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
How Psychotherapy Transforms Patient Care in Pediatric Oncology with Dr. Foster
Dr Kristi Foster email: kristin-j-foster@uiowa.edu
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 Kendra Delany
Email: Kendra@empowered-heart.com
Dr Melissa Chapman
Email: mchapman@pdastats.com
Yeah, just my take on things. My answer to number two decrease until they cease. Stop that discovery.
Speaker 2:Welcome back everybody to another episode of Pep Lau's Ghost. So happy for you to be here Again, keep getting these wonderful guests for the podcast and so very grateful that they're able to volunteer their time and be here with us. We are joined today by Dr Christy Foster, who I'm super excited to get to know and get to kind of. You know it's one of those interesting things for the podcast is that Dr Foster actually went through our program I was her academic advisor which you know feels like yesterday probably doesn't to Christy. She's probably like, oh, that was a nightmare and the doctoral work is just, it's an experience of itself.
Speaker 2:But we don't get this chance of just kind of talking and seeing where your clinical expertise has lied and the kind of cool work you're doing. So again, appreciate your time and just kind of look forward to this opportunity to get to know a little bit more. And again, as we like to do in Pepalow's Ghosts is really highlight the importance of using psychotherapy within the PMHNP role. So I'm going to get going right at it and kind of ask you our first question we like to ask most of our guests when did you first start getting interested in doing psychotherapy or where does that interest kind of come from?
Speaker 3:Yeah, so you know. First and foremost, thanks so much for having me today. It was an honor to be asked and I am always excited to share my career trajectory and how I ended up here. So the truth is, when I was in undergraduate nursing school, if someone had told me I would end up as a psychiatric mental health provider of any kind, I actually would have adamantly said that's not true. It was actually something at the time that I didn't think I'd have the skill set for, and I didn't. You know the individuals I was meeting I was interested in, but I felt like I wasn't sure you know how I would know how to help them really, and the drive behind me being a nurse which I think is true for so many nurses is we just want to help people, and so I felt like that wasn't clear to me, and it's been an interesting evolution as to how it became clear to me that mental health care was something that was not only something that I was capable of, but was a true skill set of mine. So I actually began my nursing career in a unit that had multidisciplinary types of services.
Speaker 3:Oncology was one of them, so I was very medical as a staff nurse ultimately decided to become a pediatric nurse practitioner. So my first nurse practitioner background is pediatric primary care, which also sounds interesting because I was working with oncology patients. But at the time I really thought that I would. What I loved about oncology was the continuity and the relationships with families and I thought I want to be able to do that for a more expansive population. But then the more I stepped away from oncology, the more I realized that that was in fact where I wanted to be. So I honed in a lot of my training specifically from oncology the more I realized that that was in fact where I wanted to be. So I honed in a lot of my training specifically with oncology and ultimately that first step as a nurse practitioner was in pediatrics. I've done oncology the entire time as a pediatric nurse practitioner and I was a medical care provider in the field for many years I think it was about eight before I made the transition and so in those times I was, you know, managing chemotherapy and the medical aspects of cancer care. But you, you know, working with someone who is diagnosed with cancer, and in my field, particularly in PEDS, these people are allowing you to what is probably the most, if not at least one of the most vulnerable moments of their entire lives. And so while I was managing these medical things, I also was developing these really strong reports with people, and I think, in reflection, even before psychotherapy training, I was integrating some things that I just didn't even really know were some natural components that I just needed more skill sets built on, and within that then I began to.
Speaker 3:One of the things that is true of me is that I constantly see gaps in care, and when I see gaps in care, I feel like we got to figure out how to make things better, because the patient is always the drive for me. So I had this amazing privilege of helping build several programs, including the survivorship program, the adolescent adult cancer program, things that were really being structured to help improve the care overall, and when we were working with those adolescent and young adults about what do you need in an AYA program without fail, it didn't matter what topic we talked about. They always brought it back to psychosocial aspects and mental health care concerns, and that was the moment that they changed my life right, and so my first interaction with Dr Weisman was actually people at the University of Iowa hospital saying you should connect with the following people. I didn't know in the moment I was going to go back to become a PM and HP, but that's where the road drove me and I had initially thought to myself well, this is so specific. You know, caring for mental health in cancer patients is so specific. You know, caring for mental health in cancer patients is so specific. I don't know if I need the entire training. And, as it turns out, you know what my mentors at the time were trying to tell me was you're probably going to need the whole shebang. They were right. And even though I work with children, I'm so glad that it was a lifespan, because when you're working with children, you'm so glad that it was a lifespan, because when you're working with children, you're working with a whole family unit, right. So you have to be able to understand all of those dynamics and if someone a parent is experiencing mental health concerns, you actually have to. I might not be the one that's treating them, but you have to be able to navigate it.
