Peplau's Ghost
Psychiatric-Mental Health Nurse Practitioners (PMHNP) discussing using psychotherapy within their practice. Four PMHNP program directors and a biostatistician from across the Unites States sharing their passion on how psychotherapy can help people with nearly all their emotional problems.
Peplau's Ghost
Integrative Nursing's Impact on Psychotherapy with Prof Gisli Kort Kristófersson
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This episode emphasizes the integration of psychotherapy within nursing as a vital component of holistic patient care. We explore personal experiences, barriers to practice, and the future potential for nurses in psychotherapy while underscoring the importance of therapeutic relationships.
• Importance of integrative nursing
• Personal journey into psychotherapy
• The need for a holistic approach in care
• Challenges faced in early therapy sessions
• Diverse therapeutic styles and their applications
• Barriers nurses encounter in psychotherapy
• The allure of prescribing medications
• Future directions for psychotherapy in nursing
• Emphasizing the therapeutic alliance for effective care
Let’s Connect
Dr Dan Wesemann
Email: daniel-wesemann@uiowa.edu
Website: https://nursing.uiowa.edu/academics/dnp-programs/psych-mental-health-nurse-practitioner
LinkedIn: www.linkedin.com/in/daniel-wesemann
Dr Kate Melino
Email: Katerina.Melino@ucsf.edu
Dr Sean Convoy
Email: sc585@duke.edu
Dr Melissa Chapman
Email: mchapman@pdastats.com
Exploring Integrative Nursing and Psychotherapy
Speaker 1Yeah , just my take on things . My answer number two Discovery , identifying challenge in your beliefs , framing your mind , negative thoughts release , cognitive distortions decrease .
Speaker 2Welcome to another episode of Peplow's Ghost . I'm your quote-unquote host , dr Dan Wiesman , from Iowa . I'm joined by my esteemed colleague , dr Melissa Chapman-Hayes , and I am really excited the podcast is going international , in my opinion . So really excited to get to talk to Gisli , who is from the University of Minnesota and also is from Iceland .
Speaker 3Yeah , that's where I live now . Yeah , I'm a professor at the University of Akureyri , which is in the north of Iceland , so I live kind of on the 66th latitude .
Speaker 2Wonderful .
Speaker 3That's where I am now .
Speaker 2My wife is from Minnesota and so she always reminds me and correct me if I'm wrong in thinking about this , but Iceland is green and Greenland is more ice . Is that a common acronym , or is that a common stereotype or bias , or am I way off on that ?
Speaker 3Yeah , I don't know . Sure , I mean , it's a little warmer in Iceland , we have the cold stream and we're a little bit more to the south and we're not as uh , proportionally not as covered in ice . So yeah , but it's still a rough place . It's uh , yeah , I've uh , you know , as far as islands are concerned , this is a , it's a . It's a rough place to stay . Really Wonderful .
Speaker 1I don't know about that , so I lived here .
Speaker 3I lived in Iceland for 10 years now . I moved back in 2014 . But I still have adjunct faculty positions at the University of Minnesota and teach a course there at the Center for Spirituality and Healing and things like that .
Speaker 2Thank you , yes . So yeah , I was seeing and I was kind ofity and Healing and things like that . Thank you , yes . So yeah , I was seeing and I was kind of doing a little bit of internet snooping on you and seeing kind of some of your work and your history and I was really impressed with the work you've done with integrative care and integrative nursing and the paper you wrote back in 2015 kind of laying out , kind kind of the principles of integrated nursing , which was really impactful .
Speaker 2I really kind of loved kind of the wording and kind of just really hit home for me . It just really kind of seemed like and again , I think you know , for those listening , you know it's obviously Pet Plows Ghost is one of those podcasts that's meant to highlight the use of psychotherapy and you know , continue to utilize that in a nursing role . So I think that for me and I'm happy to you know , kind of hear your thoughts on that too you know , integrative nursing using holistic approaches , treating , you know , the person individually and not kind of lumping people into those medical models . I think that this podcast is warm and receptive to that . So , again , very much appreciate you joining us today , so I get the . We're kind of as we do typically with our podcast . We kind of go back and forth asking questions , so I would get the first question us going when did you first get interested in doing or , you know , being involved with psychotherapy ?
