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Is doing therapy as a psych NP realistic?

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by Kaelif2015 Kaelif2015 (New) New

Im considering pursuing my psych NP but I know most psych NPs are med management focused and I would really want to incorporate a lot of therapy into my practice, I was wondering if this is a realistic goal? 

umbdude, MSN, NP

Specializes in Psych/Mental Health. Has 4 years experience.

It is possible. However, the demand for psych NPs to do a lot of therapy is minimal at best. You will likely have to create your own path by working in a private practice that is willing to accommodate your interests or go solo. My guess is that your income will reflect that of a therapist, not a typical PMHNP. However, some therapists do make very good money in private practice. But those therapists generally have advanced psychotherapy training such as PsyD, clinical psychology, or to a lesser extent, LCSW.

Just my two cents...the psych NP path really does not make sense if your interest lies primarily in psychotherapy. We're trained almost exclusively in the biomedical/nursing model, from A&P in pre-reqs to psychopharm and diagnostics in medically complex patients during PMHNP program. Graduating from a psych NP Program doesn't mean you'll be an expert, and that learning will go on. If your interest isn't in psychopharm and medical science, your knowledge base could fall behind rapidly.

But the most crucial issue is that the psychotherapy training in a psych NP Program is extremely limited. You will likely put in a lot of additional time and money to get certifications after graduation. It'll probably take years to feel the level of competence that a PsyD or LCSW have. 

I am not a psych NP but I have a colleague who has been one for I think at least seven, eight years (probably longer). She told me that she got to a point in her career where she got tired of being just a pill pusher and so reassessed what was meaningful to her. She has a private practice now, where she incorporates integrative mental health services, such as somatic/emotional release modalities for trauma and craniosacral therapy. I imagine with time and the right leg work, you can eventually create something that will be more meaningful for you. I believe it is possible. 

gettingbsn2msn, MSN, RN

Specializes in medical surgical. Has 5 years experience.

I dropped out of my Psych NP Program after my first clinical rotation.  I was spending 5 minutes with someone to throw meds at them.  

I am already a FNP so it was an additional certification.  Thousands of $$ down the drain but I just could not do it.  I felt that it would make ME DEPRESSED.

FullGlass, BSN, MSN, NP

Specializes in Adult and Geriatric Primary Care. Has 3 years experience.

It is unlikely.  Currently, the way reimbursements from insurance and feel schedules are set up, it makes more sense financially for MDs and NPs to focus on med management.  There are some practices that provide more flexibility, but those are a minority.  Another option is to set up one's own practice.

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro. Has 13 years experience.

I am a new graduate and I integrate therapy with every client. I use codes that pay me more for doing so.  Most of my therapeutic interventions are evidence based lifestyle and I heavily rely upon information from podcasts like The Carlat Report and Dr. David Puder's excellent podcast. However, having said that I almost always encourage my clients to see a dedicated therapist trained in the modality most suited to their needs be it CBT, CBT-T, CBT-I  EMDR, ERP, DBT or another approach.  Part of what we are trained to do as NP's (hopefully) is to identify the best evidence based therapies and then to facilitate clients receiving those therapies.  There are times when I have clients who's insurance will not pay for therapy (Medicare typically) where I will will make the followup appointments an hour rather than 30 minutes so that I can at least give them some therapy. I also almost always cover the basics of CBT(I) with anyone suffering sleep issues since it is perhaps the most evidence based intervention for insomnia, more effective in the long term than any supplement or RX.  Having 90 minute intakes and 30minute standard followups helps to create a solid opportunity to provide at least some therapy on an ongoing basis. Insurance compensates me usually in the $300 to $500 range for codes on intakes like 99205 along with 90838 and 90785 on my 90 minute intakes.  On my 30 minute followups I will often use the combination of 99214, 90833, and 90785 (where appropriate) and this compensates around $150-200 for most of my insurances for a 30 min visit.  Thus, I am getting compensated for the therapy that I offer and the time that it takes.

