Questions for psychotherapists about branching out into Psych NP

[MustIReallyThough]

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In scouring this forum I've seen a couple psychologists mention going back to school to attain a psych NP to allow them the ability to prescribe. Has anyone had or known of any experiences like these? Wouldn't this make for a great business model and niche for private practice if you could find an agreeable psychiatrist to pair with? Or one could possibly work for a hospital as a nurse and pursue a small psychotherapy practice on the side...

The problem I'm facing as someone debating doctorate education vs masters is the fear of stagnation with just a masters degree and a solely psychotherapy practice. I've heard it discussed a LOT here and I don't want that to be me.

But I don't really have any interest in conducting research, teaching, or managing a large clinic. So I feel like the psychology path isn't for me. But I still fear the limitations of a masters.

I hope that makes sense. Thank you all wonderful professionals for your time. All of your previous input on other threads is very informative and invaluable to me and others I'm sure. As a freshly graduated student, the amount of choices and variance in mental health careers is...overwhelming.

 

[medium rare]

Search some of my posts. I’ve talked about this a good deal on SDN.

 

[Therapist4Chnge]

What do you WANT to do day-to-day? If it is therapy, then a masters is prob a good fit for that. Doctoral training for psych is a lot of "other" stuff to get you to basically the same place if you don't pursue a fellowship in a niche area. Med school can be described similarly, though both of those paths also provide a much fuller and more in-depth training, it just depends how you want to spend your day. In an ideal world, someone who knows they want to be a prescriber should go to med school....best training and most complete, but you still need to continue to learn throughout your career. I say this as someone who has taught and lectured in med schools, Ph.D/Psy.D. programs, and tutored RN and NP students.

The PA or NP route can offer solid training, but a lot of it falls on the student to continue to pursue. PA training wasn't a good fit for me, but it can be for someone who enjoys the work, but is fine being 2nd banana on some/ a lot of stuff. In an out-pt clinic for psych there may be more autonomy, but ultimately you still need sign-off from your supervisor. This is true in some states for NPs, though I'm less familiar with this setup as all of the states I've lived in have had independant licensure for NPs.

An accelerated NP program (aka "direct entry") could be an option if you have the pre-reqs done for the RN, though I think this route takes away some of the value and training of going RN--> NP. Some of the best prescribers I know are NPs who work in niches (e.g. pain clinic, psych, ED), but they all had a number of years as RNs before pursuing brick & mortar NP training. I specify that because there are "hybrid" programs now that I guess are fine for some, I just don't think the training is the same.

As for the RxP route...it's super niche because after all of the doctoral training you have to go back and most programs are condensed, and it's like drinking from a firehose. I attended a brick & mortar program, loved it, but it was still a PITA. It took me 6+ yrs to finish because I had to take some time off to do my fellowship and then I still had to do my practica. I didn't bother getting licensed because I did it primarily as a backup plan in case I ever got bored doing neuro. I realized that most RxP jobs want you to be a glorified Rx pad, and you'd need to really make an effort to work for someone else and have it not be that. On your own, sure...you can set something up.... @medium rare can best speak to that experience.

I'm not sure that answers your inquiry, but any path you pursue will require a lot of your own learning because there is just too much out there to learn, regardless of which path you take. In your spot, if you want to prescribe, the NP is probably the clearest route, but make sure to compare NP training programs because they can vary greatly.

 

[PsyDr]

I would HIGHLY recommend interning or shadowing various mental health providers. Spend a week with a therapist, a nurse practitioner, and a psychiatrist. See what their day to day life is like. Maybe it's exactly what you imagined. Maybe it is not. But, at least, you will have a factual basis to make your decision.

 

[MustIReallyThough]

What do you WANT to do day-to-day? If it is therapy, then a masters is prob a good fit for that. Doctoral training for psych is a lot of "other" stuff to get you to basically the same place if you don't pursue a fellowship in a niche area. Med school can be described similarly, though both of those paths also provide a much fuller and more in-depth training, it just depends how you want to spend your day. In an ideal world, someone who knows they want to be a prescriber should go to med school....best training and most complete, but you still need to continue to learn throughout your career. I say this as someone who has taught and lectured in med schools, Ph.D/Psy.D. programs, and tutored RN and NP students.

The PA or NP route can offer solid training, but a lot of it falls on the student to continue to pursue. PA training wasn't a good fit for me, but it can be for someone who enjoys the work, but is fine being 2nd banana on some/ a lot of stuff. In an out-pt clinic for psych there may be more autonomy, but ultimately you still need sign-off from your supervisor. This is true in some states for NPs, though I'm less familiar with this setup as all of the states I've lived in have had independant licensure for NPs.

An accelerated NP program (aka "direct entry") could be an option if you have the pre-reqs done for the RN, though I think this route takes away some of the value and training of going RN--> NP. Some of the best prescribers I know are NPs who work in niches (e.g. pain clinic, psych, ED), but they all had a number of years as RNs before pursuing brick & mortar NP training. I specify that because there are "hybrid" programs now that I guess are fine for some, I just don't think the training is the same.

