Is doing therapy as a psych NP realistic?

What Members Are Saying (AI-Generated Summary)

Members are discussing the time required for medication management appointments, with some stating that the standard 20 minutes may not be necessary for all cases. They also talk about the financial aspects of different appointment lengths and codes, as well as the potential for nurse practitioners to provide therapy along with medication management. Additionally, users are sharing their experiences and perspectives on balancing therapy and medication management in their practice.

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? 

Specializes in ICU, trauma, neuro.
1 hour ago, FullGlass said:

We use 90833.  I do not see how med mgt takes a full 20 minutes unless the pt is very complicated.  This is an outpatient practice and the most common issues are anxiety, depression, PTSD, ADHD, bipolar d/o.  If the pt is stable and doing well, how does med mgt require 20 minutes for simply something like Lexapro?  It doesn't.  How is your mood?  Good.  Sleeping well?  Yes.  Appetite?  Normal for me.  Anxiety?  Not any more.  Any troubling SE?  No.  That does not take 20 minutes.

I usually take my whole 30 minutes. I will usually do a PHQ, GAD-7 and an ADHD V1.1  or Yale Brown if relevant.  I will spend time reinforcing things like CBT-I, balance exercises (such as those supported by Dr. Hallowell in ADHD 2.0), gratitude journaling, supplements like Omega three fatty acids, DASH diet (which has a recent study supporting ADHD, but is also useful in addressing hypertension that can be an issue with ADHD meds).  I will talk about Podcasts like Dr. David Puder's Psychiatry and Psychotherapy Podcast and encourage clients to participate in the "book of the month club" (this month it is Victor Frankl's "Man's Search For Meaning" and his "logos therapy".  Honestly, I could use more time than 30minutes much of the time.  

Specializes in ICU, trauma, neuro.
7 hours ago, FullGlass said:

The southeast does not seem to be a good work area for NPs.  I'm curious, how much does insurance pay for the standard 20 min follow up appts and the 40 to 50 min intake?

In Washington "my" average take for a 30min appointment (70%) averages around $150.00 for a 99214 plus 90833 NPT.  In Florida you could decrease that by about 10 to 20%.  For my 90 min intakes "my" portion is around $200-250 on average.  Thus, I do better on repeat clients.

myoglobin said:

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.

This is super helpful! I am soon starting an Accelerated BSN program and then would like to go on to become a PMHNP, and I'd like to use both medication in therapy in the treatment of my clients one day. I've been scouring the internet looking for descriptions of the role of therapy in the practice of a PMHNP, but it's been hard to find. That has made me think that providing therapy as a PMHNP is rare. But I also spoke with a few PMHNPs as well as a Psy D about the role of therapy as a PMHNP and it seems like I can boost my credentials as a therapist, outside of my MSN program, with additional trainings, certifications, residencies, etc. and carve out a niche for myself, probably in a private practice. 

In both of my conversations with a PMHNP and a Psy D, they both alluded to PMHNPs being more prescription heavy providers rather than therapists, and that being due to the money. I still have a handful of questions about how those things affect your pay and how insurance is billed, etc. Could I send you a message Myoglobin? I'm a new user to the site though, so I don't know if I have that ability yet.

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.

Honestly,  before I started this journey I spent hours researching a variety of things r/t therapy treatments.    I LOVE this stuff and I throw at my friends all the time.  I fully plan to add extra certificates so I have something to back the talk.   You have NO idea the capabilities of the person you are talking to.    

Specializes in Psychiatric and Mental Health NP (PMHNP).
LlamaMama said:

As a PMHNP who completed training years ago (1983), my masters program at UCSF (psych CNS) included 2 years of psychotherapy tng w/supervision. Post-masters I strengthened my psychopharmacology skills and have worked across settings and severity of illness. 

Unfortunately, most PMHNP programs now emphasize psychopharmacology.  While they cover talk therapy, there is very little in the way of supervised talk therapy training in these programs.  

At least in Calif, an LCSW or psychologist must complete their education and an additional 5,000 hours of supervised therapy.   There is just no way a 2 year PMHNP program can compare to that.  These programs provide 500 to 750 hours of clinical time and most of that is for med mgt.  Does anyone reasonably think that 100 to 200 hours of supervised talk therapy (maybe) is adequate to be delving into others' psyches and stirring up who knows what?

Bad talk therapy can cause a lot of harm.  As a PMHNP, I've seen this happen to my patients.  In addition, the way mental health care is structured now, PMHNPs and MDs usually only have 40 minute intakes and 15 to 20 minute follow ups.  That is not enough time for talk therapy; they are supposed to just do med mgt.  In fact, it is barely enough time for decent med mgt.  That is due to how insurance reimburses for mental health care.

Health insurance companies pay crap for talk therapy, unfortunately.  This is one reason why so many areas have a dire shortage of talk therapists that will accept insurance.