Speaker 3Well , I think back in maybe 2004 , when I graduated from the School of Nursing at the University of Iceland and I started working in psych . I got interested in that and that's why I pursued a graduate degree at the University of Minnesota back in 06 . And so I was interested in doing psychotherapy and developing that role . Then , as many of the listeners are going to be familiar with , in advanced practice , especially in the US , you know you get the prescription pad as well and it pays a little better to do that . So you have to fight for your role as a psychotherapist . But it really has been from the very start I've been interested in the psychotherapy or psychotherapist role .
Speaker 2Yeah , thank you , kind of a follow-up . Sorry , kind of jumping on Melissa's toes , but I guess one of the questions came up just a bit thinking about that response . I guess one of the questions came up just a bit thinking about that response Did the University of Minnesota offer kind of some educational opportunities for you that the University of Iceland did not ? Or why did you choose to come to the United States to kind of develop those skills ? Or were there not that opportunities at the University of Iceland ?
Speaker 3Well , I don't know if you guys know this , the US is not best at everything . I don't know if you guys know this , the US is not best at everything , but the US is pretty advanced when it comes to advanced clinical nursing . Other countries are getting better Australia , netherlands , uk , ireland but when it comes to advanced practice mental health nursing , back in 2005 , when I was looking at this , the US had the most exciting clinical degrees In Iceland . It was really more theoretical stuff , and so I didn't just want to learn how to think , I also wanted to learn how to do . I also wanted to learn how to do , and so you know . So that's why I came to Minnesota and decided to go to the United States to get my graduate degree , so I could get an advanced practice degree , not just a theoretical , you know degree .
Speaker 2Thank you . Yeah , that's good . I appreciate that and I appreciate you calling us out and I say right , we're not the best at everything , so thank you , but you are best .
Speaker 3You're kind of the best at this though , so you know that's pretty cool .
Speaker 2We'll hang the hat . Yeah , thank you .
Exploring Various Psychotherapy Approaches
Speaker 4Speaking of practical , it would really be fascinating to hear about a session that really taught you something so it could be early on or really any point in your career , just kind of looking for an example of a session that really stood out to you and why .
Speaker 3Well , there's a couple of things I mean . One of the requirements to which is cool at the University of Minnesota is that , historically speaking and I don't want to get into the whole CNS versus NP versus DNP thing we kind of wrote up I'm one of the co-editors of a book called Advanced Practice Mental Health Nursing a European Perspective for those interested in more kind of discussion on this . But at the University of Minnesota there's a long kind of a long tradition of producing CNSs , until the consensus back in 2015 where we all decided we're going to be NPs and so I took that licensure back in 2015 as well , but anyway . So when I was starting out at the University of Minnesota , we were in a CNS program , although it had a lot of what we would call now NP competencies . I don't know if I lost like all the audience now and Melissa is like losing- Different certifications , I mean I do know what they stand for ?
Speaker 3I don't know .
Speaker 4Yeah .
Speaker 3The different competencies .
Speaker 4Yeah .
Speaker 3It's a whole thing , you know , anyway . So one of the requirements was to do psychotherapy , and so I did that . I started psychotherapy in 2006 , and I've been doing psychotherapy and clinical supervision as well since that time . So it's almost 20 years now and I've tried all kinds of different approaches and different things , different approaches and different things .
Speaker 3But one of the things that stood out is the first session I attended is I really felt the need to explain to everybody else in the waiting room that I did not have a diagnosable mental illness and I was like , really , gisli , mr , non-bias , non-preditous , you know , like , hey , good for you , like I just want to . You know , there was a part of me who would stand up in the waiting room and says I know , all you people are here , you know , because you have a mental illness . I'm just here for school , you know , and I just want you . So that was a big revelation for me , because I that this bias is so deeply rooted in me that I thought I was fine , you know . So that was an early wake up call for me , where I was like , oh , really , hmm , and I have had , I've had many since that time .
Speaker 3One of the more interesting things that happened to me is I I've I did clinical supervision with a , with a great and and and uh . You know , as a psychiatrist I worked with uh and he's a . He was probably 72 or 74 or something when I started working with him and uh , he was just great , coming from uh kind of different , different and background , coming from the East Coast and thinking about things a little bit differently . And so once I was doing clinical supervision with him and I asked I've been working there for a year . It was a pretty hardcore kind of community mental health center I was working in and I asked you know his name is Jerry Kroll . So I said Dr Kroll , do you think I worry too much about things ? You know ? Am I too neurotic about you know patients and all these things ? And he said well , not , until you asked me that question .
