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T(r)IC(k)S #16

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Life's A Twitch! Celebrating 15 years.
1998 - 2018
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You Say ‘M.’D., I Say ‘Ph.’D.:
The Diagnosis Game II

Let’s recap from last time: although each province is governed by their own acts for health professions, on the whole physicians and psychologists can both diagnose mental health conditions and can both be doctors even though they differ in their training. So why would you choose to go to one over the other to obtain a mental health diagnosis? Let’s tackle that question in this instalment…

But first, I again offer my disclaimer. Psychiatrists (or other Physicians) and Psychologists are both well trained and qualified professionals – this article should NOT be perceived as an attack on one profession versus another, or an attempt to show the superiority of one to the other. They are, though, different disciplines. Given an individual’s needs and situation, a person may prefer going to one type of professional versus the other then. ALL I hope to accomplish in this 2-part article is to make you a more informed consumer by giving you enough information to make the choice that is best for you. Having said that though, despite an honest effort to be fair and accurate this article may be ‘lop-sided’ in that I simply know more about what Psychologists have to offer. Perhaps in the future a Physician counterpart will continue what I’ve started by offering a more thorough look at ‘their’ side, giving you the most complete picture possible.

Deciding whether to go see a Physician or Psychologist for diagnosis purposes largely comes down to circumstances. Physicians are covered by provincial health insurance plans (i.e. THEY ARE FREE!), but therefore require a referral (often from another physician – typically the family doctor). Speaking in generalities, family doctors typically have not received much training in recognizing or treating mental health conditions (if any at all) as they did not choose that stream as their specialty. Leaving them as both the front-line and gatekeepers to appropriate services, then, seems somewhat unfair (to both them AND the consumer) and can at times lead to problems. Over the years many parents have shared horror stories of hindered or erroneous referrals and diagnoses. Finally, because in Canada health care is a public (and publicly funded) service, wait-lists can be formidable.

On the other hand a private practice Psychologist does not require a referral, and the wait-lists (if they exist at all) are often short. The major shortcoming here is that Psychologists are not covered by all provincial health insurance plans, although most work insurance policies include at least some (and sometimes excellent to unlimited) coverage for Psychologists.

Psychologists are trained extensively in assessment skills. Like medicine, there are many types of psychology to choose to major in (industrial-organizational, developmental, cognitive, and behavioural neuroscience, to name only a few). Unlike medical students, psychology students choose the stream in which they are interested as soon as they are finished their undergraduate degree. As mentioned last time, it is in the later stages of their training where physicians choose their specialities.

The advantage to the Psychologist route, then, is that those who are working in the assessment, diagnosis, and treatment of mental disorders (called ‘clinical’ psychology) receive training particular to this specific area for their entire 5 years (or more) of graduate schooling. Physicians, as mentioned last time, don’t have that luxury – they also need to learn about how the rest of the body works, how it can fail, and how to fix it.

It certainly does not take that long to learn how to actually PERFORM an assessment – to learn to administer the various tools of our trade. In fact, probably just about anyone could eventually be trained in it. Of course, likely the same could be said about the steps of a surgical technique too. Does this mean you would want just anyone to be in charge of your operation though? Obviously not. You still want someone with the background necessary to intuitively read certain situations, and the repertoire to flex and compensate if everything doesn’t go by the book. A Physician, better than anyone else, can do these things in the operating room; rather than woodenly executing a set procedure without deviation, (s)he has the knowledge base to adapt to each individual situation. So it is with Psychologists in the mental health assessment room.

This is why oftentimes even though a Physician may be the team leader in mental health facilities or hospitals, Psychologists are frequently delegated the responsibility of the assessment. Both the Physician and Psychologist play essential roles on the team, but a recognition of which disciplines can fulfill each team expectation the best will make that team as efficient and effective as possible.

Another advantage Psychologists have because of this intense focus on the mind and brain is that we have the luxury to go beyond the organic – to look at the psychological and sociological aspects of various conditions along with their physiological aspects. In other words, rather than working from the ‘medical’ model, Psychologists work from what’s called the ‘biopsychosocial’ model.

By doing so, this aids us in understanding the bi-directional influence of psychology and neurology. We spend time learning how our neurology influences what we learn and how we act, think and feel. But we also spend time learning how psychology influences our neurology – something that most people aren’t aware happens as well.

Those who have seen my presentations may have listened to me applaud the importance of including “significant distress or impairment” as a criterion in the diagnosis of mental health disorders. I believe impairment is a crucial component of diagnosis, because my training has shown me that the presence of a brain abnormality alone is not sufficient to explain the problems that drive people to seek help. Consideration of the environment in which a client finds him/herself can add insight into understanding certain behaviours and modes of thinking, and guides treatment. This insight can be missed when one considers the neurological issues in isolation.

The best work in mental health is done when disciplines come together though – when Physicians and Psychologists pool their repertoires the result is greater than the sum of the parts. My Incidental Associations Model of Tic Formation (written for my Ph.D. defence and available for download on my website) is an example of this. By introducing certain learning principles and models from the psychological discipline into the excellent brain imaging work done in the medical field, comprehensive explanations for the origin and maintenance of certain aspects of TS can be attained. From the medical or psychological perspectives alone, these explanations are out of reach. Put together the things that Physicians and Psychologists each do best, however, and we see further than either could hope to alone.

As of this writing I am in possession of a Certificate of Registration Authorizing Supervised Practice as a Psychologist. You can recognize a registered Psychologist in Canada by the addition of the abbreviation “C.Psych.” (registered Psychological Associates put “C.Psych.Assoc.”) following their name and highest degree. Others may simply put “Dr.” in front of their name (if they have a Ph.D.) and “Psychologist” after it, for ease of public comprehension. Since these are all restricted titles you can trust in the credentials of that individual when you see them. Note that my new letters are followed by “(supervised practice)”. Until I am designated ‘autonomous’ as a practitioner (scheduled for December 2003), I will need to add this qualifier to indicate that my work is done under another College member; until then the clients I see are theirs and I am not permitted to take my own.

We’ll continue on this topic of ‘who can offer what the best and when’ again at a future date. Having thoroughly covered diagnosis, though, when we next pick up this topic again we’ll move on to the area of intervention.

B. Duncan McKinlay, Ph.D., C.Psych. (supervised practice)

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Last updated on January 3, 2018

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