Integrating Psychotherapy Alongside Psychopharmacology

In this video, taken at the 2024 Psych Congress NP Institute Annual Meeting in San Diego, Saundra Jain MA, PsyD, LPC, Steering Committee Member, and Andrew Penn, MS, PMHNP-BC, Co-Chair, discuss the importance and utility of integrating psychotherapy into their everyday clinical practice. Even when medication management is the primary concern, Dr Jain and Andrew underscore how adopting a “psychotherapeutic” approach can help establish greater trust and understanding with patients, leading to improved outcomes.

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Saundra Jain, MA, PsyD, LPC:  Hi everyone. My name is Dr Saundra Jain, and I'm an adjunct clinical affiliate at the University of Texas in Austin with their school of nursing. I also have a private practice in Austin, Texas. So glad to be here today with you, Andrew. And would you introduce yourself?

Andrew Penn, MS, PMHNP-BC: Yeah, thanks. I'm Andrew Penn. I'm a psychiatric nurse practitioner and a clinical professor in the school of nursing at the University of California San Francisco.

Psych Congress NP Institute Online: For which disease states is psychotherapy the recommended first-line treatment?

Dr Jain: So as I think about that, Andrew, the first thing that comes to mind is in the world of major depression. Treatment guidelines do recommend for mild to moderate depression, that frontline would be psychotherapy, with CBT obviously the gold standard. It's not that the other psychotherapies are not effective, but CBT is much easier to quantify and study, but that's going to be our go-to. I also know from rough times with patients, if they are not doing well, trying to integrate insight-oriented psychotherapy and sometimes even support psychotherapy, it can be a challenge without partnering with someone like you to stabilize on meds and then bring psychotherapy in.

Andrew: Yeah, for sure, that a lot of times patients can make better use of psychotherapy when they're not so symptomatic. By bringing the symptom load down a little bit with medications, then people can better utilize psychotherapy to feel better. The other state that comes to mind is anxiety disorders. I know that I have a lot of patients with anxiety disorders who are anxious about the idea of taking medication. So the idea of, Hey, why don't we start with psychotherapy instead of medication first is often actually kind of appealing to the patient. Have you encountered that as well?

Dr Jain: Oh, absolutely. Or patients that sometimes in the process of just having an encounter sitting together, the topic of conversation might trigger an anxiety attack, a panic attack, and it's very clear that when in the throes of that, that biology takes over and trying to talk someone down is just not effective. I learned that the best intervention was to say, Hey, I'll be right back. I go get a nice glass of cold water, a cold wash rag, and I just sit in presence with them, them have a sip, put the rag on their head and wait for it to pass.

Andrew: Yeah. Well, what you're making me think of is this idea of that we talk about in our talk about making every encounter therapeutic, even if it's short. So what you're talking about there of tending to this person's physical needs. We might not think of it as psychotherapy, but I think of it as psychotherapeutic.

Dr Jain: Absolutely. Yeah. I couldn't agree with you more, Andrew. Really from the time we take the referral call, every contact matters.

Andrew: Yeah, I would agree.

NP Institute Online: Why might some clinicians feel uncomfortable providing psychotherapy alongside medication management?

Andrew: So Saundra, I hear from my nurse practitioner students that we teach that they say, I don't feel like I've learned enough about psychotherapy to do it well, and I'm kind of thinking part of that may be because in a psych NP training program, there's a lot we have to cover. We have to cover obviously diagnosis and psychopathology, but we also have to cover psychopharmacology and psychotherapy. So psychotherapy, there isn't as much training usually as somebody would get, say maybe the training you went through as a psychologist. But I'm also thinking that even people who've gone through a lot of training, often they don't necessarily have that same confidence. There's still that feeling of like, oh gosh, am I doing this right? Is that a fair statement?

Dr Jain: As you were starting to answer that question, I had sort of this flashback to my training as a psychotherapist, and when they sort of unleash you into the world, that feeling of even after lots of hours, hours of practicum, supervision, consultation, I'm supposed to be doing this on my own? And I think what happens in the early part of our work is we tend to be in our heads trying to figure out what the next question is. Where do I need to go? What am I supposed to be doing? And what that does is it pulls us out of the experience.

Andrew: Yeah. We're not present.

