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Is doing therapy as a psych NP realistic?

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by Kaelif2015 Kaelif2015 (New) New

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

1 hour ago, myoglobin said:

(in my experience) 

No offense, but your experience in psychiatry is still quite limited. You may be able to legally provide and bill for psychotherapy but that doesn't mean you are competent at it. Compare the curriculum between PMHNP and LPC's, LCSW, LMFT, etc. not to mention in most states they have to have between 2,000 to 3,000 hours of supervised practice in order to be eligible for licensure. Most NP programs are what 600 hours? 700 hours at the most? And those clinical hours would be spent doing medication management and there's only so much psychotherapy you can provide in a 15-20min appointment where your primary focus are on medications. Do you really think that with the education you received, your clinical hours, and your limited experience as a psychiatric provider gives you the same grasp of understanding that a therapist has on providing therapy?

I'm not trying to be nasty and I'm not saying you're a lousy provider because it really does sound like you try to go above and beyond to provide excellent care to your patients. I simply want to point out that just because something is in your scope of practice and you bill for it, does not mean that you should do it. I think it's a case where the regulations haven't caught up with the state of PMHNP curriculum. Decades ago curriculum for psychiatric NP's and CNS's were psychotherapy heavy, in fact at most colleges and universities the only difference in curriculum was that NP's had the psychopharmacology piece added. Now that psychiatric CNS's have gone the way of the dinosaur the curriculum has gradually changed for NP's with a much heavier focus on medication management versus psychotherapy. I think this is the role that PMHNP's excel at and where the job security for the profession will lie. I really wish we could go back to the old days as far as the education, though.

myoglobin, ASN, BSN, MSN

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

54 minutes ago, TheMoonisMyLantern said:

No offense, but your experience in psychiatry is still quite limited. You may be able to legally provide and bill for psychotherapy but that doesn't mean you are competent at it. Compare the curriculum between PMHNP and LPC's, LCSW, LMFT, etc. not to mention in most states they have to have between 2,000 to 3,000 hours of supervised practice in order to be eligible for licensure. Most NP programs are what 600 hours? 700 hours at the most? And those clinical hours would be spent doing medication management and there's only so much psychotherapy you can provide in a 15-20min appointment where your primary focus are on medications. Do you really think that with the education you received, your clinical hours, and your limited experience as a psychiatric provider gives you the same grasp of understanding that a therapist has on providing therapy?

I'm not trying to be nasty and I'm not saying you're a lousy provider because it really does sound like you try to go above and beyond to provide excellent care to your patients. I simply want to point out that just because something is in your scope of practice and you bill for it, does not mean that you should do it. I think it's a case where the regulations haven't caught up with the state of PMHNP curriculum. Decades ago curriculum for psychiatric NP's and CNS's were psychotherapy heavy, in fact at most colleges and universities the only difference in curriculum was that NP's had the psychopharmacology piece added. Now that psychiatric CNS's have gone the way of the dinosaur the curriculum has gradually changed for NP's with a much heavier focus on medication management versus psychotherapy. I think this is the role that PMHNP's excel at and where the job security for the profession will lie. I really wish we could go back to the old days as far as the education, though.

Maybe but here are my main points:

1. 90% of jobs (even in the non IP states) will expect you to use the add on therapy codes (and if you don't add them they will probably do so for you in their billing dept) because failure to do so would mean the loss of great amounts of revenue. Thus, if you are not doing therapy, you probably should be because you are probably billing for it (unless they are using time based billing).

2. Your "school" education does not "limit" your education. There are abundant resources available for certification in areas ranging from CBT, to DBT and other modalities. It need not be taught (although in most cases it is taught at least to some extent) in NP programs. No doubt more course time on therapy as in many areas would be ideal, but again it would dilute one of our comparative advantages vis a vis psychiatrists which is lower cost(s) to educate (indeed most psychiatrists do not do stand alone therapy given that it is more efficient for them to do medication management along with add on therapy codes).

3. Many (perhaps most) therapists and psychiatrists you practice therapy actually resort to "talk therapy" which is often little more than supportive listening. Few, "go the extra mile" to actively employ the focused, specialized techniques involved in CBT, let along ERP or other modalities. 

Thus, whether we should or shouldn't be doing therapy is largely a "moot" point given that most jobs (W-2 and 1099 ) will be billing insurance for it therefore get as good as you can at it and bill, chart and perform accordingly. By the way the paradigm for complexity based billing will be changing in 2020 with a greater emphasis on medical decision making.  Also although, I am new at this my SO has been doing this since 2016 and she was shocked to learn that her 1099 85 hr hourly job that takes mostly Medicaid patients uses complexity based coding and billed about 200K in therapy add on codes for her last year. She at least provides some therapy (as much as you can in a 20 minute followup appointment), but she wasn't aware the codes were being added.  

