disorder (ADHD) in children and depression in adults. Likewise, many (but not all) paediatricians may be taught the basic components of ADHD diagnosis and treatment during residency. In many other circumstances, primary care physicians may receive additional training and experience in mental health diagnosis and treatment during their practice years.
Both primary care physicians/general practitioners (GP’s) and psychiatrist are just as effective (in terms of remission rates) for the treatment of depression. However, treatment resistant depression, suicidal, homicidal ideation, psychosis and catatonia should be handled by mental health specialists. Treatment-resistant depression (or treatment refractory depression) refers to depression which remains at large after at least two antidepressant medications have been trailed on their own.
Some think that mental health professionals are less credible when they have personal experience of mental health. In fact, the mental health sector goes out of its way to hire people with mental illness experience. Those in the mental health workforce with personal experience of mental health are referred to as ‘peer (support) workers’. The balance of evidence appears to favour their employment: Randomised controlled trials consistently demonstrate peer staff produce outcomes on par with non-peer staff in ancillary roles, but they actually perform better in reducing hospitalisation rates, engaging clients who are difficult to reach, and cutting substance use. There is research that indicates peer workers cultivate a perception among service users that the service is more responsive to non-treatment things, increases their hope, family satisfaction, self-esteem and community belonging.
Psychiatrists are physicians and one of the few professionals in the mental health industry who specialize and are certified in treating mental illness using the biomedical approach to mental disorders including the use of medications. However, biological, genetic and social processes as part of pre-medicine have been the basis of education in fields such as BA psychology since the 1970s, and in 2013, such academic degrees also may include extensive work on the status of brain, DNA research and its applications. Clinical psychologists were hired by states and served in institutions in the US, and were involved in the transition to community systems.
Psychiatrists may also go through significant training to conduct psychotherapy and cognitive behavioural therapy;. The amount of training a psychiatrist holds in providing these types of therapies varies from program to program and also differs greatly based upon region (Cognitive therapy also stems from cognitive rehabilitation techniques, and may involve long-term community clients with brain injuries seeking jobs, education and community housing). In the 1970s, psychiatrists were considered to be hospital-based, assessment, and clinical education personnel which was not involved in establishing community programmes.
Specialties of Psychiatrists
As part of their evaluation of the patient, psychiatrists are one of only a few mental health professionals who may conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT, MRI, and PET scanning. A medical professional must evaluate the patient for any medical problems or diseases that may be the cause of the mental illness.
Historically psychiatrists have been the only mental health professional with the power to prescribe medication to treat specific types of mental illness. Currently, physician assistants response to the psychiatrist (in lieu of and supervised) and advanced practice psychiatric nurses may prescribe medications, including psychiatric medications. Clinical psychologists have gained the ability to prescribe psychiatric medications on a limited basis in a few US states after completing additional training and passing an examination.
Educational Requirements for Psychiatrists
Typically the requirements to become a psychiatrist are substantial but differ from country to country. In general there is an initial period of several years of academic and clinical training and supervised work in different areas of medicine, in order to become a licensed medical doctor, followed by several years of supervised work and study in psychiatry, in order to become a licensed psychiatrist.
In the United States and Canada one must first complete a Bachelor’s degree. Students may typically decide any major subject of their choice, however they must enrol in specific courses, usually outlined in a pre-medical programme. One must then apply to and attend 4 years of medical school in order to earn their MD or DO and to complete their medical education. Psychiatrists must then pass three successive rigorous national board exams (United States Medical Licensing Exams “USMLE”, Steps 1, 2, and 3), which draws questions from all fields of medicine and surgery, before gaining an unrestricted license to practice medicine. Following this, the individual must complete a four-year residency in Psychiatry as a psychiatric resident and sit for annual national in-service exams. Psychiatry residents are required to complete at least four post-graduate months of internal medicine (paediatrics may be substituted for some or all of the internal medicine months for those planning to specialise in child and adolescent psychiatry) and two months of neurology, usually during the first year, but some programmes require more. Occasionally, some prospective psychiatry residents will choose to do a transitional year internship in medicine or general surgery, in which case they may complete the two months of neurology later in their residency. After completing their training, psychiatrists take written and then oral specialty board examinations. The total amount of time required to qualify in the field of psychiatry in the United States is typically 4 to 5 years after obtaining the MD or DO (or in total 8 to 9 years minimum). Many psychiatrists pursue an additional 1-2 years in subspecialty fellowships on top of this such as child psychiatry, geriatric psychiatry, and psychosomatic medicine.