Therefore, it is best for PMHNPs to stay in their lane and that means med mgt.   Talk therapists can be sued and so can PMHNPs.  A PMHNP that represents they are qualified to perform talk therapy that ends up harming a pt can be sued.  

A PMHNP that wants to provide talk therapy should consider additional education and training as an LCSW or psychologist.  This is no different from what a lot of psychiatrists do - they get a PhD or PsyD in psychology.

Specializes in trauma therapy, mind body medicine, somatic therap.

YES! I'm a PMHNP and I only do therapy! And I train nurse practitioners in the types of therapy I use which are trauma therapy, inner child healing, hypnotherapy, breathwork, mind-body therapy, somatic therapy, emotional release work, attachment wound healing, etc.

Specializes in PMHNP-BC.

I signed up in here just to be able to comment on this thread. I think it's important. I prescribe medications; I do not pretend to be an MD or a DO or have that training. I perform psychotherapy; I do not pretend to be a PsyD or LMFT/LCW/LCSW or have that training. I know that I don't, but the training I have is absolutely valuable and relevant. What I do know is that a really good PMHNP will know when psychotherapy is appropriate and needed, if they are able to provide it in the time they are allotted, but they will also know when someone needs more psychotherapy that is beyond their capacity and may do more harm than good. Good PMHNPs are not reckless! Lives and souls are precious! I am NOT saying that PMHNPs who do not believe in offering or are not able to offer psychotherapy are not good PMHNPs. I'm talking about those who do offer that treatment. I am an independent contractor, thank heavens, and would NEVER be able to function with fifteen minute follow-ups. Kudos to you if you can - great! I know my limitations, and I know I can't do that. But also, many patients that I see are absolute messes, far beyond: "Mood? Great, Sleep? Great, Anxiety, Great. Nutrition? Great. Get out of here." Many are extremely complex. Many have concomitant substance use issues and/or eating disorders. Many do not adhere to recommended treatments or get labs that are recommended (like my severely anorexic patient who refuses to get lithium labs). I cannot pretend that they do, and it is difficult to assess all of this in 15 minutes and explain to them the vital importance of WHY adhering to recommendations is necessary. I can't look the other way either. How am I helping the patient in that capacity? So many providers already look the other way, and the patient does not get help. Our patients need to know why adherence is important; this is therapy. An educated and empowered patient is more-likely to adhere to and get the most out of treatment! This is psychotherapy! And there are other ways to manage symptoms aside from psychopharmacology. We are not just bodies! We are bodies, minds, and spirits! I have been through years and years of therapy and have learned many valuable tools along the way. I have also taken it upon myself to learn more about CBT, DBT, and Solution-Focused therapy. You bet I pass these tools along to my clients. I even want to become trained and offer EMDR therapy. I myself had 20 years of unhelpful psychotherapy from PsyDs and therapists with Doctorates of Behavioural Therapy. I could have talked to my cat for free. It was a PMHNP that offered therapy and changed my life. I want to give this to my patients. If you don't agree - good for you. If you agree, keep rocking on with your bad@ss self! I don't treat bodies, I don't treat labels, I treat people. People are comprised of body, mind, spirit, and so much more that I don't know about! But I'm here for all of it. Psychotherapy and Psychopharmachology each need each other. Many of my patients have therapists who empathize, nod, say "I'm sorry," but give the patients ZERO tools to change. This was me in my first 20 years of therapy with the providers that had doctorates and more training than the PMHNP who gave me therapy and quite literally saved my life. I don't pretend to have that training of an MD, DO, PsyD, or DBH, but I am a nurse, and nurses are amazing, whether you have an LPN, RN, BSN, MSN, DNP, Ph.D,. Think about all of our nursing founders and how hard they worked for our specialty. Dang it - I know what tools I do have, which are many and are powerful, and I have the presence of mind to know when it is appropriate to use or not use them. I have the scope of practice and ability to empower my patients, and thank goodness no one can tell me that I can't. A PMHNP who dared to give me psychotherapy saved my life. I think a PMHNP has every bit of business providing psychotherapy to our patients. We are NURSES, and we treat humans, not diagnoses. If you are a nurse and you don't believe that, again, good for you, though I believe our nursing founders would all turn in their graves. But please don't trash those who do. I am so proud to be a nurse. I know that I was put on this planet to serve others. I have known it since I was very little. I am so grateful that I can give back to others in this capacity. ♥

Specializes in medical surgical.

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.

Specializes in Mental health, substance abuse, geriatrics, PCU.
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.

Specializes in ICU, trauma, neuro.
TheMoonisMyLantern said:

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?

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.  

Specializes in Psychiatric and Mental Health NP (PMHNP).
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.

Specializes in Psychiatric and Mental Health NP (PMHNP).
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

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