As for the RxP route...it's super niche because after all of the doctoral training you have to go back and most programs are condensed, and it's like drinking from a firehose. I attended a brick & mortar program, loved it, but it was still a PITA. It took me 6+ yrs to finish because I had to take some time off to do my fellowship and then I still had to do my practica. I didn't bother getting licensed because I did it primarily as a backup plan in case I ever got bored doing neuro. I realized that most RxP jobs want you to be a glorified Rx pad, and you'd need to really make an effort to work for someone else and have it not be that. On your own, sure...you can set something up.... @medium rare can best speak to that experience.

I'm not sure that answers your inquiry, but any path you pursue will require a lot of your own learning because there is just too much out there to learn, regardless of which path you take. In your spot, if you want to prescribe, the NP is probably the clearest route, but make sure to compare NP training programs because they can vary greatly.

To be honest, prescribing isn't my first thought when I envision a long term career. I do have an interest in SMI though and feel like this would be a great way to reach more people. As well as provide the option of a more holistic treatment approach in PP by combining psychotherapy and med management (and with the pay that comes with a NP I actually have room to possibly make treatment more affordable!). I'd be happy playing second fiddle in regard to the latter.

I do envision a primarily psychotherapy practice though. The problem I'm facing is that I realize conducting therapy for the rest of my life is not exactly a realistic expectation. It seems to burnout the best of us. So I feel like it's necessary to map out ways in which to branch out clinically now as opposed to later before I'm stuck with a terminal masters and nowhere else to go with it. The two options I'm considering are the niche areas in psych and a psych NP.

 

[Sanman]

To be honest, prescribing isn't my first thought when I envision a long term career. I do have an interest in SMI though and feel like this would be a great way to reach more people. As well as provide the option of a more holistic treatment approach in PP by combining psychotherapy and med management (and with the pay that comes with a NP I actually have room to possibly make treatment more affordable!). I'd be happy playing second fiddle in regard to the latter.

I do envision a primarily psychotherapy practice though. The problem I'm facing is that I realize conducting therapy for the rest of my life is not exactly a realistic expectation. It seems to burnout the best of us. So I feel like it's necessary to map out ways in which to branch out clinically now as opposed to later before I'm stuck with a terminal masters and nowhere else to go with it. The two options I'm considering are the niche areas in psych and a psych NP.

A couple of points, an NP can practice independently in some states (both medication management and paychotherapy). There are options outside of psychotherapy in psychology, SW, and nursing. The other question is what is a tolerable income for you. One can certainly do psychotherapy in PP for a career. It is a question of how much work do you want to do and how much money do you want to make. I personally have done a lot more hours of therapy in a week than the average person. So, I certainly can make a living at it.

 

[MustIReallyThough]

A couple of points, an NP can practice independently in some states (both medication management and paychotherapy). There are options outside of psychotherapy in psychology, SW, and nursing. The other question is what is a tolerable income for you. One can certainly do psychotherapy in PP for a career. It is a question of how much work do you want to do and how much money do you want to make. I personally have done a lot more hours of therapy in a week than the average person. So, I certainly can make a living at it.

Can I ask how you fare with burnout? Is therapy something you can see yourself doing until retirement?

Tolerable income is a good question. I'd like it to be some balance of ok money and affordable rates. I have a decent work ethic, but I'm not sure how well that translates to therapy. I like to think I'd put in the hours necessary to be successful though. It's all I've ever really wanted to do.

I'd be more interested in the niche areas of psychology than anything related to SW. But really, I just want to master the art of therapy (as much as possible, I realize it's a never ending process with a lot of it self taught as therapist 4change mentioned). Then tackle something else like prescribing (but still related to direct patient care) later on down the road in the event I burn completely out.

 

[MustIReallyThough]

I would HIGHLY recommend interning or shadowing various mental health providers. Spend a week with a therapist, a nurse practitioner, and a psychiatrist. See what their day to day life is like. Maybe it's exactly what you imagined. Maybe it is not. But, at least, you will have a factual basis to make your decision.

Will do. I definitely need that factual basis. There's a counselor in town that offered a volunteer position once COVID let up. I'm not really sure what he means by that, but I can probably shadow at least. There's also a medical school close.

 

[futureapppsy2]

A lot of professionals that are trained/qualified/licensed to both prescribe and conduct psychotherapy rarely end up doing psychotherapy because the pay per chunk of time is so much lower versus prescribing that either their employer doesn't want them doing it or they can't justify the decrease in income themselves.

 

[MustIReallyThough]

A lot of professionals that are trained/qualified/licensed to both prescribe and conduct psychotherapy rarely end up doing psychotherapy because the pay per chunk of time is so much lower versus prescribing that either their employer doesn't want them doing it or they can't justify the decrease in income themselves.

Very true. I'd like to think I'd be different and run a private practice based on the specific need of the client. But I realize how idealistic this sounds and how stark the pay difference is.

Still, that freedom is alluring. I'd love to be able to do some pro bono work of my choosing later on in retirement. Volunteering is very important to me.

I work as a manager of a food pantry in a very poor, rural county and see first hand how much people struggle. It's weighed on me. And I truly want to believe that one day I'll structure a practice in a way that can reach some of these folks through both quality and affordable care.

 

[Sanman]

Can I ask how you fare with burnout? Is therapy something you can see yourself doing until retirement?