Speaker 2You fooled him until you asked the question . I love it . I know we give ourselves away , don't we ?
Speaker 3And I was like damn it , yeah , I love it .
Speaker 2That's great .
Speaker 3Yeah , I've had a few of those , but those are two early ones that were kind of interesting .
Speaker 4I appreciate the self-reflection in particular , which that was powerful .
Speaker 2Yeah .
Speaker 3Yeah .
Speaker 2Yeah , very good , you were hinting at this . So this is a little bit more of a kind of a technical question we like to ask but what forms of therapy or what types of therapy are you kind of drawn to ? I mean , maybe kind of what did you first fall in love with and what are you kind of doing now , or how are you'd like to answer that question ?
Speaker 3Well , my first of all , I am a very poor drinker of Kool-Aid . That is that's . It's really not . I just don't like to guzzle guzzle the stuff . You know , it's really not . I just don't like to guzzle the stuff . So I don't really get these . I don't get enamored by different philosophies and approaches where I feel like this is going to work for everything . It's like nothing works for everything except oxygen and water . It's like it just doesn't . I've never been able to .
Speaker 3I often envy people who are able to get really kind of dogmatic about different psychotherapies . It's like , what am I doing wrong ? Why can't I believe in this so much ? So I'm really , you know , I just like stuff that works for people . So I have training and my latest kind of is EMDR , which is , you know , evidence-based for PTSD , where I do a lot of part working with parts as well as a part of that . So I like that .
Speaker 3But I also like supportive psychotherapy a lot . I think it's undertaught , I think it's taken for granted . I think the components that help us build up the therapeutic alliance are often neglected and we think they're going to come for free . If we learn a new , shiny therapy , the therapeutic alliance is just going to come for free somehow , that we're just going to get it because we're doing a , a shiny , fancy manualized therapy . I don't believe in that . I think we really need to work at supportive psychotherapy , get training in that , and that's what we do in our program in iceland . We developed , where we developed , a clinical training program , you know , with , uh , with a lot of clinical hours , which was one of the reasons I went to the states because there was none in iceland . But you , so I like supportive psychotherapy too and I urge people to look at that because it's so honest about just we're going to work with what works for the therapeutic alliance . Basically , we're going to do stuff that works for that and then not going to do stuff that doesn't .
Speaker 3And a lot of the work we're doing , especially with people with significant impairment or significant symptoms or in a crisis mode , we're doing a lot of supportive psychotherapy . And why not be intentional about it and honest with ourselves and other people ? What we're doing here , right ? Why do we always need to call it something else ? I mean , it has good evidence . There's clinical manuals , you can train it , you can teach it , you know you can define it , can teach it , you know , you can define it . So , yeah , I like supportive psychotherapy .
Speaker 3I like motivational interviewing as well . I've had some training in that and it just re-re-upped on my training this last year and I I feel that fits really well with uh , supportive , I like something called the , and people can gluco that if they want to . I like the y model of psychotherapy , of teaching psychotherapy if you heard about that uh , where the stem of the y is really stuff like supportive psychotherapy , motivational interviewing , therapeutic alliance , and then psychodynamic is on one thing and cpt is on the other branch of the y and and that's . You know , it's such a cool way to kind of think about this . And the most complex cycle . Even I and I do some CPT , you know , for depression and generalized anxiety as well , nothing more specialized than that , but I still use it quite a bit .
Speaker 3And I've gotten training in narrative therapy too , which came out of me . I got training in narrative therapy too , which came out of me . You know I'm a big white dude from Iceland and I just didn't have tools to work with people coming from different backgrounds and I didn't have the framework really to do it . So I did a couple of years of narrative therapy training , which you know that was back a long time ago and it was , I don't know , around 2010 , 12 , something like that . That's really stuck with me too . So different things , different things I've been interested in . Of course , my PhD is about adapting mindfulness practices . Or mindfulness-based intervention for people with traumatic brain injury and substance use disorders . Or mindfulness-based intervention for people with traumatic brain injury and substance use disorders . So mindfulness is always big with me too , although that can't be a part of psychotherapies . I was into mindfulness , like some other people , probably listening before . It was cool .
