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What are the advantages and disadvantages of being a psychopharmacologist versus also integrating psychotherapy in your practice?
? I believe, this question should probably be reworded to ask, “What are the disadvantages to integrating psychotherapy in your practice.” The benefit to doing both seems obvious, the provider is getting to know the patient better, thus able to treat based more on their needs rather than a symptom checklist and a prescription. The client is getting more robust treatment, and hopefully working out both biological issues and any deeper emotional issues that synergistically impacting their lives. The problem is, in our current system of managed care, doing both and making a living won’t always coincide. Psychopharmacologic treatment alone is far more beneficial in sustaining a practice, in fact, the benefits are almost tangible. There is no question that the financial gains of seeing 20 medication management patients a day being better than seeing 8 medication & therapy patients per day. Adding to the financial benefit of volume is that most insurance providers pay less for psychotherapy than they do for psychopharmacology (Harris, 2011). For example, the reimbursement schedule for MassHealth pays out only $72.73 for 45 minutes of psychotherapy while paying out $128.18 for a 45-minute medication management visit (Mass.gov, 2019). Another issue to contend with is patient preference. For many patients, it seems easier to swallow a pill to calm emotions than to speak with a psychotherapist for weeks about conflicts and unpleasant, possibly embarrassing feelings (Greenberg, 2016).
How do you envision the role of psychotherapy in your future practice?
This is a difficult question for someone that has never had to navigate the world of reimbursement or out of pocket costs for patients. Idealistically, I hope to provide both to my clients, and make enough money to justify the financial burden I have put on myself in going back to school and furthering my education. Realistically I am not sure that this lofty goal will be possible to the extent that I would like it to be. I think if I’m being honest about what my treatment of patients will entail it will be a mix of both that for patients that do not require much in the way of psychotherapy will be enough. For patients requiring more involved therapy such as Cognitive Behavioral Therapy or Biofeedback therapy, they may need to see another provider while I maintain management of their medication. A utopian clinic would be one that I am the prescriber and multiple other licensed professionals provide the more involved therapy. Possibly a synergistic group of mental health professionals in one practice so patients can get all of the mental health treatment they need from one practice, even if it isn’t by one provider.
What does it look like in your community and state-levels for PMHNPs in practice (i.e., psychopharmacological management and psychotherapy)?
Many PMHNPs work as contractors for mental health practices that utilize mental health professionals that cannot prescribe. Unfortunately, this is where the real money can be made. Just a quick Indeed job search shows a variety of positions like this for NPs, some offering up to $200k per year and working as little as 6 hours per day. Some of these jobs are telehealth where you can make this kind of money and work from home. None of these jobs include any form of psychotherapy and numbers like this make adding psychotherapy to one’s practice hard to rationalize. There are multiple contributing factors to why mental health prescribers are not also providing psychotherapy. With economics pushing pharmacological interventions, an evidence base that partially supports these interventions, patient preference, and movement in graduate programs away from traditional therapy training, a case can be made that without some sort of change, psychotherapy could be phased out of an APRN’s practice all together (Delaney, & Handrup, 2011).
Is this different from what you envision your practice to look like?
I’m not convinced that it is always best for a patient to receive all mental health services from one provider. Every mental health clinician is going to have a different set of strengths and weaknesses when it comes to their skill set. To assume that every provider must provide all of the treatment seems idealistic and potentially inaccurate. If my co-worker is fantastic at performing psychotherapy with eating disorder clients, why should my patient be required to only see me when I may be good at medication management but provide lack luster psychotherapy? Eating disorder clients absolutely require in depth therapy, as medication therapy alone won’t even scratch the surface of treatment, so why waste her time? Let her see me for medication and my co-worker for therapy. That being said, this is where collaboration would be critical. If both clinicians are discussing the case from both perspectives, I believe the result can be the best treatment for the client. The expression, “two heads are better than one” certainly applies here. We are all human and even the most experienced practitioner can miss critical elements of their patient’s needs. If there are two clinicians collaborating, the chances of missing key pieces of information obviously decrease. The ultimate goal should always be providing the best care for the client. This may include multiple providers in some cases.
What does the literature say (i.e., support for or lack of evidence) for integration of therapy and prescribing by the same clinician (APRN or MD)?”
To be honest the literature does not say a lot. Most of the research appears to be in agreement that combining psychotherapy and psychopharmacology is more effective than psychopharmacology alone, however data is limited regarding the need for a sole provider. This could be because controlled studies take considerable time and money, and the methodology required is so complex (Glick, 2004). A proper scientific study of this would require one provider to see multiple patients, some with psychotherapy added, and some without. All of the clients would need to have the same diagnosis, be on the same medication, and see the practitioner for the same amount of time in order to ensure that the only variable is psychotherapy or lack of psychotherapy. There would also need to be a control group with all of the same variables but seeing two different providers. It is easy to see why this would be a lengthy undertaking.
- Greenberg, R. P. (2016). The rebirth of psychosocial importance in a drug-filled world. American Psychologist, 71(8), 781.
- Harris, G. (2011). Talk doesn’t pay, so psychiatry turns instead to drug therapy. New York Times, 6.
- Mass.gov. (2019). 101 CMR 306: Rates of payment for mental health services provided in community health centers and mental health centers. Executive Office of Health and Human Services. Retrieved from: https://www.mass.gov/regulations/101-CMR-306-rates-of-payment-for-mental-health-services-provided-in-community-health
- Glick, I. D. (2004). Adding psychotherapy to pharmacotherapy: data, benefits, and guidelines for integration. American journal of psychotherapy, 58(2), 186-208.
- Delaney, K. R., & Handrup, C. T. (2011). Psychiatric mental health nursing’s psychotherapy role: Are we letting it slip away?. Archives of psychiatric nursing, 25(4), 303-305.
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