Therapist or psychiatric nurse practitioner: who should I see first?

If the main thing you want is to talk through what is happening and change how you handle it, start with a therapist. If the main question is what is going on and whether medication should be part of the answer, start with a psychiatric evaluation by a psychiatric nurse practitioner. If you are not sure which, the free 15-minute consultation exists to sort exactly this, and many people end up with both.

The rest of this article explains what each person actually does, how they differ from a psychiatrist, and the three signals that point one way or the other.

What a therapist does

A therapist is a licensed counselor or clinical social worker with a master’s degree and supervised clinical hours behind the license. In Arizona the licenses you will see are LCSW, LPC and LAC, and a counseling intern works under a licensed clinician’s supervision while finishing training.

Therapy is the work of talking, usually 60 minutes a week with the same person. A therapist helps you understand a pattern, change how you respond to it, and process what has happened to you, using approaches such as cognitive behavioral therapy, dialectical behavior therapy and trauma-informed work. A therapist does not prescribe medication. Individual therapy at PATH explains what a session is like.

What a psychiatric nurse practitioner does

A psychiatric mental health nurse practitioner, PMHNP for short, is a registered nurse with a graduate degree and board certification in psychiatric mental health. In Arizona, nurse practitioners can evaluate, diagnose and prescribe on their own. At PATH, the psychiatric evaluations and the medication management are done by a board-certified psychiatric nurse practitioner.

The first visit is a 60-minute psychiatric evaluation: your history, what you have tried, sleep, mood, concentration and the rest, ending with a diagnosis where one fits, a recommendation and a plan. Follow-ups are 20 to 30 minutes, to review how the plan is working. A nurse practitioner can prescribe when an evaluation supports it, and plenty of evaluations end with a recommendation for therapy and no medication at all.

How that differs from a psychiatrist

A psychiatrist is a physician, an MD or a DO, who completed medical school and then a residency in psychiatry. A psychiatrist also evaluates, diagnoses and prescribes. The training paths are different, and for the outpatient work most people are looking for, an evaluation, a diagnosis and ongoing medication management, the appointment covers the same ground.

PATH does not have a psychiatrist on staff. If your situation needs one, the nurse practitioner will tell you plainly and help you get there. That is not a failure of the evaluation; knowing when to refer is part of doing it well.

Three signals that point one way

1. Your question is about diagnosis or medication. You want to know whether what you have is anxiety, depression, ADHD or something else, or whether medication is worth considering. Start with the evaluation. You can decide against medication afterwards; the evaluation does not commit you to anything.
2. Your question is about a pattern. The same fight, the same spiral, grief that has not moved, a trauma you have never talked about. Start with a therapist. If progress stalls after a few months, an evaluation is a reasonable next step, and your therapist can say so.
3. Both are true. This is common. Some people start therapy and add an evaluation; others have the evaluation first and get a therapy recommendation out of it. Under one roof, the two can coordinate without you carrying messages between offices.

How PATH decides with you

Every patient starts with a free 15-minute video consultation with our front desk. You describe what is going on in a few sentences, you ask about cost, and we tell you which first visit fits and what it will cost before anything is final. If the answer is both, you hear that too.

Therapy is $75 to $150 a 60-minute session if you are paying yourself; a psychiatric evaluation is $300 and a follow-up is $150. We accept Aetna, Cigna, Carelon Behavioral Health and Curative for all of these, and your plan’s normal copay or coinsurance applies instead. Both paths can be in person in Tempe or by video anywhere in Arizona.