Speaker 2Before the psychologist realized it was cool and wanted to own it . It kind of clicked right .
Speaker 3Yeah , there's a lot of clicky stuff with mindfulness , yeah all of a sudden , like it's a part of all kinds of stuff and I'm like , well , I've known it , it works , for quite some time , but thank you . So , yeah , you know there's different things , but I really have this really strange philosophy about trying to use the approach that works for the patient , not just what I know how to do or what I think is shiny today . So trying to meet the patient where he's at and not just saying , well , if you don't want to do EMDR , but EMDR , buddy , you know , go over there , and if my approach doesn't work , there's something wrong with you .
Speaker 3I think a big part of what we do with psychotherapy sometimes especially I think nurses have a tendency to do this because of the strange power differential we kind of work with . But I think other professions who do psychotherapy do it too . Is we like to blame people if our therapy doesn't work ? Who do psychotherapy do it too ? Is we like to blame people if our therapy doesn't work , like , oh , he wasn't ready for treatment or , you know , like any other explanation other than us or our method or approach didn't work for that person ? Like we never like to kind of , because it's painful to do , and so so I like to be kind of of , kind of open and and sometimes I refer people out to do other things like especially specified cpt I have a lot of respect for , and not a lot of people have that training .
Speaker 3I mean , people that use cpt may not have this specific like ocd uh , cpt for ocd training or you know whatever it is . So you know , but so so I have a few different . How can I say this ? I've had affairs but I've never gotten married to one of these things . Do you know what I mean ? They're always kind of . I don't .
Speaker 2as I said , I'm a poor drinker of kool-aid that that might be the title of this episode the poor drink drinker of Kool-Aid . I love it , that's . That's a great analogy , thank you .
Speaker 4The question I was going to ask actually segs really nicely from what you said and I was on mute but laughing when you talked about like psychologists picking up mindfulness because my training is in psychology , yeah . But my question is so like why ?
Speaker 3in what ways is nursing a leader in providing psychotherapy ? I don't know if there's , yeah , I don't know , or can they be ?
Speaker 3Yeah , I don't know . Yeah , I mean for me , I mean there's no evidence that one profession does psychotherapy better than another profession . I mean you can let me just send me the articles if you've seen them . I haven't seen any data to suggest that , as long as there's adequate training , of course , and supervision involved and and so I don't , I don't really , to be honest with you I think it's just good that we have different philosophical underpinnings of people providing psychotherapy .
Speaker 3I think , uh , just everybody coming from kind of a same school of thought is not good . I think if we only had nurse psychotherapists , that wouldn't be good . And I think having somebody coming , you know , everybody coming like that's kind of the case in Iceland , where most psychotherapy is done from psychologists , which is great , but it's very hard to do something else , get something else than CPT , and I don't know if you heard this , but there are other things that work for mental illness , you know , except for CPT . I mean , cpt works , I mean , and for some things it works best , but it doesn't work for everybody all the time Because , like I said earlier , nothing works for everybody except oxygen and water . So I think I don't really see it like that no-transcript .
Speaker 3What do you call it ? Like a Venn diagram , kind of almost like a thing where you know psychotherapy is a shared competency between some different professions and providing they have the right kind of education and background , you know that quality is assured . I don't think one is going to do , I think it , and I probably think it's going to be more . When we look at data or if we would look at data , I think it's probably going to be more when we look at data or if we would look at data . I think it's probably going to be more personal you know difference than than profession . You know what profession you're coming from , but I think diversity is important when it comes to this . So I I do think nurse psychotherapy is important , but I don't think it's more important than other kind of psychotherapy .
Speaker 3Yeah , I'm sorry , yeah , I , and I'm sorry about I just don't route for nursing like a sports team . I don't Like I route for the patients . I mean I don't want to be facetious or pretentious here , but it's really the sports team I route for is the users or service users or the patients we're working with . I don't really care so much about . I mean I don't want us to do anything that's not . You know , that doesn't benefit them , you know , and I don't , I don't , yeah .
Speaker 2No , I appreciate it Does that make sense yeah .