In the United Kingdom, the Republic of Ireland, and most Commonwealth countries, the initial degree is the combined Bachelor of Medicine and Bachelor of Surgery, usually a single period of academic and clinical study lasting around five years. This degree is most often abbreviated ‘MBChB’, ‘MB BS’ or other variations, and is the equivalent of the American ‘MD’. Following this the individual must complete a two-year foundation programme that mainly consists of supervised paid work as a Foundation House Officer within different specialties of medicine. Upon completion the individual can apply for “core specialist training” in psychiatry, which mainly involves supervised paid work as a Specialty Registrar in different subspecialties of psychiatry. After three years there is an examination for Membership of the Royal College of Psychiatrists (abbreviated MRCPsych), with which an individual may then work as a “Staff grade” or “Associate Specialist” psychiatrist, or pursue an academic psychiatry route via a PhD. If, after the MRCPsych, an additional 3 years of specialisation known as “advanced specialist training” are taken (again mainly paid work), and a Certificate of Completion of Training is awarded, the individual can apply for a post taking independent clinical responsibility as a “consultant” psychiatrist.
A clinical psychologist studies and applies psychology for the purpose of understanding, preventing and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. In many countries it is a regulated profession that addresses moderate to more severe or chronic psychological problems, including diagnosable mental disorders. Clinical psychology includes a wide range of practices, such as research, psychological assessment, teaching, consultation, forensic testimony, and program development and administration. Central to clinical psychology is the practice of psychotherapy, which uses a wide range of techniques to change thoughts, feelings, or behaviours in service to enhancing subjective well-being, mental health, and life functioning. Unlike other mental health professionals, psychologists are trained to conduct psychological assessment. Clinical psychologists can work with individuals, couples, children, older adults, families, small groups, and communities.
Specialties of Clinical Psychologists
Clinical psychologists who focus on treating mental health specialises in evaluating patients and providing psychotherapy. They do not prescribe medication as this is a role of a psychiatrist (physician who specialises in psychiatry). There are a wide variety of therapeutic techniques and perspectives that guide practitioners, although most fall into the major categories of Psychodynamic, Cognitive Behavioural, Existential-Humanistic, and Systems Therapy (e.g. family or couples therapy).
In addition to therapy, clinical psychologists are also trained to administer and interpret psychological personality tests such as the MMPI and the Rorschach inkblot test, and various standardised tests of intelligence, memory, and neuropsychological functioning. Common areas of specialization include: specific disorders (e.g. trauma), neuropsychological disorders, child and adolescent, family and relationship counselling. Internationally, psychologists are generally not granted prescription privileges. In the US, prescriptive rights have been granted to appropriately trained psychologists only in the states of New Mexico and Louisiana, with some limited prescriptive rights in Indiana and the US territory of Guam.
Educational Requirements for Clinical Psychologists
Clinical psychologists, having completed an undergraduate degree usually in psychology or other social science, generally undergo specialist postgraduate training lasting at least two years (e.g. Australia), three years (e.g. UK), or four to six years depending how much research activity is included in the course (e.g. US). In countries where the course is of shorter duration, there may be an informal requirement for applicants to have undertaken prior work experience supervised by a clinical psychologist, and a proportion of applicants may also undertake a separate PhD research degree.
Today, in the US, about half of licensed psychologists are trained in the Scientist-Practitioner Model of Clinical Psychology (PhD) – a model that emphasizes both research and clinical practice and is usually housed in universities. The other half are being trained within a Practitioner-Scholar Model of Clinical Psychology (PsyD), which focuses on practice (similar to professional degrees for medicine and law). A third training model called the Clinical Scientist Model emphasizes training in clinical psychology research. Outside of coursework, graduates of both programmes generally are required to have had 2 to 3 years of supervised clinical experience, a certain amount of personal psychotherapy, and the completion of a dissertation (PhD programmes usually require original quantitative empirical research, whereas the PsyD equivalent of dissertation research often consists of literature review and qualitative research, theoretical scholarship, programme evaluation or development, critical literature analysis, or clinical application and analysis).
