Treating psychosexual issues

Simplyroses · Jul 14, 2015

Have you considered Psych Mental Health Nurse Practitioner? It would enable you to diagnose and prescribe in addition to the good work you currently do.

slashdot · Jul 14, 2015

I would very much like those responsibilities! I am just wondering if, as a PMHNP, I would get to do very much of this type of work. It may be a geographical thing, but in my experience, most of them work in community MHMR where I am thinking this would be a very slim portion of my job description... but that's why I'm here.

Thank you for your thoughts!

Psychcns · Jul 14, 2015

It sounds like these women need psychotherapy. I am surprised your psychology mentors are not more encouraging since they have the most education in psychotherapy. As a psych np you can do psychotherapy meds diagnoses. Often psych NP s don't do as much psychotherapy because others can do it cheaper.

What kind of further education do your psychology mentors suggest?

Jules A, MSN · Jul 14, 2015

Psych NPs do a minimal amount of therapy because we get paid so much for medication management. Unless someone wasn't very income oriented and wanted to open their own practice they would be hard pressed to find an employer willing to pay them what we make to do therapy.

slashdot · Jul 14, 2015

It's been mostly suggested that I stay where I am unless I want to teach. I wouldn't mind that, but it's not what I get up for in the morning, you know? The issue most often cited is the extensive education and cost for little guaranteed return on investment.

Jules, may I ask you: bipolar disorder, depression, anxiety, addiction, you treat these types of things but perform minimal (or no?) therapy? You could say I'm not necessarily income oriented, although I should think adding med management would potentially increase my earnings somewhat. I think. But as you point out, it may be unrealistic to land a day job doing what I want, in which case private practice may be the only avenue and take time to build, presumably.

If you have experience with this, is private practice uncommon for pmhnps? More trouble than it is worth? I appreciate any insight any of you may offer.

Jules A, MSN · Jul 15, 2015

I personally have no interest in my own private practice because I prefer inpatient work but depending on your state and the NP ability to practice independently it can be a lucrative and rewarding experience for some psychiatric NPs. My guess would be that if you did this and wanted to do psychotherapy as well you won't be making much on billing and again it would be cheaper to hire a therapist or even psychologist who in my area only make 40-60% of what we make.

I see all the illnesses you mentioned and more including but not limited to schizophrenia, dementia, ADHD, ODD, DMDD, conduct, borderline and antisocial disorder. On my inpatient unit I do evaluations, diagnosing and medication management as well as consult liaison on medical floors and in the ED. Outpatient I do 20-30 minute med checks and 45-60 minute evaluations so that doesn't leave any time to do in depth therapy which suits me perfectly.

PG2018 · Jul 15, 2015

I'm beginning to see more and more transgender and gender dysphoria which really bothers me. I initially said I would never treat them and don't want to. I find it particularly vexing so I focus instead on their reported depressive and/or anxious symptomology. I find it disturbing actually.

PG2018 · Jul 15, 2015

I've ticked med checks back to 15 mins to better fit a 99213 and evals at 30 minutes. This allows me to see more patients. Had 22 in clinic today. I see everything including a genuine psychopath today.

Regarding therapy, I shoot for a therapeutic dialogue but stick to biomedical stuff. I only do therapy-lite when I have kids in with waste of space parents. I would like to learn hypnosis.

But of course since we're psychiatry we know what you're thinking, why you do what you do, when you're lying and what you do when you're by yourself. Or that's what people think anyway. Totally untrue.

Or is it?

slashdot · Jul 18, 2015

How do you guys handle the med seeking and manipulation? That is one of the reasons I love the population I work with and am somewhat hesitant to do pmhnp. There is fairly little of that going on with the women I see, but then, as you mention Jules, psychologists in general make only a bit more than my therapist peers so I am also reluctant to do that. In my first job, and my masters rotations, I was inundated with people desperate for xanax or welbutrin, whether they actually needed it or not, and therapy was quite moot for a large number of them. Billing was hell. How does that issue look from your side of things?

Jules A, MSN · Jul 18, 2015

How do you guys handle the med seeking and manipulation? That is one of the reasons I love the population I work with and am somewhat hesitant to do pmhnp. There is fairly little of that going on with the women I see, but then, as you mention Jules, psychologists in general make only a bit more than my therapist peers so I am also reluctant to do that. In my first job, and my masters rotations, I was inundated with people desperate for xanax or welbutrin, whether they actually needed it or not, and therapy was quite moot for a large number of them. Billing was hell. How does that issue look from your side of things?

Much of it will depend on the practice's culture. I worked one place where I was encouraged to give the patients whatever they wanted in an effort to retain them as clients. Management, who were social workers, didn't care whether that be stimulants for the patient with therapist diagnosed "adult onset ADHD" and substance abuse history who weren't working or Xanax for the alcoholic with multiple DUIs. I don't prescribe like that and I don't care how much the patient screams, threatens and cries or the practice manager gets pissed.

Anecdotally the good news is most of the younger physicians don't play Dr. Feel Good that seems to be more of a leftover from the really old physicians. The bad news, at least in my experience is that many NPs have no concept on what is appropriate anxiety, ADHD or pain management prescribing. I think it is a combination of a lack of knowledge of substance abuse coupled with the inability to identify cluster B driven behavior and some of it takes us back to the codependency and wanting to be liked that runs rampant in nursing, imo. "But she was shaking and crying. What was I supposed to do?" :nono:

The practices where I enjoy working feel it is more important that our patients are alive rather than happy if the two can't be achieved together at this time. The patients who are willing to move out of their comfort level and stay with us to combine judicious prescribing and therapy often achieve life changing growth.

Psychcns · Jul 18, 2015

I have been fortunate to work in practices where prescribing controlled substances is not pushed. I try other meds first and expect people to be working in therapy. Sometimes people self medicate mental illnesses and I try to evaluate for that. Often substance users are willing to try different meds when I discuss it with them. I try to avoid stimulants. I tell people most of their treatment is therapy and lifestyle change; meds are a small part.