Dr Jain: We're just not present.

Andrew: The patient can feel it.

Dr Jain: Oh, I've heard you say many times that as we are doing evaluations, they're evaluating us.

Andrew: Yeah. They're assessing us to see if we're safe to talk to. Yeah. And I remember that feeling when I first got a prescription pad. I thought, oh my gosh, people trust me to prescribe medication? But that imposter syndrome feeling that comes up and like, oh, maybe other people know more about this than others. And it makes me think about why we call it practice, because when we're doing this work, we're practicing. We're in practice.

Dr Jain: That's right.

Andrew: It's an interesting choice of terms. It's like we're not experts. We're always getting better. We're always practicing. And so I think about my own abilities as a psychotherapist over the last 20 years. They're still improving. They're still evolving. I don't feel like I've ever fully arrived at any kind of ultra confidence with it. No mastery. No. I've gotten better at it, but I think mastery would be a bit of a conceit.

Dr Jain: It reminds me once, a friend of mine is a yoga instructor, and she was saying, Saundra, yoga is not a thing that you do and master, that's why they call it the practice of yoga. And I think you're right, Andrew, that it is a relational exchange. It's a relational interaction, and that as we do it more and more and sort of soften into it, we just get better at it.

Andrew:  Yeah. And one of my favorite things to do is ask the patient, how's this going? How is this working out for you? Are there things that we could be doing differently? Really ask for that real time feedback because I think it telegraphs to the patient that their concerns matter, and it gives us a chance to improve.

Dr Jain: That's right. Yeah. Sometimes as you're describing how you phrase that, oftentimes I'll say to somebody towards the end of the session, do you feel like we're talking about the right things?

Andrew: Yeah, exactly.

Dr Jain: And I'm often surprised they'll say, yeah, but you know what? There is something that I want to make sure that you understand. Or they're sort of waiting till the last minute for that invitation, if you will, to share what they want to talk about.

Andrew: Yeah. I got asked once by a new primary care clinician. I just thought this was so masterful. I've taken it on as my own. He said, he came in, he was taking over for a previous PCP, and he said, I've read your chart, but I want to know from you, what do I need to know about you to take the best care of you? And I thought, wow, that's an amazing question. Right?

Dr Jain: That's what we all want to hear.

Andrew: Yeah, exactly. I felt really cared for and listened to, and I've tried to adopt some of that in my own work, really just circling back and making sure that we covered what people really want to talk about.

Saundra Jain, MA, PsyD, LPC, is an Adjunct Clinical Affiliate at the School of Nursing at The University of Texas at Austin and a psychotherapist in private practice. Dr. Jain is a co-creator of WILD 5 – A Proven Path to Wellness and co-author of The Science and Practice of Wellness: Interventions for Happiness, Enthusiasm, Resilience, and Optimism (HERO). She is the co-creator of the Psychedelics and Wellness Survey (PAWS), exploring the intersection between psychedelics and wellness. Dr. Jain is active in peer-to-peer education, especially in the disease states of depression, bipolar disorder, anxiety disorders, and ADHD. Another strong clinical and educational interest involves the differential diagnosis of major psychiatric disorders. She serves as a member of the Psych Congress Steering Committee, providing direction regarding educational gaps/needs for mental health practitioners.

Andrew Penn, MS, PMHNP, is a Clinical Professor in the University of California, San Francisco, School of Nursing where his teaching has received the UCSF Academic Senate Distinction in Teaching Award, among other recognitions. He works as a psychiatric/mental health nurse practitioner, treating veterans at the San Francisco Veterans Administration Hospital. As a researcher, he collaborates on psychedelics studies of psilocybin and MDMA in the Translational Psychedelics Research (TrPR) lab at UCSF. A leading voice in nursing, he is a cofounder of the Organization of Psychedelic and Entheogenic Nurses (OPENurses.org), advocating for the perspective of nurses in psychedelic therapy, he has published on psychedelics in the American Journal of Nursing, Frontiers in Psychiatry, The Journal of Humanistic Psychotherapy, and JAMA. An internationally invited speaker, he has lectured at SXSW, Aspen Health Ideas Festival, TEDx, the Singapore Ministry of Health, and Oxford University and can be found at Andrewpennnp.com.

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