Speaker 2It makes perfect sense and I love the diversity and the embracing of , you know , multiple field , multiple professions can do psychotherapy . I , I agree , I mean even physicians , you know they they've done it as well . Um , so it's not unique . I I will kind of maybe give some background on that question . It's just kind of you know , what sprung board a little bit of this podcast is the idea that you know there is , you know , some of us here in the United States , nurses , especially psych , mental health nurse practitioners , who are concerned about the loss of use of psychotherapy within nursing , and so I think that's why we asked the question . But I love your answer and love that you root for the patients . So my next question kind of spins off that a little bit Are you concerned at all about psych , mental health and nurses using psychotherapy or what are your ? Yeah , I mean you mentioned kind of you know everybody's got the same , you know similar approaches and things like that . But is anything about nursing that concerns you being a psychotherapist or what are your ?
Speaker 3thoughts on that . No , as long
Advancing Psychotherapy in Nursing
Speaker 3as we just have . You know , we have the same demands on nurses as we have on other professions providing psychotherapy , and I think it benefits people , some people , to meet somebody who has more kind of a can I say like a medical background or has some more knowledge of physical stuff , medications and things like that . I think we have people with chronic illnesses , for example , that benefit often from seeing somebody that has some insight and experience with that and other things , people that are on more complex medications , side effects , etc . Where I think a neuropsychotherapist would come in handy sometimes and would provide some deeper understanding in some areas . And then it's vice versa with other things . So no , there's no concern . I haven't seen any evidence to indicate cause for concern . I haven't seen any evidence to indicate cause for concern . It's more that the prescription pad is so alluring , it's so tempting and I wrote about this in one of the articles that I did and you probably read that , one of the articles that I did and you probably read that where it's just so easy to get to forget about other things . You know , and we get paid more to prescribe medications and there is this feeling of legitimacy , of course , because we get some of the glow from medicine on us as we do that as well . There's legitimacy , and a lot of nurses are looking for legitimacy for very , very kind of legit reasons , uh , so . So I think there's uh , there's a little bit of a it's , it's almost like a , you know it's so . It's so tempting to reach for that and it's such a powerful tool . So , you know , I think it was very helpful for me , because I can't prescribe in Iceland .
Speaker 3I don't have prescriptive privilege this year , and so when I moved back in 2014 , I had to kind of reinvent myself a little bit .
Speaker 3I had done , you know , narrative therapy training and basic training in some of these interventions .
Speaker 3I'd done narrative therapy training and basic training in some of these interventions , but I got advanced training in a couple of different things after I moved home and it was good and I saw that I started to think things a little differently . And you know , again , the problem is it's not . You know , I use medications quite a bit in my team and I advise on it and , and so it's nothing against that , but we know that when you have a hammer , everything starts to look like a nail , you know . And so that's why I think it's important for us I mean in our training programs , both in in europe and around the world and in the us that we continue to have psychotherapy as a core competency and using something like the y , that we continue to have psychotherapy as a core competency and using something like the Y model , where we teach people , you know , supportive psychotherapy in the very least and some basic principles of some other things , and then they can go out and get additional training and certification , like often is done with these evidence-based interventions .
Speaker 2We did find one , found a concern , and I agree I mean I totally agree that allure of , like you said , everything looks like a nail when you got a hammer in your hand and the hammer of a prescription pad is quite an alluring thing , as you mentioned as well . So , thank you , Appreciate that perspective .
Speaker 4Yeah , what do you see as the barriers for more pm hnps using psychotherapy in practice ?
Speaker 3reimbursement . That's , of course , the main thing , I think you know . First of all , lack of training in some of these programs . You know where people are kind of either don't have a competency like that although they should , of course but kind of pay up Like there's a nod to it but it's not serious , and so the students don't feel they're ready to do anything else except for prescribe and do those things when they crisis management , those things when they graduate . So that's one barrier . And the other barrier is reimbursement .
Speaker 3As we know , I had to kind of fight for being able to do psychotherapy and you have to kind of nudge things a little bit and your clinic has to give you 30 minutes . You get 30 minutes and then the 30 minutes are kind of on the house and so that's a big issue too . So you don't have these hour appointments , you do 30 minutes . You can get good at supportive psychotherapy though through that and you can use some basic interventions . But doing in-depth psychotherapy with these evidence-based models , it's going to require some differences .