Tolerable income is a good question. I'd like it to be some balance of ok money and affordable rates. I have a decent work ethic, but I'm not sure how well that translates to therapy. I like to think I'd put in the hours necessary to be successful though. It's all I've ever really wanted to do.

I'd be more interested in the niche areas of psychology than anything related to SW. But really, I just want to master the art of therapy (as much as possible, I realize it's a never ending process with a lot of it self taught as therapist 4change mentioned). Then tackle something else like prescribing (but still related to direct patient care) later on down the road in the event I burn completely out.

I don't see many patients anymore due to my current job. Volume of patients was never a cause of burnout. Non-clinical factors are a different story. I would challenge your beliefs here as they are a bit idealistic. Prescribing for most will entail getting a new degree and many will not do that. Making money by "mastering therapy" generally involves charging significant and unaffordable rates for many people (cash rates because insurance does not pay for mastery). If you want your rates affordable, you are going for volume not necessarily quality to make a good living. That brings us back to what is an adequate salary because some of what you mention is unlikely unless you are practicing as more of a hobby than a vocation.

 

[MustIReallyThough]

I don't see many patients anymore due to my current job. Volume of patients was never a cause of burnout. Non-clinical factors are a different story. I would challenge your beliefs here as they are a bit idealistic. Prescribing for most will entail getting a new degree and many will not do that. Making money by "mastering therapy" generally involves charging significant and unaffordable rates for many people (cash rates because insurance does not pay for mastery). If you want your rates affordable, you are going for volume not necessarily quality to make a good living. That brings us back to what is an adequate salary because some of what you mention is unlikely unless you are practicing as more of a hobby than a vocation.

Non-clinical factors? How so? Billing/paperwork?

That's good to hear. I'd love to feel fulfilled for the rest of my life doing therapy, but I just don't know if that's realistic. But I'm glad to hear someone say volume never bothered them. What about the repetitive nature of therapy I've heard about?

I understand, that all makes a lot of sense. My pro bono aspirations will probably have to be saved for retirement.

Adequate money? Hard to say with this economy. I guess I'd be satisfied long term with 50+. Which seems do-able with a moderate client load in PP if I understand correctly. I'd want to manage a high volume if I could swing it though. Big believer in investing as early as possible.

 

[Sanman]

Non-clinical factors? How so? Billing/paperwork?

That's good to hear. I'd love to feel fulfilled for the rest of my life doing therapy, but I just don't know if that's realistic. But I'm glad to hear someone say volume never bothered them. What about the repetitive nature of therapy I've heard about?

I understand, that all makes a lot of sense. My pro bono aspirations will probably have to be saved for retirement.

Adequate money? Hard to say with this economy. I guess I'd be satisfied long term with 50+. Which seems do-able with a moderate client load in PP if I understand correctly. I'd want to manage a high volume if I could swing it though. Big believer in investing as early as possible.

Spend a few hours per day arguing with an insurance company to get paid for work you have already done while the people on the other end of the phone are paid to waste your time. Listen to them suggest that you do more work for free so that they can decide if they will pay you. Then decide if you want to be part of that system so that clients can retain affordability.

$50+k a year? That is easily doable, but it is unlikely you will ever be retiring or providing pro bono work, especially if you have a family.

 

[MustIReallyThough]

Spend a few hours per day arguing with an insurance company to get paid for work you have already done while the people on the other end of the phone are paid to waste your time. Listen to them suggest that you do more work for free so that they can decide if they will pay you. Then decide if you want to be part of that system to that clients can retain affordability.

$50+k a year? That is easily doable, but it is unlikely you will ever be retiring or providing pro bono work, especially if you have a family.

My dear Sanman, I think I just got burnt out and I haven't even started yet 😂

I hear you, for sure. Could you work in a group practice or hire an assistant for billing? That brings it's own set of problems though.

Very true. I worry about retirement. Makes a NP salary with a psychotherapy practice on the side very appealing. But that's a helluva lot of work and, like you said, most won't go back to school for another masters.

Do you recommend the PhD in psych in general for the increased opportunity?

 

[Sanman]

My dear Sanman, I think I just got burnt out and I haven't even started yet 😂

I hear you, for sure. Could you work in a group practice or hire an assistant for billing? That brings it's own set of problems though.

Very true. I worry about retirement. Makes a NP salary with a psychotherapy practice on the side very appealing. But that's a helluva lot of work and, like you said, most won't go back to school for another masters.

Do you recommend the PhD in psych in general for the increased opportunity?

I worked in a large group practice with billing support and supervised a number of clinicians then. Insurance company audits/authorizations often require them to speak with the treating clinician.

My recommendations really depend on what you want to do and echo what others have said.

Psychologists can do other things besides general therapy. Do you want to do those things? If not it can be extra time, money, and relocation headaches for you without much reason.

Are you in a state or do you want to live in a state where a psych NP can practice independently? Are you in a state where psychologists can prescribe?

Do you want to limit your practice to a smaller higher paying psychotherapy clientele or work with those in need?

All of these goals necessitate a different plan because otherwise you might find yourself with $200K in debt making $50k/yr with too much education and no interest in earning more money. Take some time and get some exposure before making the big decisions.