Edited by myoglobin

FullGlass, BSN, MSN, NP

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

16 hours ago, myoglobin said:

Thus, whether we should or shouldn't be doing therapy is largely a "moot" point given that most jobs (W-2 and 1099 ) will be billing insurance for it 

You are missing the point.  Yes, PMHNPs can bill add-ons for therapy.  That doesn't mean they very well trained or qualified to provide it, unfortunately.  And it is not possible to provide good therapy in 15 or 20 minutes once a month or so.  The job description of most PMHNPs clearly focuses on med management.  The PMHNP curriculum is in no way adequate preparation for delivering serious talk therapy.  Poor quality therapy can also harm the patient.

myoglobin, ASN, BSN, MSN

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

7 hours ago, FullGlass said:

You are missing the point.  Yes, PMHNPs can bill add-ons for therapy.  That doesn't mean they very well trained or qualified to provide it, unfortunately.  And it is not possible to provide good therapy in 15 or 20 minutes once a month or so.  The job description of most PMHNPs clearly focuses on med management.  The PMHNP curriculum is in no way adequate preparation for delivering serious talk therapy.  Poor quality therapy can also harm the patient.

I will agree that we should generally encourage clients to have "stand alone" therapists in addition to providing supportive therapy and medication management. However, in response to the primary post questions concerning whether or not it is possible to do a lot of therapy as a PMHNP I would assert that it is not only possible, but optimal and an essential part of what we do.  Again, rather than distressing over our limitations, I would rather celebrate the abundant opportunities that we have. Keep in mind you are free to expand your education to your heart's content. I am in the process of signing up for a $5,000 CBTi certification course which will take me about three to six months to complete for example and I will be one of the only providers (out of a practice with more than 200 therapists and 40 PMHNP's) who has this certification. I had also investigated a year long course which would give me ERP therapy for OCD certification, but that is beyond my ability to pursue at this point.

Edited by myoglobin

DrCOVID, DNP

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

On 11/21/2020 at 1:49 PM, FullGlass said:

You are missing the point.

Your retorts are "theoretically" correct. We all know theory is often far from reality and that just because someone spends 3,000 hours at something, doesn't mean they are going to be good or better. You think if you spend 10,000 hours playing basketball that you can beat some kid that is physically built for it and more conditioned? Most likely not, but who has more time? Not the best example, but you get the point.

There are always going to be better and worse. There are patients that come to NPs because the Psychiatrist gave up or said they couldn't help the patient anymore. Guess that was part of the 10k hour training. To tell someone you can't help them. Even between other MD's that have 10k hours doing whatever, guess what? Outcomes are still highly variant based on the setting and provider that you have. Go look it up, it is well documented in literature.

There are still really good suggestions you can make based on your knowledge in 15-20 minute appointments. Did you know diet high in refined carbs contributes to depression? I'm in South so most everyone is metabolically unhealthy here. One of last people I saw in clinic was not exercising and eating really poorly. While I probably didn't correctly perform motivational interviewing or CBT, I hopefully open her eyes to making some changes that could help how she was feeling. And that is what we are there for. Not "no you can't offer other advise or therapy because it doesn't make economic sense" or "because it is not the normal." 

Really irks me how so many seem to stifle any semblance of creativity or lack the luster to smash the norm. Our profession will surely benefit from this type of belief.

Edited by adammRN

FullGlass, BSN, MSN, NP

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

23 hours ago, adammRN said:

Your retorts are "theoretically" correct . . . Really irks me how so many seem to stifle any semblance of creativity or lack the luster to smash the norm. Our profession will surely benefit from this type of belief.

PMHNPs can certainly provide supportive therapy during their allotted appointment times, as well as advise on topics like nutrition.  My point is that they do not have the education or training, nor do most of them have enough time during their appointments to provide what most people would consider a regular talk therapy session.  We are NOT trained to the level that psychologists or LCSWs are to provide talk therapy.  And poorly conducted talk therapy can cause harm to the patient.  I have patients that have suffered severe physical and psychological trauma from living in war-torn countries and literally seeing family members tortured and killed in front of them.  That sort of trauma has to be handled very carefully and there is no way I am qualified to do that.  

As for psychiatrists, I don't know what that has to do with this topic.  Most of them aren't well trained in talk therapy, either, which is why they also focus on med mgt.

myoglobin, ASN, BSN, MSN

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

1 hour ago, FullGlass said:

PMHNPs can certainly provide supportive therapy during their allotted appointment times, as well as advise on topics like nutrition.  My point is that they do not have the education or training, nor do most of them have enough time during their appointments to provide what most people would consider a regular talk therapy session.  We are NOT trained to the level that psychologists or LCSWs are to provide talk therapy.  And poorly conducted talk therapy can cause harm to the patient.  I have patients that have suffered severe physical and psychological trauma from living in war-torn countries and literally seeing family members tortured and killed in front of them.  That sort of trauma has to be handled very carefully and there is no way I am qualified to do that.  