Speaker 3And I talk about reimbursement because we , you know it's sometimes it may seem expensive to the institution to have us prescribers provide psychotherapy , and the psychiatrists or colleagues in psychiatry feel the same way . I know many of them . They're pigeonholed into , you know , out of psychotherapy , and these are maybe most of the brilliant and best educated psychotherapists . We have sometimes A lot of clinical training , a lot of in-depth stuff , clinical training , a lot of in-depth stuff . And our mom , you know , and uh the uh , the system doesn't allow them to to practice their art , if you will so , and it happens to nurses as well no , I thank you again and again .
Speaker 2I'm really appreciative that this kind of international perspective , at least from two different countries , um , because that's the answer I would give as well , um , for the united states , and only having that experience . So I'm assuming in Iceland is socialized medicine or do you have private insurance and such ?
Speaker 3Yeah , it's socialized medicine . It's less pressing for us because we don't prescribe , but we still need so many nurses and so it's a little bit hard sometimes to sell that role . So we have to make sure that we give them adequate training and there's always a little . Psychologists are kind of new in Iceland compared to other countries , and so they're fighting for legitimacy and standing and power as well , and sometimes we underestimate the power of nursing .
Speaker 3I mean we're really like I don't want to offend anybody , but we're really like cockroaches throughout the entire healthcare system . I mean we are everywhere and we often , you know we have power . So I think I have empathy towards professions that are not as established in the system as we are , because often when there are cutbacks and things need to change , they're the first ones to go and oh , we're just going to keep the nurses and the physicians . So I mean I have empathy towards that , but I do think it's important because sometimes we're the only ones that are there . Sometimes , especially in rural areas , especially when people are dealing with all kinds of complex chronic illnesses , and there's a need for that kind of holistic understanding of health that we have that it's important to have some nurses that know how to do psychotherapy as well .
Speaker 2Yeah , so again , appreciate your time . I'm kind of running up on our a lot of time here , so I've got one more question to kind of get you out the door . So what do you see for the future of psychotherapy within psych , mental health , nursing ? What's your crystal ball ? Tell you where , where are we heading or where are we growing ? Where do we need to kind of protect ? What are your thoughts on that ?
Speaker 3Well , the Royal College of Nursing defines kind of four main pillars of the advanced practice role and I think with the advent of the DNP programs we have in the US and maybe that will become an entry into advanced practice in a couple of years , I don't know , in a few years at least , what we have is the opportunity to make sure that the psychotherapy competencies are held true in these programs and with three-year programs we should have the time to do it . So , you know , I think we need to fight for that , not fight , you know , other people . We need to fight ourselves , we need to fight our programs . We need to kind of fight for having that understanding , because I think it matters to the patients . I think it matters that we have some core competencies and basic knowledge and maybe advanced knowledge in some cases . I think it matters for career development that we can pivot , like I was able to pivot into psychotherapy . That's my main role today and I do a lot of EMDR with people and I do a lot of supportive psychotherapy as well , some basic CPT . I use quite a bit of motivational interviewing , so different evidence-based practices . Narrative therapy is always kind of playing in the background . So you know , I think it's important all kinds of reasons that we keep those competencies in there and as well .
Speaker 3Supportive psychotherapy is the most complex of psychotherapies . I mean we use that with the people that have most symptoms and are the most complex to work with . Often , and although it's not new and shiny and fancy and the other kids don't envy us because of it it's still often the most complex work I do and I know a couple of shiny things , but still the supportive psychotherapy bit is under . It's often poo-pooed and looked down upon and I think it's a very important competency to have as well . So I think that's the future is we need to focus on the therapeutic alliance and I think we need to focus on teaching people how to establish that , maintain that , and if they're able to do that , it's easy for them to add other competencies on top of that and they'll be good psychotherapists in whatever direction they choose to steer themselves , and they're also going to be better prescribers and better crisis management people and better evaluators and better at anything that has to do with the patient .
Exploring Mental Health Perspectives
Speaker 2Yeah , thank you . Thank you for your perspective . This has been great . Your perspective , this has been great . Um , yeah , this has been . I hope anyone out there listening gets as much out of this as I do . So please like , subscribe . Drop comments . Um , happy to kind of share those information . If there's a couple of references that dr giesli mentioned , I'm happy to kind of share those as well . So , but , thank you so much for joining us and , uh , look forward to another episode coming your way .
Speaker 1Beliefs Core beliefs , reframing your mind . Negative thoughts release , let it go . These cognitive distortions decrease until they cease .