 

[Psycho Bunny]

I worked in a large group practice with billing support and supervised a number of clinicians then. Insurance company audits/authorizations often require them to speak with the treating clinician.

My recommendations really depend on what you want to do and echo what others have said.

Psychologists can do other things besides general therapy. Do you want to do those things? If not it can be extra time, money, and relocation headaches for you without much reason.

Are you in a state or do you want to live in a state where a psych NP can practice independently? Are you in a state where psychologists can prescribe?

Do you want to limit your practice to a smaller higher paying psychotherapy clientele or work with those in need?

All of these goals necessitate a different plan because otherwise you might find yourself with $200K in debt making $50k/yr with too much education and no interest in earning more money. Take some time and get some exposure before making the big decisions.

Old thread I know but this is really interesting to me. I want to do a mixture of therapy and Prescribing. Do you think it's worth it to get my PHD then go back and get the accelerated RN-NP degree? I'd be fine charger higher rates for a higher income clientele.

 

[Sanman]

Old thread I know but this is really interesting to me. I want to do a mixture of therapy and Prescribing. Do you think it's worth it to get my PHD then go back and get the accelerated RN-NP degree? I'd be fine charger higher rates for a higher income clientele.

Why get the PhD and NP degree? Psychologists can only prescribe in a few states with a masters degree. Licensed psych NPs are legally allowed to practice psychotherapy in any state licensed. It is cheaper to get the NP or PA degree and spending some time and money going to the Beck Institute, A psychoanalytic society, etc. to get some psychotherapy training. Or just go to med school.

 

[AcronymAllergy]

Why get the PhD and NP degree? Psychologists can only prescribe in a few states with a masters degree. Licensed psych NPs are legally allowed to practice psychotherapy in any state licensed. It is cheaper to get the NP or PA degree and spending some time and money going to the Beck Institute, A psychoanalytic society, etc. to get some psychotherapy training. Or just go to med school.

From an ROI perspective, I agree. The biggest "bang for the buck" is going to be the NP route. My understanding is that PA programs have higher pre-reqs and/or may take longer, and you're guaranteed to require supervision afterward, which may not be the case as an NP (depending on your state). I have no idea as to how the quality of training stacks up for PA vs. NP.

If you want more in-depth training/knowledge and know you want to prescribe, go the psychiatry route. Ph.D. + NP will get you some unique training/experience/expertise, but I don't know if it's worth the extra time and hassle.

At least in my experience, the Ph.D. + NP route is usually taken by folks after getting their doctorate and practicing for a little while, and then realizing that they want to add prescribing to their toolbox. Rather than planning to do that ahead of time/before starting training.

 

[psych.meout]

Why get the PhD and NP degree? Psychologists can only prescribe in a few states with a masters degree. Licensed psych NPs are legally allowed to practice psychotherapy in any state licensed. It is cheaper to get the NP or PA degree and spending some time and money going to the Beck Institute, A psychoanalytic society, etc. to get some psychotherapy training. Or just go to med school.

This person posts the same threads on psychology-related subreddits and gets so salty when people tell them that they should go to med school if they're so interested in prescribing, instead of trying to do RxP or some other path.

 

[Psycho Bunny]

Why get the PhD and NP degree? Psychologists can only prescribe in a few states with a masters degree. Licensed psych NPs are legally allowed to practice psychotherapy in any state licensed. It is cheaper to get the NP or PA degree and spending some time and money going to the Beck Institute, A psychoanalytic society, etc. to get some psychotherapy training. Or just go to med school.

Yes, that was something I was considering. Going the Psych NP route and training at an analytic institute. But as someone who wants to do psychotherapy as well as prescribe I'm concerned that the analytic institute won't give me the foundational skills to do therapy, especially since the PSYCH NP programs have basically no training in therapy whatsoever. That's why I thought PHD, work for a few years, go back to become a Psych NP and prescribe like one person did here but I'm quite conflicted.

 

[Psycho Bunny]

This person posts the same threads on psychology-related subreddits and gets so salty when people tell them that they should go to med school if they're so interested in prescribing, instead of trying to do RxP or some other path.

I just don't think it's neccessary to get where I want to be. If that offends you I don't know what to tell you.

 

[EnPsychlopedia]

I just don't think it's neccessary to get where I want to be. If that offends you I don't know what to tell you.

To play Devil's advocate here, you make it explicitly clear that you want prescribing to make up a significant portion of your career. Frankly, if you want to work in prescribing and want to do so primarily, then there really is no more appropriate path than psychiatry, full stop. It may not be "necessary," but psychiatrists are the highest authority when it comes to pharmacological treatment of mental health conditions, and any clinician worth their individual salt will want to be trained to the highest possible standard on their core competency (which in the case of your stated desires seems to be prescribing). Also, it really seems like what you want is to be all things to all patients. Though this is admirable, this kind of thinking simply betrays that you've still got a lot of developing to do as a student (that's not an insult--we all start there, and all of us have to go through that process). Put bluntly, no one can be everything to everyone. Psychiatrists cannot do everything psychologists do. Psychologists cannot do everything psychiatrists do. NPs cannot do everything these others do. That is just the nature of human limitations and career specialization. When one is a curious and ambitious person, it can be hard for one to relinquish hold on the idea of pursuing every interest to the highest level, but it is really is something that needs to be embraced. Specialization (which in this case means specializing in a particular career field and not others) makes you better. Trying to be everything to everyone likely means you'll be less-than-great at everything you try to be, whereas choosing a lane and being damned good at it means you're damned good at the things you do.

