Nurse Psychotherapist

elkpark · Aug 14, 2006

Psychiatric clinical nurse specialists (CNSs) have been psychotherapists for decades (we were the first advanced practice nursing role, in fact). Psych nurse practitioners (NPs) are a relatively new development within the last several years. Traditionally, psych CNSs were educated solely/purely as psychotherapists, without any (or only very little) education about meds because there was no question of Rx authority. Psych NPs, of course, like all other NPs, focus on prescribing as a big part of the educational preparation, and most psych CNS programs do, now, too, because so many states now offer Rx authority to CNSs. In fact, it's becoming pretty hard to tell the difference between educational programs for psych NPs and CNSs. Of course, one important (to me, anyway) change this has produced is that much less of the MSN program is focused on the psychotherapy end of things. In fact, looking at the curricula at various programs these days, the psychotherapy "piece" seems to be almost an afterthought, after all the physical assessment & prescribing stuff. Very different from when I went to school in the Dark Ages ... :)

Yes, you must be Master's prepared, as either a psych NP or CNS, to be considered a nurse psychotherapist. That is the "entry level," but, of course, you can go as far beyond that as you choose. Many schools offer an MSN with a psychiatric NP or CNS concentration (or, more and more common these days, a combined psych NP/CNS program).

"Daily responsibilities" and sites of employment vary greatly. I've been a child psych CNS for >10 years, and have worked in outpatient mental health centers, inpatient acute and residential programs, emergency rooms and have done psychiatric consultation-liaison work in a general hospital. Many MSN-prepared psych nurses work in private outpatient practice, independently or in group practices that are often multi-disciplinary.

I hope this info is helpful; I'm sure that other members will have something to say, also. I'll be glad to try to answer any other questions you may have; feel free to PM me if you prefer.

amanda sue · Aug 15, 2006

That's exactly the kind of answer I was looking for! Thank you so much! :)

I know exactly what you mean about how "nowadays" the medication is the primary concern, and the psychotherapy is considered an afterthought (or a nice, but not needed addition.) As a psychology major, I've run into many professors/clinical psychologists who believe that medication is the answer to everything and the chemical imbalance is the only problem. I'm not denying the medicaition is often necessary and undoubtably helpful, but I fear that today's mental health professionals are forgetting the power of medication combined with a skilled psychotherapist. The power of talk therapy, in my opinion, seems to be falling to the side as people focus exclusively on curing those chemical imbalances. Anyhow, I digress...

I'm almost embarrassed to admit I have never heard of the title CNS! I thought all advanced practice nurses were NPs; I never knew there was another "type" of advanced practice nurse! All you hear about these days is NPs.

Two more questions...

1. On the simplest level, what are the differences between NPs and CNSs? I know both are Master's prepared, advanced practice nurses who have the power to practice independently or alongside others (i.e. in a hospital). And from your post I understand that Psych CNSs are more involved in the psychotherapy side of treatment in addition to the standard medical care. What are the differences in their roles? Are they more similar than dissimilar? Also, in fields outside of Psych/MH, how do NPs and CNSs differ in their roles/duties (i.e. a Critical Care NP vs. CNS)

2. Is there much demand for Nurse Psychotherapists? I know the demand for RNs in general is great, and also there is a growing need for advanced practice nurses, but what about job availability? It seems to me that, for example, an advanced practice OR or ICU nurse could feasibly find work in most places, but what is the need in the medical field for Nurse Psychotherapists?

Thanks again for your information. I truly appreciate it!

elkpark · Aug 15, 2006

"Advanced practice nurse" (or "nursing") is a generic term because there are four categories of APNs -- nurse practitioners (with a variety of available specialties within the general category), clinical nurse specialists (ditto), certified nurse anesthetists (CRNAs), and certified nurse midwives (CNMs).

There are many older threads here that you can search and find that discuss the similarities and differences between NPs and CNSs. I would have been able to give you a clear and straightforward answer a few years ago, but, in psych esp., the roles have become so similar/blurred in recent years that I'm honestly no longer sure of how to explain the difference.