My wife often talks to former classmates (PMHNP) who charge $400.00 for intakes and $150.00 per 30 minute visit cash only without regard to whether or not it is therapy, prescribing, or a combination of the two. I am not to that point yet (and may never get there), but it is something to keep in mind ($300 x 32 billable hours per week times 48 weeks per year would gross around $460,800 per year if my math is correct. Not too bad). I probably get 20-30 calls or emails per week from my poorly written Psychology Today ad and my troll like picture., and many more appointments provided by the company that I work with. If I had a nice website and worked to build some Google reviews I suspect that I could generate many more leads, but such organizational precision is beyond my severely ADHD impacted brain.

Edited by myoglobin

DrCOVID, DNP

Specializes in psych/medical-surgical. Has 12 years experience.

On 10/24/2020 at 3:04 PM, myoglobin said:

I am a new graduate ...

^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^

My preceptor just told me last week to do exactly what Myoglobin talks about.  PMHNP's are trained in therapy and why not do 3 days of RX focus/+therapy or just a therapy business on the side? I swear some people just think the world is black and white, or just all gray (depressing)!

On 10/16/2020 at 3:03 PM, gettingbsn2msn said:

I was spending 5 minutes with someone to throw meds at them. 

I was worried about this too. I was a surgical/medical RN, no psych exp. I thought it was a load of horse****. Then I stuck with it and found, a lot of people benefit from the right medication (I mean from hallucinating/paranoid, to able to live a productive life). It is well worth it my friend, when you can do that for just one person. And as myoglobin points out, we can do therapy as well if you want to. That is where you come in as a PMHNP. You gave up too soon and have a lot of limiting beliefs!

I am high in trait conscientiousness... there would be no way to do this work if it were unethical/worthless.

Edited by adammRN

umbdude, MSN, NP

Specializes in Psych/Mental Health. Has 4 years experience.

8 hours ago, adammRN said:

I swear some people just think the world is black and white, or just all gray (depressing)!

Nobody above said doing therapy is impossible, so I don't know why you're suggesting that people think that the world in black and white. Maybe you just think that you know it all and everyone else is a dunce.

The kind of model myo and you are after is mostly limited to private practices as independent contractors. Nobody suggested that NPs cannot bill E/M + add-on therapy, but most employers (including many private practices that hire w-2 employees) will not hire you to do 30-min f/u nor does every patient want these "therapy."

It's also unclear what OP means by "doing a lot of therapy." I don't consider "add-on" therapy as a lot of therapy. Frankly, I did a lot of these sleep hygiene psychoed, meditation, nutrition/exercise, MI, supportive therapy, and basic cognitive restructuring as a psych tech and psych RN. You don't need a PMHNP for that. You can literally work as a psych RN and run these groups (I did).

If OP wants to do full-hour therapy using CBT, DBT, psychodynamic, family therapy, or EMDR, OP will need lots more training than what PMHNP curriculum can provide, and almost certainly have to work as an independent contractor to have the flexibility to do this because employers won't hire PMHNPs to solely do therapy.

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro. Has 13 years experience.

While getting more training post grad for therapy is optimal and indeed imperative if you aspire to do certain specific approaches such as EMDR, DBT. ERP and others much of the time therapists in my experience mainly use “supportive” or “talk” therapy. In the 200 or so hours where I sat in on therapy (or assisted) in school this was the modality actually utilized more than 90 percent of the time. Also, of the 20 or so jobs that I investigated in states like Washington, Oregon, Maine, Colorado and New York none of them expected me to do less than 30 min followup. The 15 min and 20 min follow ups are more of a Arizona, Texas. and Florida approach where physician owned practices or “Medicaid oriented” practices are seeking to squeeze maximum revenue from their employees and clients.

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro. Has 13 years experience.