Continuing Education Requirements for Clinical Psychologists
Most states in the US require clinical psychologists to obtain a certain number of continuing education credits in order to renew their license. This was established to ensure that psychologists stay current with information and practices in their fields. The license renewal cycle varies, but renewal is generally required every two years.
The number of continuing education credits required for clinical psychologists varies between states. In Nebraska, psychologists are required to obtain 24 hours of approved continuing education credits in the 24 months before their license renewal. In California, the requirement is for 36 hours of credits. New York State does not have any continuing education requirements for license renewal at this time (2014).
Activities that count towards continuing education credits generally include completing courses, publishing research papers, teaching classes, home study, and attending workshops. Some states require that a certain number of the education credits be in ethics. Most states allow psychologists to self-report their credits but randomly audit individual psychologists to ensure compliance.
Counselling Psychologist or Psychotherapist
Counselling generally involves helping people with what might be considered “normal” or “moderate” psychological problems, such as the feelings of anxiety or sadness resulting from major life changes or events. As such, counselling psychologists often help people adjust to or cope with their environment or major events, although many also work with more serious problems as well.
One may practice as a counselling psychologist with a PhD or EdD, and as a counselling psychotherapist with a master’s degree. Compared with clinical psychology, there are fewer counselling psychology graduate programs (which are commonly housed in departments of education), counsellors tend to conduct more vocational assessment and less projective or objective assessment, and they are more likely to work in public service or university clinics (rather than hospitals or private practice). Despite these differences, there is considerable overlap between the two fields and distinctions between them continue to fade.
Mental health counsellors and residential counsellors are also the name for another class of counsellors or mental health professionals who may work with long-term services and supports (LTSS) clients in the community. Such counsellors may be advanced or senior staff members in a community program, and may be involved in developing skill teaching, active listening (and similar psychological and educational methods), and community participation programmes. They also are often skilled in on-site intervention, redirection and emergency techniques. Supervisory personnel often advance from this class of workers in community programmes.
Behaviour Analysts and Community/Institutional Roles
Behaviour analysts are licensed in five states to provide services for clients with substance abuse, developmental disabilities, and mental illness. This profession draws on the evidence base of applied behaviour analysis, behaviour therapy, and the philosophy of radical behaviourism. Behaviour analysts have at least a master’s degree in behaviour analysis or in a mental health related discipline as well as at least five core courses in applied behaviour analysis (narrow focus in psychological education). Many behaviour analysts have a doctorate. Most programmes have a formalised internship programme and several programmes are offered online. Most practitioners have passed the examination offered by the behaviour analysis certification board or the examination in clinical behaviour therapy by the World Association for Behaviour Analysis. The model licensing act for behaviour analysts can be found at the Association for Behaviour Analysis International’s website.
Behaviour analysts (who grew from the definition of mental health as a behavioural problem) often use community situational activities, life events, functional teaching, community “reinforcers”, family and community staff as intervenors, and structured interventions as the base in which they may be called upon to provide skilled professional assistance. Approaches that are based upon person-centred approaches have been used to update the stricter, hospital based interventions used by behaviour analysts for applicability to community environments. Behavioural approaches have often been infused with efforts at client self-determination, have been aligned with community lifestyle planning, and have been criticised as “aversive technology” which was “outlawed” in the field of severe disabilities in the 1990s.
Certified Mental Health Professional
The Certified Mental Health Professional (CMHP) certification is designed to measure an individual’s competency in performing the following job tasks. The job tasks are a sampling of job tasks with a clinical emphasis, and represents a level of line staff in community programmes reporting to a community supervisor in a small site based programme. Personnel in community housing, nursing facilities, and institutional programmes may be covered by these kinds of certifications.
Maintain confidentiality of records relating to clients’ treatment (and daily affairs as desired by the person).
Encourage clients to express their feelings, discuss what is happening in their lives, and help them to develop insight into themselves and their relationships.
Guide clients in the development of skills and strategies for dealing with their problems (and desired life outcomes).
