Psych NP & psychotherapy

[human_nerd]

Hi everyone, first time poster, long time lurker!

I am not yet a nurse, however I have dreams of becoming an NP (psych specifically). This might be long so I did a tl;dr and made some sections. I appreciate any response :)

tl;dr: I would like to do therapy as well as med management. Would it be worth it to pursue an additional license (Psy. D.), do extra training in specific therapy modalities (CBT, psychodynamic, EMDR, etc), or just focus on CE related to therapy/the therapeutic relationship?

Why psych NP instead of counseling?

I'm going to address this first because I've seen a lot of people saying "if you want to do therapy, become a counselor." I want to become an NP because NPs seem to have a much better job market/pay than counselors. Additionally, I may ultimately decide against psych, and being a nurse allows me to choose a different specialty instead of being locked into one field forever. Acute care or an FNP working in urgent care also seems cool to me- luckily I'll have time as a bedside nurse to decide!

More importantly, I really like therapy, but I also love the neuro/pharmacology aspect of brains. I harbor some frustrations with medicine right now, which is why I do not want to be an MD. I personally know several people who just get put on a slew of drugs after getting evaluated by a psychiatrist for 1-2 hours. Many of these people don't even go to therapy- even the two people who regularly explain how their abusive parents greatly influenced their eating disorders and anxiety.

I am definitely not against meds I just feel like a lot of people are put on meds to cover up issues (such a childhood trauma) rather than resolve the issues (through trauma work or psychodynamic/analytic therapy). Obviously some things are simply chemical (ADHD, bipolar, schizophrenia), but that's not true for everyone. The idea of being able to do both meds/therapy is awesome to me because you can really get to know a person and understand their problems before making a diagnosis. I know lots of people (myself included) who went through several diagnoses before finding the right treatment. A lot of diagnoses have overlap. I imagine being able to work closely with someone in a therapeutic context would help distinguish which treatment would best help their symptoms.

Personal experience with a psych NP

Like many people in the psych field, I'm drawn to it from my own experience with mental health. I currently see a psych NP who does both med management and psychotherapy, and it's seriously amazing. He's the first person to focus on childhood trauma with me, even though I've tried to get other therapists to talk about it. He's also been able to recognize my ADHD despite being highly functional. With the work we're doing, I actually feel I can get better and eventually not need therapy. Before, I was (mis)diagnosed with bipolar 2, which is lifelong and chemical, instead of just having some trauma and ADHD (and previously depression). ADHD is lifelong but definitely not as scary as bipolar!

I only mention all my personal experience because I see people all the time telling me psych NPs don't do therapy. I get it, it's less common. I understand that my first few years will likely be spent doing mostly meds, since I will be a new grad NP. I'm just more drawn to nursing for the above reasons.

The question of training

So, if I want to do therapy with med management, what sort of extra steps I should take? I really want to do psychodynamic therapy, and I've found some places that will train you if you're in the mental health field (Psychodynamic Psychotherapy Program). I'm just not sure if that's really "enough" to be able to do therapy, or if I should consider getting a Psy D eventually.

I know most NPs just do med management, but after some research, it seems like there are people out there who do therapy as well. My particular provider worked with an MD for 5 years who became a psychiatrist in the era of psychoanalysis. My NP does psychodynamic and he's very good at it. He said he's leaned his CE that way (as well as being mentored by someone who specializes in psychoanalysis), but doesn't have extra credentials. His situation is sort of unique, though, and I can't just plan on being mentored by someone who specializes in psychoanalysis lol

If anyone can offer any insight, I'd greatly appreciate it! I know I'm getting ahead of myself with these specifics, but I want to cover all my bases before getting too deep into nursing.