As for psychiatrists, I don't know what that has to do with this topic.  Most of them aren't well trained in talk therapy, either, which is why they also focus on med mgt.

The Psychiatrist that I trained with had an entire year of his residency focused on therapy. He said that although he enjoys therapy he only has time to do supportive therapy because the expectation was to see 3-4 patients per hour. My point was that most effective PMHNP's will do significant amounts of therapy in their jobs and will be expected by their employers to bill for it (unless doing time based billing in which case they will probably be required to see 3-4 patients per hour).  Indeed, it is the "complexity based" coding along with add on therapy codes that make PMHNP's relatively more valuable (and therefore higher paid) than FNP's. 

FullGlass, BSN, MSN, NP

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

On 11/23/2020 at 7:41 PM, myoglobin said:

The Psychiatrist that I trained with had an entire year of his residency focused on therapy. He said that although he enjoys therapy he only has time to do supportive therapy because the expectation was to see 3-4 patients per hour. My point was that most effective PMHNP's will do significant amounts of therapy in their jobs and will be expected by their employers to bill for it (unless doing time based billing in which case they will probably be required to see 3-4 patients per hour).  Indeed, it is the "complexity based" coding along with add on therapy codes that make PMHNP's relatively more valuable (and therefore higher paid) than FNP's. 

I stated that PMHNPs can and do provide supportive therapy, and that is billed for.  Same for psychiatrists.  But the original question seemed to be about providing a lot of therapy and the answer to that is no and it should be no for most PMHNPs, given the limited education and training most have, as well as the limited time most have.

As for psychiatrists:

"The vast number of psychiatrists no longer practice psychotherapy, and the percentage that do seems to shrink annually. In fact, only around 11% of outpatient psychiatrists continue to practice psychotherapy extensively after residency. Many say that financial incentives that favor medication management over psychotherapy are leading psychiatrists away from psychotherapy. That undoubtedly covers some percentage of psychiatrists. However . . . something else is driving the changing tide, and a good bet would be that a substantial number of incoming residents are far less interested in psychotherapy than they claim to be."

https://opmed.doximity.com/articles/why-psychotherapy-training-shouldn-t-be-part-of-psychiatry-residency-22e1d4e0-1537-4e9a-b4b6-c07a62956967?_csrf_attempted=yes

myoglobin, ASN, BSN, MSN

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

Perhaps it is a matter of semantics, , but at least 16 minutes of every 30 min followup, and 45 min of every 90-120 intake. Given that I see about 15 patients four days per week that seems like a good deal of therapy.  In fact it is so much that my wife who will be starting at the same company often expresses that she “isn’t sure she can do what I do and in her words coddle her patients so much.” I’m not saying I am particularly good at the therapy that I do, but I do earn from $600 to 1k per day in add on therapy fees.

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 14 years experience.

On 11/25/2020 at 8:23 PM, myoglobin said:

Perhaps it is a matter of semantics, , but at least 16 minutes of every 30 min followup, and 45 min of every 90-120 intake. Given that I see about 15 patients four days per week that seems like a good deal of therapy.  In fact it is so much that my wife who will be starting at the same company often expresses that she “isn’t sure she can do what I do and in her words coddle her patients so much.” I’m not saying I am particularly good at the therapy that I do, but I do earn from $600 to 1k per day in add on therapy fees.

If you are admittedly not particularly good at a provided service, I think you should evaluate whether or not to continue to do it. Sure, it takes practice to become competent in any skill but that practice usually takes place under supervision. I just don't think it's ethical for PMHNP's to be providing in depth psychotherapy with the lack of education and practical experience in psychotherapy. Supportive therapy during an appointment, sure that's great, should be done, and is appropriate. Many mental health patients with severe mental illness need more than just basic talk therapy and that is more appropriately handled by an LPC, LCSW, PsyD, or PhD. 

Out of curiosity though, do you if PA's are allowed to add on therapy fees the way NP's can? You don't see very many PA's in psychiatry, at least in my area, and the ones I have seen were therapists prior to becoming a PA. Most PA programs from my understanding have just one course/rotation in psychiatry, is it in depth enough for them to provide psychotherapy?

myoglobin, ASN, BSN, MSN

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

All digressions aside this was the original post/ question"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? "

The answer is a definitive YES at least in the state where I practice ie Washington. Essentially, every NP in my practice (well over 40) bills add on therapy codes and earns an income well above 300K (of those that work full time) in part for doing so.  Many of done so for more than a decade.  Thus, I submit that it is beyond reasonable argument that therapy can be part of a successful practice. Also, in almost every case the clients see a dedicated therapist on a weekly basis on top of the PMHNP.   

On 10/16/2020 at 2:03 PM, gettingbsn2msn said:

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.

Can we DM gettingbsn2msn?