Prepare and maintain all required treatment (and/or community service) records and reports.
Counsel clients and patients, individually and in group sessions, to assist in overcoming dependencies (seeking new relationships), adjusting to life, and making changes.
Collect information about clients through interviews, observations, and tests (and most importantly, speaking with and planning with the person).
Act as the client’s advocate in order to coordinate required services or to resolve emergency problems in crisis situations (often first line of emergency response).
Develop and implement treatment (or “person-centred”) plans based on clinical (and community) experience and knowledge.
Collaborate with other staff members to perform clinical assessments (and health may be contracted for specific consultations) and develop treatment (service) plans.
Evaluate client’s physical or mental condition (plan, not condition) based on review of client information (Evaluate outcomes as planned with the client on a “quarterly basis”).
However, these position levels have undergone decades of academic field testing and recommendations with new competencies in development in 2011-2013 by the Centres for Medicaid and Medicare (at the categorical aide levels). New professionals were recommended with a community services coordinator (commonly known as “hands on” case management), together with services and personnel management, and community development and liaison roles for community participation.
School Psychologist and Inclusion Educators
School psychologists’ primary concern is with the academic, social, and emotional well-being of children within a scholastic environment. Unlike clinical psychologists, they receive much more training in education, child development and behaviour, and the psychology of learning, often graduating with a post-master’s educational specialist degree (EdS), EdD or Doctor of Philosophy (PhD) degree. Besides offering individual and group therapy with children and their families, school psychologists also evaluate school programmes, provide cognitive assessment, help design prevention programmes (e.g. reducing drops outs), and work with teachers and administrators to help maximise teaching efficacy, both in the classroom and systemically.
In today’s world, the school psychologist remains the responsible party in “mental health” regarding children with emotional and behavioural needs, and have not always met these needs in the regular school environment. Inclusion (special) educators support participation in local school programmes and after school programmes, including new initiatives such as Achieve my Plan by the Research and Training Centre on Family Support and Children’s Mental Health at Portland State University. Referrals to residential schools and certification of the personnel involved in the residential schools and campuses have been a multi-decade concern with counties often involved in national efforts to better support these children and youth in local schools, families, homes and communities.
Psychiatric rehabilitation, similar to cognitive rehabilitation, is a designated field in the rehabilitation often academically prepared in either Schools of Allied Health and Sciences (near the field of Physical Medicine and Rehabilitation) and as rehabilitation counselling in the School of Education. Both have been developed specifically as preparing community personnel (at the MA and PHD levels) and to aid in the transition to professionally competent and integrated community services. Psychiatric rehabilitation personnel have a community integration-related base, support recovery and skills-based model of mental health, and may be involved with community programmes based upon normalisation and social role valourisation throughout the US. Psychiatric rehabilitation personnel have been involved in upgrading the skills of staff in institutions in order to move clients into community settings. Most common in international fields are community rehabilitation personnel which traditionally come from the rehabilitation counselling or community fields. In the new “rehabilitation centres” (new campus buildings), designed similar to hospital “rehab” (physical and occupational therapy, sports medicine), often no designated personnel in the fields of mental health (now “senior behavioural services” or “residential treatment units”). Psychiatric rehabilitation textbooks are currently on the market describing the community services their personnel were involved within community development (commonly known as deinstitutionalisation).
Psychiatric rehabilitation professionals (and psychosocial services) are the mainstay of community programs in the US, and the national service providers association itself may certify mental health staff in these areas. Psychiatric interventions which vary from behavioural ones are described in a review on their use in “residential, vocational, social or educational role functioning” as a “preferred methods for helping individuals with serious psychiatric disabilities”. Other competencies in education may involve working with families, user-directed planning methods and financing, housing and support, personal assistance services, transitional or supported employment, Americans with Disabilities Act (ADA), supported housing, integrated approaches (e.g. substance use, or intellectual disabilities), and psychosocial interventions, among others. In addition, rehabilitation counsellors (PhD, MS) may also be educated “generically” (breadth and depth) or for all diagnostic groups, and can work in these fields; other personnel may have certifications in areas such as supported employment which has been verified for use in psychiatric, neurological, traumatic brain injury, and intellectual disabilities, among others.
