fidelio

Mental health has always had a big political side to it due to funding issues. Right now, scope of practice is the big issue. Good luck with your choice.

Perhaps psychiatrists gravitate towards my area (the pacific nw) because they like to treat seasonal affective disorder. It seems like I can't walk 3 steps without tripping over a psychiatrist in Portland or Seattle. I work at a psych hospital and know quite a few psych MDs and residents. Only one out of perhaps 10 of the psychiatrists w/ whom I work is foreign trained but that is just my area and my hospital. Nationally, a lot of psych residencies go to FMGs. That's true. The same is true of general practitioner residency spots. On the other hand, two local universities have psych NP programs that are at capacity and I have heard professors discussing concerns of saturation. So the sky isn't falling up here in terms of numbers of clinicians. But, access remains a problem due to lack of insurance which is a whole other issue about which I have much stronger feelings than I do over rxp.

Most metro areas don't have a shortage. And, in case of psychiatric emergencies, joint commission rules stipulate a requirement for psych consult services in every single emergency dept (even rural ones). RxP advocates claim that psychologists need to be able to prescribe to alleviate the shortage of psychiatrists in rural areas. As if there isn't a shortage of all healthcare services in rural areas (including psychologists). There is a shortage of jewelry stores and delis, hardware stores and ice cream shops and beauty parlors for that matter. The reason is that it is very hard for a small business to survive in an area with a limited population. That's always been true. Psychologists prescribing isn't going to change that. But I'll tell you what it will change ... the number of medical students opting for psychiatry residencies in states with rxp laws. It will go down. If medical students see that lawmakers have decided that the job of a psychiatrist can be learned in one weekend a month online, their reaction will be to pick another specialty or get matched with a residency in another state. Then we will see what a true shortage of physicians in mental health really looks like.

If doctorally trained physical therapists were to purpose similar legislation allowing them to function as sports medicine physicians, most lawmakers would recognize a serious incongruence in training and regard that proposal with great skepticism. But, since the word "psychologist" sounds so much like the word "psychiatrist", I think that there is a great deal of role confusion on the part of the public about just how different these 2 professions really are. And, that confusion is only enhanced by popular culture's portrayal of anyone who works in mental health being a "shrink". But if we look beyond the stereotype, we can see that a psychiatrist has gone to medical school and therefore has a doctorate in medicine while a psychologist has a doctorate in what is primarily a social science. They may have rather complex physiology classes in their psychology programs and even take those classes with medical students (though this is the first I've ever heard of these two groups sharing any classes). But, patient care is such a different thing in practice between these two professionals. The psychologist may have thousands of hours of therapy and testing experience but as you know, the NP has around 1200 total (rn + np) in whole patient assessment/ care and usually thousands of on the job hours, administering meds, monitoring for side effects and assessing for changes. As a nurse, I can sort out a medical mimic in psych because I've cared for patients with the real disease. A psychologist has never cared for a CHF patient in as much depth as most undergrad nursing students have. And I don't think that nursing programs vary so widely in prereqs that taking basic sciences becomes a negligible issue. It's a very important issue. My NP program won't admit students if they don't have enough chem in undergrad. Doctorally trained Physical therapists do have training in basic sciences but they seem content to stick to physical therapy. So, I don't see why we would even consider having an individual with training in psychotherapy function like a physician or NP especially when half of their profession doesn't even want this legislation to pass anyway. BTW, if we are going to continue our debate, we should probably start a new threat and stop hijacking this one. It's my fault. I got us off track w/ this rxp stuff.

Dual licensure as a psych NP and as a clinical psychologist is a very good avenue. In the larger sense, I have no problem with psychologists prescribing so long as they go back and take the same basic science classes that they were not required to take as psychology majors. Completion of basic sciences such as chemistry and biology is a necessary minimum standard to which all other prescribers are help prior to starting their training. Otherwise, the professional portion of the training will largely be comprised of information that the students would have already known had they bothered to take biology 101 at a junior college level. Neuroanatomy, neurophysiology, pharmacology and psychopharmacology are useful but they do not take the place of the basic sciences. I see no reason for psychologists to circumvent or skip these classes to take other classes in their own programs. At this point, most patients can take for granted that the person prescribing for them has taken at least two years of basic sciences prior to beginning their professional training. But, if the RxP legislation passes that does not require psychologists to take science classes prior to entering their RxP programs, patients will not be able to take for granted that the person prescribing for them has taken a single chemistry class even at the junior college level. Patients deserve more than that. Every other prescriber takes the time to become knowledgeable about science prior to their training. Those looking to skip over the basics are not doing their patients any favors.

Thanks just cause. After finals are over next week, I can post again w/ more info. Till then, here are some interesting links. http://www.poppp.org RxP training programs. - mostly online programs designed to teach psychologists how to go from practicing talk therapy to prescribing psychoactive medications (including controlled substances). These programs can be completed in one day per week over a 20 month period - no science prerequisites needed) http://www.prescribingpsychologist.com/Training%20Programs.htm The site below is interesting because it lists states with active RxP legislative movements. If your state is listed, I highly recommend clicking on the "legislature" link for your state and contacting your state representatives to share your concern about these outrageously low standards for prescriptive authority. After all, licensed psychologists have less training in basic sciences than do dental hygienists (or LPNs for that matter. I'm not one to pick on dental hygienists). http://www.prescribingpsychologist.com/Legislation.htm

