As National Nurse Practitioner week comes to an end, it is with pride that I showcase Kristina Stevens, PMHNP-BC. Kristina is a zen-filled Psychiatric Nurse Practitioner working at University of Illinois at Chicago’s Psychiatric Outpatient Clinic in the Neuropsychology Institute. She started as an English major in college and spent twelve years in public radio as a producer and editor before switching over and becoming a nurse practitioner. She was kind enough to sit down for a one-on-one interview about how she became a Psych NP, and share some insight into her daily life for those who are interested in pursuing this route.
What made you pursue a career as a psychiatric nurse practitioner?
I came from a family with a lot of mental health challenges and I personally have dealt with a lot of mental health issues. I think that history makes me a better mental health provider. Sometimes I share my experiences when appropriate and a light bulb goes off for them because they see me as someone who gets them, rather than someone who just read about their condition from a textbook. As my own former psych NP told me, you only have to be more mentally well than your patient for that hour you are seeing them. So it wasn’t that hard for me to “go to the other chair.”
There have been times where I experience counter-transference, when issues hit a little too close to home. When this happens I talk about that during supervision – which is a monthly meeting I have with my mentor where I talk about cases, professional worries, best practices, etc.
How did you know you were ready “to go to the other chair”?
It felt very comfortable from the moment I started seeing patients during my first clinicals, when my instructor just threw me in. It allowed me to give back what was given to me when I was suffering. I had started with midwifery and it was really hard to change, and I grieved for a good year about whether this was the right choice for me, but once I started clinicals I just knew that this was right for me.
And now looking back I can see that midwifery was definitely not my path and I’m glad I made the choice to change when I did.
Tell us about where you work.
I have a nice office where I see my patients. They let me pick a paint color so it’s a nice light blue. It’s Univerisity of Illinois at Chicago (a state facility), so I got salvaged furniture, but I decorate it so that it’s a peaceful space for my patients and myself.
What is your relationship with your collaborating physician?
For Medicare patients UIC just changed their policy, and I have to have an attending physician every 6 months just to review the plan of care. Otherwise if they’re not Medicare patients, I am completely on my own. However, I am well supported by my colleagues and my collaborating physician, and I can ask questions when I need help. I frequently text or email my collaborating physician with questions and concerns and always get a prompt, helpful, encouraging and friendly responses.
Tell us about your typical day.
I start to see patients early in the day starting from 8am and my last patient is out at 4:30pm. Sometimes I start later in the day so I end at 6. I have 60 minutes for intake and therapy, and for patients I am seeing only for medications I am seeing them for 30 minutes. However, most of my patients I see for combined medication and therapy. I see most patients every 2-4 weeks, and there are a handful of patients I see weekly if they need a lot of help. I spend an hour with them, and for the first 15 minutes we tend to start on medications, what’s going on with their life, what their sleep is like, etc. Usually they come in with a pressing problem, something that’s urgently on their mind, so we address that first.
I see patients back to back for 2-3 patients at a time. I handle my own scheduling, so then I’ll give myself 30 minutes after the chunks of patients to chart and have some downtime that doesn’t involve talking to patients to catch up on phone calls and charting.
Being in psych you’re listening to a lot of really hard stuff. Patients are telling me very personal stories about their lives and sometimes this can be really difficult. You have to be nonjudgmental, and it takes patients a long time to feel like they can trust you with stuff. It doesn’t exhaust me though, and I think that’s because I meditate every day. My mindfulness practice (which I frequently teach to patients) allows me to usually not bring my work home.
How was it different when you first started working?
In the beginning when I was seeing all new patients I would see 6-7 new patients every day and it was really overwhelming. But now I don’t see that many new intakes and I have a regular panel of patients, so it’s much better. Also I’ve mastered the art of doing intakes so I can do them much easier.
What is the most challenging part of your typical day?
I haven’t had to commit any patients yet, but I definitely deal with suicidal ideation all the time. For example, I had two young college students recently who weren’t suicidal with plan or intent, but they definitely had passive suicidal ideation (they were thinking about suicide a lot). Then I had a mother later that day who had just given birth and was a heroin addict, and I hadn’t seen her since she gave birth, but the day I saw her again was only three days after her baby had died. That day I went home really emotionally drained.
To deal with this every day, I get to work early, I meditate for 30 minutes, and then I start my charting from the previous days for an hour, before I start seeing patients. I think I’ve taken lunch three times since I started, but that’s my choice to chart through lunch so that I can walk out the door when my last patient leaves. It helps me maintain a work life balance, especially helping to raise my 11 year old daughter.
How do you feel about your role as the psychiatric NP?