Social workers in the area of mental health may assess, treat, develop treatment plans, provide case management and/or rights advocacy to individuals with mental health problems. They can work independently or within clinics/service agencies, usually in collaboration with other health care professionals.
In the US, they are often referred to as clinical social workers; each state specifies the responsibilities and limitations of this profession. State licensing boards and national certification boards require clinical social workers to have a master’s or doctoral degree (MSW or DSW/PhD) from a university. The doctorate in social work requires submission of a major original contribution to the field in order to be awarded the degree.
In the UK there is a now a standardised three-year undergraduate social work degree, or two-year postgraduate masters for those who already have an undergraduate social sciences degree or others and relevant work experience. These courses include mandatory supervised work experience in social work, which may include mental health services. Successful completion allows an individual to register and work as a qualified social worker. There are various additional optional courses for gaining qualifications specific to mental health, for example training in psychotherapy or, in England and Wales, for the role of Approved Mental Health Professional (two years’ training for a legal role in the assessment and detention of eligible mentally disordered people under the Mental Health Act (1983) as amended in 2007).
Social workers in England and Wales are now able to become Approved Clinicians under the Mental Health Act 2007 following a period of further training (likely at postgraduate degree/diploma or doctoral level). Historically, this role was reserved for psychiatrist medical doctors, but has now extended to registered mental health professionals, such as social workers, psychologists and mental health nurses.
In general, it is the psycho-social model rather than, or in addition to, the dominant medical model, that is the underlying rationale for mental health social work. This may include a focus on social causation, labelling, critical theory and social constructiveness. Many argue social workers need to work with medical and health colleagues to provide an effective service but they also need to be at the forefront of processes that include and empower service users.
Social workers also prepare social work administration and may hold positions in human services systems as administration or Executives to Administration in the US. Social workers, similar to psychiatric rehabilitation, updates its professional education programmes based upon current developments in the fields (e.g. support services) and serve a multicultural client base.
Educational Requirements for Social Workers
In the United States, the minimum requirement for social workers is generally a bachelor’s degree in social work, though a bachelor’s degree in a related field such as sociology or psychology may qualify an applicant for certain jobs. Higher-level jobs typically require a master’s degree in social work. Master’s programs in social work usually last two years and consist of at least 900 hours of supervised instruction in the field. Regulatory boards generally require that degrees be obtained from programmes that are accredited by the Council of Social Work Education (CSWE) or another nationally recognised accrediting agency for promotion and future collaboration.
Before social workers can practice, they are required to meet the licensing, certification, or registration requirements of the state. The requirements vary depending on the state but usually involve a minimum number of supervised hours in the field and passing of an exam. All states, except California, also require pre-licensure from the Association of Social Work Boards (ASWB).
The ASWB offers four categories of social work license. The lowest level is a Bachelors, for which a bachelor’s degree in social work is required. The next level up is a Masters and a master’s degree in social work is required. The Advanced Generalist category of social worker requires a master’s degree in social work and two years of supervised post-degree experience. The highest ASWB category is a Clinical Social Worker which requires a master’s degree in social work along with two years of post-master’s direct experience in social work.
Continuing Education Requirements for Social Workers
Most states require social workers to acquire a minimum number of continuing education credits per license, certification, or registration renewal period. The purpose of these requirements is to ensure that social workers stay up-to-date with information and practices in their professions. In most states, the renewal process occurs every two or three years. The number of continuing education credits that is required varies between states but is generally 20 to 45 hours during the two- or three-year period prior to renewal.
Courses and programs that are approved as continuing education for social workers generally must be relevant to the profession and contribute to the advancement of professional competence. They often include continuing education courses, seminars, training programs, community service, research, publishing articles, or serving on a panel. Many states enforce that a minimum amount of the credits be on topics such as ethics, HIV/AIDs, or domestic violence.
