Psychotherapy

Psychotherapy accounts for approximately 10% of the ANCC exam. While PMHNPs primarily prescribe, the exam expects you to understand evidence-based psychotherapies well enough to recommend them, recognize when they are first-line treatment, and integrate therapeutic techniques into medication management visits.

Core modalities tested include CBT (cognitive restructuring, behavioral activation, exposure), DBT (distress tolerance, interpersonal effectiveness, emotion regulation), motivational interviewing (OARS, stages of change), and trauma-focused therapies (CPT, PE, EMDR). You need to know which therapy is evidence-based for which condition and the key mechanisms that make each effective.

The exam also tests therapeutic relationship concepts: the working alliance (Bordin's model of goals, tasks, and bond), alliance rupture and repair, transference and countertransference, and boundary management. Expect questions on group therapy factors (Yalom's therapeutic factors), family therapy models (structural, strategic), and when to refer for specialized psychotherapy vs. providing brief interventions yourself.

• ✕Recommending insight-oriented psychotherapy for patients in acute psychosis. Supportive therapy is appropriate during acute episodes; insight-oriented and exposure-based therapies require cognitive stability to be effective and safe.
• ✕Confusing CPT and PE — both are gold-standard PTSD treatments, but Cognitive Processing Therapy works on modifying maladaptive beliefs ("stuck points"), while Prolonged Exposure uses repeated engagement with trauma memories and avoided situations to reduce fear conditioning.
• ✕Not knowing DBT's four skill modules (mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness) or that DBT is the only psychotherapy with strong evidence for borderline personality disorder. The exam tests specific skills like DEAR MAN for interpersonal effectiveness.
• ✕Mixing up motivational interviewing stages. MI is most effective during the contemplation stage. Pushing action-stage interventions on a precontemplative patient creates resistance. The exam tests your ability to match the intervention to the patient's readiness for change.
• ✕Assuming psychotherapy is always adjunctive to medication. For mild-to-moderate depression and most anxiety disorders, CBT alone is as effective as medication and is a valid first-line monotherapy option.