You can’t really see a psychiatrist for therapy anymore, and social worker can’t really do medications, but as a psychiatric NP I get to do both meds and therapy. When patients learn that they can do both with me, they really like it because it’s less of a hassle when they don’t have to go back and forth between providers. It’s easier and better to have one person know your story and seeing the full picture. When I’m just doing meds I don’t get the full picture because we don’t have time to talk, and same if I’m doing just therapy. So it’s nice to be able to have the time to manage both. I feel very fortunate where I work to be able to have so many therapy patients. Unless you are in private practice, most psych NP’s are hired to do 15-30 min med management only. Most days I really love what I do.
What type of therapy do you provide?
I provide an eclectic type of therapy, drawing from mindfulness, interpersonal behavior therapy, cognitive behavior therapy and other modalities. I actually do pretty active, skill-based patient therapy -giving my higher functioning patients a lot of homework, which a lot of my patients really like, because it extends the therapy we do in one hour every two weeks. Having something to work on between visits that involves learning instead of just talking usually helps patient progress faster in recovery. I use various workbooks that I’ve found over time for PTSD, cognitive processing therapy for rape, anxiety and panic attacks, and depression. Sometimes I assign bibliotherapy for patients who are interested – I give them book recommendations to read on their own time. I also love using a lot of handouts so when I teach a new skill I give them a handout to help them remember what we discussed after the appointment.
Do you tend to see patients that are under a specific branch of mental illness or do you take on patients from all over the spectrum of mental illness?
For the most part my patients are mood-anxiety just because that’s the most common. I specialized in women’s mental health so I get the pregnant and post-partum patients as well, and in that population I get schizoaffective, bipolar, schizophrenic, and a lot of depression and anxiety in the prenatal and postpartum period. I deal with a lot of rape and PTSD from rape and childhood molestation so that’s become one of my specialties. I refer out the ones I don’t feel comfortable with, usually patients in autistic spectrum and ones who are in heavy duty psychosis because I’m not equipped to deal with those. We have a psychosis unit so I refer to them. Otherwise I will treat pretty much everyone. My business card says women’s mental health but I still have a lot of male patients.
How did you choose to specialize in women’s mental health?
I chose this specialty because I started out in midwifery and it didn’t work for me. I didn’t even know psych NP’s existed until I started my accelerated nursing program. When I left labor and delivery and when I started psych, I was recommended to go into women’s mental health because it was a very natural transition and fit from midwifery. I did a year of clinicals with the hospital’s women’s mental health and agreed that it was a great transition and fit. Also, mentally ill pregnant and postpartum women is a really underserved population that, frankly, most providers are scared to treat.
What are some challenges that you face in your career as a Psych NP?
My biggest challenge is worrying about my patients, especially the suicidal ones. Statistics show that most people who commit suicide have seen their mental health provider in the last 30 days before they do it. So I always ask about suicide and whether they have an intent and plan, but then if a patient is really intent on doing it, are they really going to tell me? Hard to say. I tell all of my patients during intake that if they say they want to hurt themselves or others, I have to get someone else in the room and involved. I have a patient who told me “then I won’t tell you anything.” I remember one patient who I was really close to committing, but she swore that she wasn’t suicidal that day, so I didn’t end up committing her. But then again, she never came back because she didn’t want to be committed.
So yeah, worrying about the suicidal stuff is one of the scarier challenges.
My other challenge is trying not to bring work home with me. You worry about your patients, and your mind is constantly thinking about the ones that are really sick, what can you do better for them, and what therapy would work better for them.
To overcome these challenges, I meet with my collaborative physician a lot, I talk to her, I am always asking for help. I talk to my risk assessment group to ask about what I should do whenever there are is any doubt. Additionally, I belong to a closed listserv and Facebook group specifically for psychiatric NP’s, which are great forums for asking questions and learning from what others ask and discuss. But I am never afraid to ask for help, I reach out and get reassurance when I need it, and I encourage anyone practicing in the medical field to do the same no matter how long they have been in practice. I don’t want to ever stop learning.
If someone is interested in pursuing a career as a psychiatric NP, what should they think about and question themselves before making that commitment?
One of the most important things is that you have to learn to be a really good listener. I have always been a really good talker, and I’m good at not being judgmental, but I know I’ve had to really consciously strengthen my listening skills and to let patients talk while not interrupting them. You have to be willing to tolerate really distressing emotions and be present for people in really distressing, sad, uncomfortable situations and be able to sit with that discomfort. Basically you have to be really comfortable with being uncomfortable. You also should really know your own baggage and know what issues you aren’t comfortable dealing with – for instance I share custody of an 11 year old girl with an ex and we are still working through a lot of custody issues; I don’t for a minute think I would be comfortable doing family therapy or couples therapy, because it would bring up too much counter-transference. So you need to know your limits as well as your strengths!