If the thing you want to do is medicine, and you want to do it at the highest level of training and safety, do psychiatry. If what you want to do is be a psychologist, be a psychologist. But don't try to be some hybrid mixture of both.

Anyway, best of luck to you. I hope my words are helpful and formative in some way.

 

[Psycho Bunny]

To play Devil's advocate here, you make it explicitly clear that you want prescribing to make up a significant portion of your career. Frankly, if you want to work in prescribing and want to do so primarily, then there really is no more appropriate path than psychiatry, full stop. It may not be "necessary," but psychiatrists are the highest authority when it comes to pharmacological treatment of mental health conditions, and any clinician worth their individual salt will want to be trained to the highest possible standard on their core competency (which in the case of your stated desires seems to be prescribing). Also, it really seems like what you want is to be all things to all patients. Though this is admirable, this kind of thinking simply betrays that you've still got a lot of developing to do as a student (that's not an insult--we all start there, and all of us have to go through that process). Put bluntly, no one can be everything to everyone. Psychiatrists cannot do everything psychologists do. Psychologists cannot do everything psychiatrists do. NPs cannot do everything these others do. That is just the nature of human limitations and career specialization. When one is a curious and ambitious person, it can be hard for one to relinquish hold on the idea of pursuing every interest to the highest level, but it is really is something that needs to be embraced. Specialization (which in this case means specializing in a particular career field and not others) makes you better. Trying to be everything to everyone likely means you'll be less-than-great at everything you try to be, whereas choosing a lane and being damned good at it means you're damned good at the things you do.

If the thing you want to do is medicine, and you want to do it at the highest level of training and safety, do psychiatry. If what you want to do is be a psychologist, be a psychologist. But don't try to be some hybrid mixture of both.

Anyway, best of luck to you. I hope my words are helpful and formative in some way.

I want to do a mixture of psychotherapy and Prescribing, and I'm trying to find the most logical path to follow for my interests. I'd want more of an emphasis on therapy rather than prescribing, which is why I have considered getting my PHD, working for a while and getting my psych NP degree afterwards, as well as the Psych rxp path (which is lackluster compared to the NP route)

 

[EnPsychlopedia]

Yes, that was something I was considering. Going the Psych NP route and training at an analytic institute. But as someone who wants to do psychotherapy as well as prescribe I'm concerned that the analytic institute won't give me the foundational skills to do therapy, especially since the PSYCH NP programs have basically no training in therapy whatsoever. That's why I thought PHD, work for a few years, go back to become a Psych NP and prescribe like one person did here but I'm quite conflicted.

Training in psychoanalysis is probably one of the least effective and efficient ways to learn how to do empirically-based, scientific psychotherapy. Psychoanalysis is a pseudoscience and is not resource efficient at all. I know lots of psychiatrists still have a love affair with it, but frankly I do not think their opinions on psychological therapy are, speaking broadly, grounded in the scientific literature.

 

[EnPsychlopedia]

I want to do a mixture of psychotherapy and Prescribing, and I'm trying to find the most logical path to follow for my interests. I'd want more of an emphasis on therapy rather than prescribing, which is why I have considered getting my PHD, working for a while and getting my psych NP degree afterwards, as well as the Psych rxp path (which is lackluster compared to the NP route)

I understand that you want to do both, but I stand by what I said. Based on your numerous posts both here and Reddit (which I assume are also you since the prompts are often verbatim), it really feels like you're throwing a bunch of stuff at the wall and seeing what sticks. I really recommend that you doing some shadowing like @Sanman recommended and see which path best fits your interests. I would choose PMHNP plus therapy training last of all the options because I frankly do not think PMHNP training is standardized and rigorous enough to compete with psychiatrists in medicine or psychologists in psychosocial intervention.

 

[psych.meout]

I just don't think it's neccessary to get where I want to be. If that offends you I don't know what to tell you.

It doesn't "offend" me, I'm not sure where you're getting that.

 

[Psycho Bunny]

Training in psychoanalysis is probably one of the least effective and efficient ways to learn how to do empirically-based, scientific psychotherapy. Psychoanalysis is a pseudoscience and is not resource efficient at all. I know lots of psychiatrists still have a love affair with it, but frankly I do not think their opinions on psychological therapy are, speaking broadly, grounded in the scientific literature.

It's not just psychiatrists. The APA has its own division for psychoanalysis. It's also one of the apa recognized board certified specialties. There are also some well established Psychology PHD programs with a psychodynamic focus, especially in NY. If I'm not mistaken, there is research showing psychodynamic therapy to be effective for certain mental illnesses.

Anecdotally, you can read from some patients online that it's helped them when behavioral therapy has not.

By far, the most opposition I've encountered to psychodynamic/psychoanalysis has been from psych academic professors, most of which had been teaching for many years and had limited clinical experience if any at all. Just my observation.