Psychiatric and Mental Health Nurse
Psychiatric Nurses or Mental Health Nurse Practitioners work with people with a large variety of mental health problems, often at the time of highest distress, and usually within hospital settings. These professionals work in primary care facilities, outpatient mental health clinics, as well as in hospitals and community health centres. MHNPs evaluate and provide care for patients who have anything from psychiatric disorders, medical mental conditions, to substance abuse problems. They are licensed to provide emergency psychiatric services, assess the psycho-social and physical state of their patients, create treatment plans, and continually manage their care. They may also serve as consultants or as educators for families and staff; however, the MHNP has a greater focus on psychiatric diagnosis (typically the province of the MD or PhD), including the differential diagnosis of medical disorders with psychiatric symptoms and on medication treatment for psychiatric disorders.
Educational Requirements for Psychiatric and Mental Health Nurses
Psychiatric and mental health nurses receive specialist education to work in this area. In some countries, it is required that a full course of general nurse training be completed prior to specialising as a psychiatric nurse. In other countries, such as the UK, an individual completes a specific nurse training course that determines their area of work. As with other areas of nursing, it is becoming usual for psychiatric nurses to be educated to degree level and beyond. Psychiatric aides, now being trained by educational psychology in 2014, are part of the entry-level workforce which is projected to be needed in communities in the US in the next decades.
In order to become a nurse practitioner in the US, at least six years of college education must be obtained. After earning the bachelor’s degree (usually in nursing, although there are master’s entry level nursing graduate programs intended for individuals with a bachelor’s degree outside of nursing) the test for a license as a registered nurse (the NCLEX-RN) must be passed. Next, the candidate must complete a state-approved master’s degree advanced nursing education program which includes at least 600 clinical hours. Several schools are now also offering further education and awarding a DNP (Doctor of Nursing Practice).
Individuals who choose a master’s entry level pathway will spend an extra year at the start of the programme taking classes necessary to pass the NCLEX-RN. Some schools will issue a BSN, others will issue a certificate. The student then continues with the normal MSN programme.
Mental Health Care Navigator
A mental health care navigator is an individual who assists patients and families to find appropriate mental health caregivers, facilities and services. Individuals who are care navigators are often also trained therapists and doctors. The need for mental health care navigators arises from the fragmentation of the mental health industry, which can often leave those in need with more questions than answers. Care navigators work closely with patients through discussion and collaboration to provide information on options and referrals to healthcare professionals, facilities, and organisations specialising in the patients’ needs. The difference between other mental health professionals and a care navigator is that a care navigator provides information and directs a patient to the best help rather than offering diagnosis, prescription of medications or treatment.
Many mental health organisations use “navigator” and “navigation” to describe the service of providing guidance through the health care industry. Care navigators are also sometimes referred to as “system navigators”. One type of care navigator is an “educational consultant.”
Behavioural health disorders are prevalent in the United States, but accessing treatment can be challenging. Nearly 1 in 5 adults experience a mental health condition for which approximately only 43% received treatment. When asked about access to mental health treatment, two-thirds of primary care physicians reported that they were unable to secure outpatient mental health treatment for their patients. This is due, in part, to the workforce shortage in behavioural health. In rural areas, 55% of US counties have no practicing psychiatrist, psychologist, or social worker. Overall, 77% of counties have a severe shortage of mental health workers and 96% of counties had some unmet need. Some of the reasons for the workforce shortage include high turnover rates, high levels of work-related stress, and inadequate compensation. Annual turnover rate is 33% for clinicians and 23% for clinical supervisors. This is compared to an annual PCP turnover rate of 7.1%. Compensation in behavioural health field is notably low. The average licensed clinical social worker, a position that requires a master’s degree and 2,000 hours of post-graduate experience, earns $45,000/year. As a point of reference, the average physical therapist earns $75,000/year. Substance abuse counsellor earnings are even lower, with an average salary of $34,000/year. Job stress is another factor that may lead to the high turnover rates and workforce shortage. It is estimated that 21-67% of mental health workers experience high levels of burnout including symptoms of emotional exhaustion, high levels of depersonalisation and a reduced sense of personal accomplishment. Researchers have offered various recommendations to reduce the critical workforce gaps in behavioural health. Some of these recommendations include the following: expanding loan repayment programmes to incentivise mental health providers to work in underserved (often rural) areas, integrating mental health into primary care, and increasing reimbursement to health care professionals.
Social workers also tend to experience competing for work and family demands, which negatively affects their job well-being and subsequently their job satisfaction, resulting in high turnover in the profession.