My concern is not just that, in the larger mental health community, the pendulum has swung from therapy to a biological/pharmacological focus, but that the people who are being prepared nowadays as psych NPs and CNSs are supposedly (allegedly :)) also being prepared as psychotherapists, but they are getting only a small fraction of the education and supervised cliinical experience in psychotherapy that we "old-timer" psych CNSs got, because the programs now are primarily focused on preparation for Rxing ...

I look at it this way (admittedly, v. politically incorrect in nursing circles, but I don't care :); I've been in nursing 'way too long to just hop onto whatever bandwagon comes along) -- traditional (primary care ("medical," not psych) focused) NP programs are 2-year MSN programs. Traditional psych CNS programs are (were!) 2-year MSN programs. Psych NP (and, nowadays, most psych CNS) programs supposedly combine both roles -- but they're not 4-year programs; they are also 2-year MSN programs. So, doesn't that mean that you're getting half an NP program and half a CNS program (at best)? Do these programs really prepare people adequately for either role (Rxing and/or therapy)?? And because, obviously, the Rxing piece is the greater risk/obligation (people can die if you don't get it right), the programs focus on that and appear (from the curricula I've looked at lately) to offer only minimal coursework in therapy, almost as an afterthought.

Other posters here may have different experiences and viewpoints (I know they do, in fact), and people who are in private outpatient practice have a great deal of control over how they divide their time between Rxing and doing therapy, but, now that psych NPs/CNSs are out there with prescriptive authority, many agencies consider their time much too valuable to be conducting therapy when they could be writing scripts. Many agencies (both inpatient and outpatient settings) only want to use psych NPs in the physician extender role, to see clients for 15 minute med management appointments like the psychiatrists do, and hire lower-cost social workers and LPCs to be psychotherapists. If you look around (or have already done so), you'll notice that very, very few psychiatrists do any psychotherapy at all (and, again, their training has adjusted to reflect that reality over the years; they now get v. little training in therapy, so they wouldn't be competent to do it if they wanted to) -- they (quickly) diagnose people and Rx meds, and hand the clients off to others for therapy. That is the direction I see advanced practice psych nursing going ("psychiatrist Lite" just as the NPs have always been "physician Lite"). It's not a role that interests me, personally, at all, but to each her/his own ... Obviously, this is the wave of the future and I'm now, officially, an outdated old fogey.

As for employment opportunities and job availability, that varies greatly from region to region around the country, so I can't really speak to that. I do feel confident saying that, if you choose to pursue education as a psych NP or CNS, be aware up front that you will spend most of your time studying physical assessment, pharmacology, and medical management, not psychotherapy. You can easily do a web search for universities offering psych MSN programs (many schools now offer a combined NP/CNS program that prepares you for either certification exam) and see what their curricula look like.

amanda sue · Aug 16, 2006

Thank you for all that information--it was exactly what I was looking for!! I really appreciate the time you put into both replies. Thanks again! :specs:

mtdnk · Aug 19, 2006

1. On the simplest level, what are the differences between NPs and CNSs?

I would have been able to give you a clear and straightforward answer a few years ago, but, in psych esp., the roles have become so similar/blurred in recent years that I'm honestly no longer sure of how to explain the difference.

Part of the answer lies in your state Nurse Practice Act. In New York, a CNS is a RN and functions, by law, under the RN license (same as diploma, ADN, BSN). The education allows for the ability to provide a therapist role. BSN and below are termed "generalist nurse" and can do counseling versus therapy. The ANA Standards of Care for Psychiatric Nursing is a good resource.

The NP functions under a NP license. In New York the difference is that a NP can formulate a medical diagnosis and prescribe meds.I don't know if this rule applies in every state, so check out your states laws.

MSNpsychnurse · Sep 12, 2006

I am finding that the opportunities for APRNs such as a CNS (as I myself am) seem to be much more limited in my state (PA) PRECISELY because, unlike NPs, we can not prescribe, and are thus, less marketable since we can not generate income in the same way that an NP can.

Unfortunately, I am finding that as such, a CNS does not have something that s/he can do that from an employer's perspective sets them apart from an experienced psych staff nurse, social worker, etc. Does anyone have any suggestions/strategies? Any suggestions re: private practice for CNSs?

isenephthys, BSN, RN · Nov 12, 2006

great thread; i am considering a move from icu nursing to getting my psych np. i appreciate all the information.