I'm not nearly as willing to argue as you seem to be, I'm simply looking for advice and answers to questions I have. It just seems like every time you respond to one of my posts there's an air of combativness and it always takes the conversation in a different direction from what was initially discussed.

 

[EnPsychlopedia]

It's not just psychiatrists. The APA has its own division for psychoanalysis. It's also one of the apa recognized board certified specialties. There are also some well established Psychology PHD programs with a psychodynamic focus, especially in NY. If I'm not mistaken, there is research showing psychodynamic therapy to be effective for certain mental illnesses.

1. That APA division is incredibly small and has very little membership.

2. Psychodynamic =/= psychoanalysis.

3. Therapeutic efficacy does not equate to scientific validation of the theory.

4. I am currently in NYC. It is a hotbed for psychodynamic views. It is about the only place left in the whole U.S. where such views are seen as mainstream.

By far, the most opposition I've encountered to psychodynamic/psychoanalysis has been from psych academic professors, most of which had been teaching for many years and had limited clinical experience if any at all. Just my observation.

4. For good reason. Psychoanalysis makes few scientifically-testable predictions, and those it does make have for the most part been falsified. It is not an accurate psychological model. Even among clinically-licensed psychologists, psychoanalysis is a minority framework, and becoming more of one every day.

It just seems like every time you respond to one of my posts there's an air of combativness and it always takes the conversation in a different direction from what was initially discussed.

I think I have only commented on one other thread of yours, wherein you directly asked about the evidence for psychoanalysis as a treatment and whether other modalities are more suited for certain things--a question which I answered pointedly.

I understand you are asking for advice, and I have tried to offer helpful feedback by commenting directly on the plans you describe. You mentioned a number of different paths and I tried to give reasonable advice on choosing one. You mentioned psychoanalysis and I responded that I don't think that would be an efficient or effective use of time for learning to do therapy. I am sorry if you find it combative, but if you're going to ask for advice then you have to also be willing to hear advice that is not exactly what you want to hear. I assure you there was no combativeness intended. My advice could always be wrong, but I genuinely am not trying to be combative. I just don't think NP + psychoanalytic training is a cost-effective, time-efficient, or scientifically-informed way to get training in psychotherapy, nor do I think provision of psychoanalysis to be cost- or time-efficient for patients.

 

[Doctor Eliza]

What is your ideal practice setting in the future? What do you want your typical day to look like?

 

[Psycho Bunny]

What is your ideal practice setting in the future? What do you want your typical day to look like?

My *ideal* practice would be having my own cash only private practice (or something close to that) doing a mixture of therapy and Prescribing.

 

[psych.meout]

My *ideal* practice would be having my own cash only private practice (or something close to that) doing a mixture of therapy and Prescribing.

Ok, but what does a hypothetical day look like?

 

[WisNeuro]

Ok, but what does a hypothetical day look like?

In a cash pay practice for this provider? 40% of patients looking for stims, 40% looking for benzos, and maybe 20% with accurately reported concerns.

 

[Psycho Bunny]

In a cash pay practice for this provider? 40% of patients looking for stims, 40% looking for benzos, and maybe 20% with accurately reported concerns.

What makes you say that? I don't want to be a pill dispenser. I would want to do more therapy than prescribing.

 

[Doctor Eliza]

I think cash pay changes the equation a bit. When people are willing to pay cash for something that they could choose to use their insurance for, they are expecting a superior product. No shade to NPs, but the general perception is that an MD is superior. Yes, you could be a one stop shop, but I don't know how great of a demand there is for that that people paying cash would take a nurse over a doctor. One data point is that there are many cash only psychiatrists in my town, but it is easy to get in with an NP who takes insurance. Again, only one data point. I think if you have an interest in rx'ing medical school is the way to go. On the other hand, you say you want to do more psychotherapy than rx'ing then why not work to be the best psychotherapist you can be? You can develop a niche that makes it possible to demand cash for your services.

 

[Sanman]

I want to do a mixture of psychotherapy and Prescribing, and I'm trying to find the most logical path to follow for my interests. I'd want more of an emphasis on therapy rather than prescribing, which is why I have considered getting my PHD, working for a while and getting my psych NP degree afterwards, as well as the Psych rxp path (which is lackluster compared to the NP route)

My *ideal* practice would be having my own cash only private practice (or something close to that) doing a mixture of therapy and Prescribing.

The most straightforward path to your ideal vision is med school and a psychiatry residency. You seem to want to work longer for a less straightforward and ideal path. It can be done, but why?

 

[psych.meout]

What makes you say that? I don't want to be a pill dispenser. I would want to do more therapy than prescribing.

Ok, and what benefit do you get from prescribing as a psychologist vs. being the best psychologist you can be and referring out to a psychiatrist for med management?

 

[WisNeuro]

What makes you say that? I don't want to be a pill dispenser. I would want to do more therapy than prescribing.

I say that because this is generally how it works at the cash pay clinics. People want a specific thing and expect to get it when they cash pay. Additionally, with therapy, in many areas there are so many options for insurance pay, it's a tough road to build a cash pay. On top of that, if you have midlelevel type training in therapy, even harder to build that case load or get people to refer to you.