One thing to be aware of if you are planning on entering into this field is that mental health (like so many other specialties) is in the middle of a very political turf war. Currently, psychiatrists and psych NPs are the only clinicians who prescribe psychoactive medications in mental health (well, not including primary care providers who are the biggest prescribers of psych meds). Anyway, there is a movement underfoot by psychologists to gain prescriptive authority by legislative means. They have already been successful in this endeavor in Louisiana and New Mexico. So, hospitals are less interested in NPs in those states (as far as mental health goes). I'm sure that fewer med students in those states are opting for psychiatry residencies as well. The movement is commonly referred to as "RxP". Supporters purpose a self-regulated, 30 credit psychopharmacology (the minimum required for a masters) program w/ 400 clinical hours for those w/ a doctorate in psychology to get prescriptive authority. No prereqs in basic sciences required (no biology, chemistry or other sciences). As a soon to be psych NP grad myself who spent 2 years in basic sciences, 2 for my RN and nearly 3 years for the NP, I'm concerned that my job might end up going to a psychologist if my state passes the RxP bill that will probably surface in early 2009. So I'm writing letters to my state law makers here in Oregon to urge them to vote against such a bill. I think that if these providers want to learn how to care for patients with medications that affect the whole body, they should be responsible enough to learn how to care for the whole patient. Okay, sorry for the rant. I guess that I just wanted to point out that the psych field is likely to get more competitive down the road. At the same time, ya gotta love the irony. 20 years ago, newly minted physicians who had just spent over a decade training and a fortune on medical school must have been incensed by the hordes of nurses heading for state capitals all over the country to lobby for prescriptive authority. The best policy is to pay less attention to the gold rush stories about anesthesia, emergency, psych, onco, anything really. Pursue the specialty that floats your boat because this year's hot thing could be next year's bust.

Most of the psych NPs that I know function like psychiatrists. They offer medication management services and do psych consults on patients admitted to medsurg or ED. Psych NPs are trained to do talk therapy, but in reality talk therapy is usually done by licensed therapists, clinical social workers and psychologists.

There are some effective techniques for those who haven't been too proliferant in their offending. These mostly center around impulse control. If you get people early in their "careers" they still may have a good shot at rehabilitation. As a psych NP student, I don't like to think that anyone is beyond hope, but obviously this is a very tricky area. Many sex offenders have antisocial personality traits. Such people are more likely to feign remorse than to actually feel it. Severe torment on the part of an offender could be a positive sign as far as I am concerned. It can mean that the offender has an idea of the damage that he or she has done. Or they could just be upset they got caught. Again, it's tricky. It's natural to have a lot of strong feelings about these patients (particularly pedophiles). A provider has to come from a very grounded place in order to offer help to a sexual offender. I would state something on the order of the following: "By your own admission, you have done horrible things. You have damaged lives including your own. If any repair to your own life is possible, you are the only one who can make that repair. Any success that you have in this area may only be partial. Talking with a professional may help. I am willing to listen to you objectively and support you in making positive choices." The humanistic theorist Carl Rogers wrote a great deal about approaching patients with an "unconditional positive regard" in therapy. Such an approach can be therapeutic in and of itself particularly for this group. Sex offenders are often without a support group and their problems tend to follow them for life. This being the case, as a provider you should feel fairly comfortable listening to issues related to religious faith as these issues may be of considerable importance to the patient. Good Luck

As a psychiatric nurse practitioner student in the great NW, I am beginning to wonder how my future practice will be affected if the current legislation pending in the OR state senate to grant rx authority to psychologists actually passes this time. I am curious if there are any NPs in Louisiana or New Mexico who can describe how their practice has been affected by psychologists getting prescriptive authority in their states. Thanks.

Hi Spaniel. Happy belated birthday! (per your profile). Could you tell us if those PMHNPs worked inpatient or outpatient? When you say "quick" do you mean less than a half hour for a psych eval and med consult? Thanks for sharing what you know.

To those who work in psych hospitals or on psych units; Do you have a security team available other than your coworkers? I have been working as a charge nurse in a psych hospital for the last few months. I just don't feel like there is much backup should things go wrong. I have seen and been part of the response when a "code" is called and its not impressive. Staff have been seriously injured by patients at the hospital where I work, but the administration is opposed to having a security guard or two on staff insisting that would not be appropriate for our type of "milieu". Caring words aren't enough though and our crisis training was laughable. If this 250 pound psychotic guy puts another nurse in a headlock, how am I and a couple small, middle aged female techs going to help her? Because of my small size, there is a chance that I would have to stop a patient who was intent on hurting a coworker in a manner that would probably hurt the patient. Harming a patient would be a tragic nightmare not to mention a career wrecker. Shouldn't an 82 bed psych hospital shell out for a security guard position?

To those who work in psych hospitals or on psych units; Do you have a security team available other than your coworkers? I have been working as a charge nurse in a psych hospital for the last few months. I just don't feel like there is much backup should things go wrong. I have seen and been part of the response when a "code" is called and its not impressive. Staff have been seriously injured by patients at the hospital where I work, but the administration is opposed to having a security guard or two on staff insisting that would not be appropriate for our type of "milieu". Caring words aren't enough though and our crisis training was laughable. If this 250 pound psychotic guy puts another nurse in a headlock, how am I and a couple small, middle aged female techs going to help her? Because of my small size, there is a chance that I would have to stop a patient who was intent on hurting a coworker in a manner that would probably hurt the patient. Harming a patient would be a tragic nightmare not to mention a career wrecker. Shouldn't an 82 bed psych hospital shell out for a security guard position?

I'm a charge nurse in a psychiatric hospital. Yes, my profile needs updating.

I wouldn't be too quick to lecture the nurses or NPs on this board until you have worked in their ranks. If you ask for the "nitty gritty" and then in return scold a nurse practitioner for not being politically correct, you are going to put people off. The correct response is to listen. Caring for people all day long requires a tremendous amount of fortitude and emotional muscle. After the patients get what they need from us, we try to be supportive by listening to one another rather than policing each other's choice of words. On a different note, I have noticed that some of the very best nurses have health challenges. Illness can be a great teacher. Good luck with your research.