On 11/2/2020 at 12:09 AM, umbdude said:

Nobody above said doing therapy is impossible, so I don't know why you're suggesting that people think that the world in black and white. Maybe you just think that you know it all and everyone else is a dunce.

The kind of model myo and you are after is mostly limited to private practices as independent contractors. Nobody suggested that NPs cannot bill E/M + add-on therapy, but most employers (including many private practices that hire w-2 employees) will not hire you to do 30-min f/u nor does every patient want these "therapy."

It's also unclear what OP means by "doing a lot of therapy." I don't consider "add-on" therapy as a lot of therapy. Frankly, I did a lot of these sleep hygiene psychoed, meditation, nutrition/exercise, MI, supportive therapy, and basic cognitive restructuring as a psych tech and psych RN. You don't need a PMHNP for that. You can literally work as a psych RN and run these groups (I did).

If OP wants to do full-hour therapy using CBT, DBT, psychodynamic, family therapy, or EMDR, OP will need lots more training than what PMHNP curriculum can provide, and almost certainly have to work as an independent contractor to have the flexibility to do this because employers won't hire PMHNPs to solely do therapy.

Also, while you may not consider add on codes "doing a lot of therapy" I probably earn almost $700.00 per day in add on codes for the therapy that I do and in terms of time it amounts to at least four hours each day that I work.  You may have done some of these things as a Psych tech or RN, but did you get reimbursed by insurance for them?  My license as a PMHNP equips me to do therapy and bill insurance essentially on par with therapists in the states where I practice. Their license does not let them prescribe medicines. We can argue whether or not this is appropriate, but from a legal and regulatory standpoint it is essentially the standard of practice.  

FullGlass, BSN, MSN, NP

Specializes in Adult and Geriatric Primary Care. Has 3 years experience.

5 hours ago, myoglobin said:

My license as a PMHNP equips me to do therapy and bill insurance essentially on par with therapists in the states where I practice. Their license does not let them prescribe medicines. 

Your practice is NOT the norm.  You are a contractor.  Most NPs are employees.  As employees, they must abide by their employer's rules.  Psychotherapy and medication management are generally separated out because insurance reimbursement differs for these services.  Talk therapists get less reimbursement and are paid less than NPs or MDs.  And the norm for most mental health clinics, for medication management, is 40 to 50 minutes for a new patient and 20 minutes for a follow up.  Talk therapists get more time with a patient.

PMHNPs do NOT have anywhere the level of education and training as most psychologists or LCSWs in talk therapy.  While PMHNPs can provide talk therapy, let's not delude ourselves that we have the expertise of a PsyD.  

The hard reality, for most PMHNPs, is that they are not going to get to provide much talk therapy because that is not what they are being paid to do by their employer.  It is not cost-effective, given insurance reimbursements.  

myoglobin, ASN, BSN, MSN

Specializes in ICU, trauma, neuro. Has 13 years experience.

Even at W-2 jobs such as the one where I was a student there are two types of billing. Complexity based coding or time based coding. It is only possible to add on therapy codes if you do "complexity" rather than time based coding (your charting must support the elements for complexity based coding).  Even the place where I "worked" as a student most providers added therapy codes despite only having 20 minute appointments. Thus, they did therapy and their company was reimbursed (in many cases much the same as I am now or close).  The fact that their training may be superior is not relevant as to our scope or billing ability. Also, in 90% of cases the therapy actually performed (in my experience) is simple "talk therapy" as opposed to actual CBT, EMDR, or ERP therapy. It least when I do therapy it is consistent with the modality advertised and billed. (usually CBT). Again, even in most non IP jobs therapy is being billed otherwise companies would be leaving "money on the table" and they seldom wish to do this in successful practices. Hence, therapy can be billed and performed in most Psych NP jobs in the United States. Also, on those instances where I have done "dedicated" therapy (no medication management) I have been informed that my reimbursement rates are equal or superior to that received by PhD level psychologists. It may not be "the best thing" but it reflects the reality "on the ground" in many IP states.

Edited by myoglobin