 

[Psycho Bunny]

Ok, and what benefit do you get from prescribing as a psychologist vs. being the best psychologist you can be and referring out to a psychiatrist for med management?

Multiple benefits:



1. Patients having access to medications or refills they may need if they can't afford to see a psychiatrist or have no access to one for one reason or another.

2. Boost in income (I wouldn't make or charge anything close to a PP psychiatrist but I still would make a comfortable living and be able to charge more than the average psychologist for my niche. Marketable too.

3. I genuinely have an interest in psychopharmacology as well as psychology. I'd refer out to a psychiatrist for extremely complex patients with Co-morbidities that are biological in nature or if for one reason or another I felt it was beyond my knowledge/training.

 

[Sanman]

Multiple benefits:



1. Patients having access to medications or refills they may need if they can't afford to see a psychiatrist or have no access to one for one reason or another.

2. Boost in income (I wouldn't make or charge anything close to a PP psychiatrist but I still would make a comfortable living and be able to charge more than the average psychologist for my niche. Marketable too.

3. I genuinely have an interest in psychopharmacology as well as psychology. I'd refer out to a psychiatrist for extremely complex patients with Co-morbidities that are biological in nature or if for one reason or another I felt it was beyond my knowledge/training.

I am a bit confused as to how you reconcile these statements. Not sure who you think fits this niche and can pay cash vs using their insurance.

 

[psych.meout]

Multiple benefits:



1. Patients having access to medications or refills they may need if they can't afford to see a psychiatrist or have no access to one for one reason or another.

2. Boost in income (I wouldn't make or charge anything close to a PP psychiatrist but I still would make a comfortable living and be able to charge more than the average psychologist for my niche. Marketable too.

3. I genuinely have an interest in psychopharmacology as well as psychology. I'd refer out to a psychiatrist for extremely complex patients with Co-morbidities that are biological in nature or if for one reason or another I felt it was beyond my knowledge/training.

I don't understand how 1 and 2 are compatible. How are they going to have the money to pay you for med management but not have the money to pay a psychiatrist for the same service?

And what do you mean you won't charge what a psychiatrist would? Are these cash pay patients or will you be accepting insurance and you know something about billing codes that the rest of us don't? And if it's the former, why would they go to you instead of a psychiatrist? Typically people who have money to pay out of pocket like that also want the prestige of working with the highest level of whatever service they're paying for, I'm not sure why they'd go to you over a psychiatrist.

For #3 how large do you think that patient base is and how are you going to fill your caseload to make it worth your while?

 

[AcronymAllergy]

I would still say, as have folks above, that it sounds like medical school + psychiatry residency + additional training in psychotherapy seems like the clearest path toward your ideal career.

If you're cash pay as a psychiatrist, you can charge whatever you want. There's nothing stopping you from charging less than your peers. Whereas if you're a psychologist with prescribing privileges charging less than psychiatrists, it could send the message to patients that psychologists are "worth less" than psychiatrists (i.e., you get what you pay for).

 

[pricklyhare]

IMO there is no point in prescribing if you are not qualified to take on “complex” patients. Psychiatrists and (good) PNPs have a strong background in biology and chemistry and therefore should have expertise in not only HOW psychiatric medications work but also what would or would not make a patient a good candidate for a medication. If you prescribe without that medical training you risk prescribing something that is harmful to a patient. Also, I feel like any patient can become “complex” - for example, you might be treating someone for depression with an SSRI but one day they have a manic episode and are hospitalized - you can’t really just refer that patient out (I mean, I suppose you can but it would be an unkind thing to do).

I have worked with excellent psychiatrists and PNPs. They did not provide therapy but worked closely with a patients therapist to inform treatment. Their medical training allowed them to adapt to the needs of each patient and prescribe based an individuals history/medical conditions/symptoms.

There is nothing wrong with choosing one path and not the other, in fact it’s probably ideal if you want to be reeeeally good at your job to the point where patients can feel justified in paying you out of pocket. I agree that med school sounds more in line with your goals.

 

[Psycho Bunny]

The most straightforward path to your ideal vision is med school and a psychiatry residency. You seem to want to work longer for a less straightforward and ideal path. It can be done, but why?

If I'm being completely honest, the main reason why I haven't seriously considered medical school is because I have very little interest in human biology and anatomy beyond whats necessary with regard to psychotropic medications. From what I've read it's very intensive courses on topics that Psychiatrists often will never use nor have any relevance to the practice. I just can't convince myself that the intensive first 4 years is necessary to be a competent prescriber of psychotropic medications after knowing that Prescribing Psychologists and Psych NPS exist. Additionally knowing that most antidepressants are prescribed by PCPs who have that baseline 4 years medical training with little to no psych experience and hearing how much of a poor job they do anecdotally (and also how their skillset to prescribe those drugs is far inferior to Psych NPs and Psych RXPs from the studies I've seen, although granted those studies had limitations and there aren't enough of them) . So if I have no interest in the coursework and can't justify that those 4 years would make me a more effective prescriber, I can't convince myself it's a good idea to suffer through it. I understand that may be a very controversial opinion here but it's honestly how I see it. But it kills me because the Psych residency clearly has the best training in psychopharmacology of all programs. I wish it could be it's own academic pathway like dentistry honestly.