[pro-student]

PMHNPs are expected to be trained and qualified to provide psychotherapy in addition to their other functions however the reality of both education and the job market heavily lean away from psychotherapy. In most job markets, it simply is not practical to hire PMHNPs to do therapy (even if it only makes up a part of their clinical time). First of all, most employers could hire on average 3-4 master's prepared therapists for they same salary as 1 NP. Meanwhile, they can schedule that NP for 5-15 minute med check appointments which are often reimbursed at a hire rate than the hour long therapy sessions (and are more likely to be covered by insurance). Second, the other master's prepared therapists they could hire typically went through a degree the was mostly, if not entirely, focused on providing psychotherapy including significantly more didactic and clinical practice in psychotherapy.

You certainly could pursue an additional advanced degree in mental health that is more focused on therapy however, beyond the basics, therapy is best learned by practice (ideally with some supervision). A quality PMHNP program will give you at least the basics and some programs are quite well-rounded in their training of providers. Nonetheless, the major trend is for PMHNPs to be prescribers who know about therapy rather than therapists who also prescribe. There are also psychotherapy fellowships (especially for psychodynamic/psychoanalytic) that are open to PMHNPs but these are generally only found on the coasts and can be competitive.

Since the advent of the Consensus Model, all PMHNP programs are now required to include the whole lifespan (child, adolescent, adult, and older adult). Essentially every other mental health profession still trains providers who specialize in either child/adolescent or adult because there are pretty significant differences between these populations in terms of assessment, diagnosis, and treatment. Since most practicing and academic PMHNPs were trained as specialists, the quality of training for this lifespan still remains to be seen. Once you get out of school and pass boards, you're obviously free to practice with only a specific population but I think the move to lifespan scope of practice has just further diluted the psychotherapy content and practice in grad programs.

I think a lot boils down to the quality of program you attend and being able to negotiate a position that provides some ability/support for your desire to be a complete mental health provider. Some people have been successful in moving into a private/group practice after a few years of initial experience that gives them the freedom to be the kind of provider they would like to be. If you can network into a practice or have enough of an entrepreneurial spirit to wade into private practice, then I think the PMHNP could be ideally suited to your career goals. But it will be a bit of an uphill battle to get there. I hope that help and wish you the best of luck regardless of what route you choose.

[Oldmahubbard]

You are correct that an RN license will open many doors, psychiatric and otherwise, and that salary prospects for Master's prepared counselors are mediocre. You have been working with a Psych NP who has helped you a great deal, and you admire that person. How to proceed?

No matter which road you take, there will be pluses and minuses. Your best bet is to get your RN license, and get the lay of the land by working inpatient psych. You don't give your age, but who knows, your feelings could change a lot in the next few years.

I thought I wanted to do therapy until I actually did it for a year, haha. As a Psych NP, the therapy training is quite limited, but I put a lot of extra effort, ie independent study into therapy techniques, before realizing that therapy does not really interest me. Most people cannot handle, and do not want cognitive- behavioral psychotherapy. I don't count that "how did you feel about that?" mumbo jumbo as therapy.

If you do decide to pursue the Psych NP, a lot depends on where you live. Most psychiatrists and some NPs do not take or deal with insurance at all in wealthier parts of the country. They are much more free to practice as they see fit, but you have to have a population to sustain that type of practice.

From my experience, a large percentage of psychiatric patients cannot benefit from psychotherapy, for a variety of reasons. That was the conclusion I reached after several years in the field.

All that being said, in a private practice I had for about 5 years with a physician, I had some freedom and ability to do psychotherapy appointments with select patients. An average day might include one or at most two such appointments, although I probably flatter myself, because I did not adhere to a strict treatment protocols.

There were many, many times when I thought the patient would probably benefit almost as much from a similar conversation with the local bartender.

Currently I am a consultant in several nursing homes. Many of the patients do not even answer to their name. When I do get a coherent patient, it is a breath of fresh air, and I often let them talk, even though I can't bill for the time.

Most of what I do there is to reassure people that their response to the negative situation of being in LTC is normal.

I have had very little exposure to the psychoanalytic tradition. I am somewhat a fan of Acceptance and Commitment Therapy, Solution Focused therapy and Dialectical Behavioral Therapy. The patient has to be fully on board with these.

I am somewhat jaded, as you can see. I do know that if I insisted on seeing my patients for an hour, no one locally would continue to employ me.