 

[Psycho Bunny]

I am a bit confused as to how you reconcile these statements. Not sure who you think fits this niche and can pay cash vs using their insurance.

Well, I was under the assumption that prescribing psychologists make more than the average clinical psychologists but less than psychiatrists. And I was under the assumption that was because they charged rates that reflected that. But perhaps I'm wrong on that?

 

[psych.meout]

If I'm being completely honest, the main reason why I haven't seriously considered medical school is because I have very little interest in human biology and anatomy beyond whats necessary with regard to psychotropic medications. From what I've read it's very intensive courses on topics that Psychiatrists often will never use nor have any relevance to the practice.

Honestly, this is most telling thing you've posted and not in the way that you think.

 

[Psycho Bunny]

I don't understand how 1 and 2 are compatible. How are they going to have the money to pay you for med management but not have the money to pay a psychiatrist for the same service?

And what do you mean you won't charge what a psychiatrist would? Are these cash pay patients or will you be accepting insurance and you know something about billing codes that the rest of us don't? And if it's the former, why would they go to you instead of a psychiatrist? Typically people who have money to pay out of pocket like that also want the prestige of working with the highest level of whatever service they're paying for, I'm not sure why they'd go to you over a psychiatrist.

For #3 how large do you think that patient base is and how are you going to fill your caseload to make it worth your while?

There's plenty of people who can afford to pay for services without paying top of the line. Otherwise cash only midlevels wouldnt exist. I don't know anyone who always goes to the most expensive steakhouse they can when they crave a steak. My target income range would be 160-180k gross (adjusted with inflation over time). Which is less than the average psychiatrist. I'm going under the assumption that the market value for a prescribing psychologist is less than that of a psychiatrist but more than what is normal for a Clinical psychologist.

 

[Psycho Bunny]

Honestly, this is most telling thing you've posted and not in the way that you think.

Well if I'm wrong, why is it that PCPs prescribing of these drugs is inferior to Psych NPs and Psych RXPs from the data that exists? Even on this forum I've been told that PCPs can and often do a horrible job. Is it really that unreasonable to assume that the superior prescribing of Psychiatrists stems from their more rigorous training in psychopharmacology from their Psych residency rather than their initial 4 years of medical school that hardly covers the topic?

 

[pricklyhare]

There's plenty of people who can afford to pay for services without paying top of the line. Otherwise cash only midlevels wouldnt exist. I don't know anyone who always goes to the most expensive steakhouse they can when they crave a steak. My target income range would be 160-180k gross (adjusted with inflation over time). Which is less than the average psychiatrist. I'm going under the assumption that the market value for a prescribing psychologist is less than that of a psychiatrist but more than what is normal for a Clinical psychologist.

I mean you’re not dining at an Outback Steakhouse with the expectation that it will help you manage your mental illness, you’re just there to eat a steak but you can’t afford that fancy wagyu place. And if your job covered 90% of your bill at the wagyu place and 0% at outback you’d be going to the wagyu place every day. And it’s not like people crave mental health services - patients are simply trying to find a provider who has the training and expertise to provide med management long term. Even with your steak analogy you’re expressing that your services would be less desirable/valuable. If someone makes enough money to pay out of pocket for mental health services they probably have a job with insurance, and they’d rather see a psychiatrist with a copay. The “cash only mid levels” I have met provide very niche services and they built a client base before transitioning to PP. I think you’re jumping the gun on all of this, you have plenty of time to figure out what you want to do and what you need to do to get there.

 

[Therapist4Chnge]

Well, I was under the assumption that prescribing psychologists make more than the average clinical psychologists but less than psychiatrists. And I was under the assumption that was because they charged rates that reflected that. But perhaps I'm wrong on that?

Earning and being successful are much more the result of a good business person than a good clinician.

 

[tr]

Well if I'm wrong, why is it that PCPs prescribing of these drugs is inferior to Psych NPs and Psych RXPs from the data that exists? Even on this forum I've been told that PCPs can and often do a horrible job. Is it really that unreasonable to assume that the superior prescribing of Psychiatrists stems from their more rigorous training in psychopharmacology from their Psych residency rather than their initial 4 years of medical school that hardly covers the topic?

The psych residency builds on the medical school. Agreed that four years of medical school doesn't by itself turn you into a competent psychiatrist. It does, however, prepare you for residency in psychiatry.

You couldn't dump someone without a medical background into psychiatry residency and expect them to be able to either manage the work or benefit from the training.

From what I've read it's very intensive courses on topics that Psychiatrists often will never use nor have any relevance to the practice.

I use my medical training every day.

If I'm being completely honest, the main reason why I haven't seriously considered medical school is because I have very little interest in human biology and anatomy beyond whats necessary with regard to psychotropic medications.

Ok so why do you want to prescribe if you have no interest in the knowledge area required to do so competently?

It's just not siloed in the way that you think. The brain is a physiological organ and it is in constant, networked, indissoluble communication with all of the body's other organs and systems.

Just skip the prescribing and work on being a really good psychologist. You'll do a lot more good that way vs becoming an uninterested, undertrained prescriber of medication.