Speaker 3:So, as I was going through all of that training and structuring a program here that was going to serve not just the AYAs but all the pediatric and adolescent patients treated at Stead Family Children's Hospital on level 11, I started to conceptualize what that really meant and I knew from the get-go that the approach was proactive and it actually wasn't going to be medicine that was needed most often. But I knew that a major gap was that we didn't have anyone to prescribe mental health medication. So I knew that would that would be something that I did. But the predominant aspect of the nurse practitioner role in what is now a formalized program is assessing all of the components of the social, emotional and cognitive aspects of cancer care and the key is actually to plug people in with the resources they need, with the large scale hope that if we can avoid medicine, that would be ideal. But very early on in me making this transition I knew that even if medicine was indicated, it would always only be the bandaid and the bandaid would be there. But we needed to have the other aspects psychotherapy, a huge piece of this to make sure they learned how to cope with the reality of the situation they faced. Sure they learned how to cope with the reality of the situation they faced.
Speaker 3:And you know my pathway in learning psychotherapy was so interesting because even before I was back in the PNHP program I was taking courses on CBT, going to training sessions and and learning the nuts and bolts of thinking. How do I put this? For example, how do I take CBT, where the goal is to reframe thoughts that maybe aren't true and say have somebody use that when they're actually fearing that their cancer might come back, when we can't say that that's actually definitively not a true thought? So it was interesting to get different experience and expertise from different places and as this program grew I realized that when I thought mostly my job was going to be assessment and medicine, what many of these individuals actually needed was the brief integration of therapy, because so many people are scared at the idea of therapy.
Speaker 3:So if I were to immediately recommend let's get you connected with a therapist that can help you cope with this, I actually often got told no.
Speaker 3:And when I gained skills and became more, you know, effective with the actual skill sets I was using, not just using something that came natural to me, I then was able to say, after we had this great rapport built and we had done therapy that that this 16 yearold didn't really recognize we were doing, and then I suggest let's try to get you connected with somebody that has the capacity to see you weekly, because I think this would be helpful. They will still say I don't think I need a therapist and I can say let me ask you what it is you think we've been doing and I educate them right. And so it's been a cool evolution of how you integrate this, how powerful it is and and how this proactive approach where you can briefly integrate therapy strategies and get somebody to be more on board with really accepting those pieces as really critical components of their care, has been neat to see and it's really helped structure things.
Speaker 2:Christy, I hear your passion just pouring out of you. It's amazing, and you're right. This is such a vulnerable population and again, it's you know it's. It's like being a being a part of the club that no one ever wants to be a member of, and so this is, you know, a parent's worst nightmare in a lot of ways. And so, yes, being able to, to be there in that moment as you were talking, I just kind of was like. You know the person I hear right now, I would love to take a time trip and go back to that undergrad student and be like, no, just take some more psychology classes.
Speaker 4:You're going to love it. It's going to be good, so that's great, thank you. Yeah, you bet. I would love to hear more about a time that you perform psychotherapy. That's memorable so maybe it's the first time, or maybe it's just you know. Stands out for some particular reason, a story that you might want to share about performance psychotherapy.
Speaker 3:Yeah, you know, I mean there are so many great snippets that have, and again, a lot of it goes back to the, to the brief integration, where you know individuals who are proactively visiting with me because you know it's, it's a part of your cancer care. We have to just make sure that these cognitive pieces are, you know, okay, you're not starting to struggle with learning or focus attention. So much of it is about the idea that I can educate these individuals about just some of the strategies that we've been doing, not in a way that like I'm trying to trick them and do therapy and not know it, but just you know they are engaging with me and finding things helpful. So so many of them are are small snippets in time where it wasn't a 60 minute psychotherapy session, I think sometimes as nurse practitioners we forget that. Right you, 15 minutes of. Of. You know structured psychotherapy work can be so impactful and and so I think those things are so amazing. But because I dabbled in so many different types of therapy as I was trying to learn, one of the types of therapy that I have found very impactful, especially in survivors of pediatric cancer, is narrative therapy, and there's actually an adolescent adult journal that has been made for survivors by a nonprofit organization called Elephants of Tea, and this journal actually has prompts that are meant for narrative therapy to be done either independently by the person or with a professional to guide you. So I took a course on that and have utilized it with only a few individuals, because with my capacity I often don't have the ability to do really frequent sessions that are dedicated to therapy. And that's just with the structure of our program.
Speaker 3:But these are individuals that there was no other way in which they were willing to open up, and most of them they have an artistic flair and so just kind of getting to know the person right, and saying, all right, what kind of thing is going to be effective for you? And the one individual that I can think of that really has been impactful is that this is now a young woman who's in her mid twenties, and when she she was diagnosed, when she was a senior in high school and she literally wanted nothing to do with me when we first met and so we meet people where they are we kind of backed off. The proactive approach is really to plant seeds and eventually she actually circled back herself and it did not begin with therapy straight out of the gates. It began with this uncomfortable question of I know, I know that my friends so and so and so and so have worked with you, which I obviously can't acknowledge. I just listen, right, and they say it's really helpful because you understand things about cancer care, and so then she had to start to sort of open up. But she still had this block, like I can't talk about cancer, but I know that's what I'm here to do.
Speaker 3:And so we engaged her with these prompts and the way that she opened up, based on these narrative therapy prompts, which then also resulted in this beautiful you know I had her go out and purchase something that was going to become the forever the theoretical let's process it and put it on the shelf, and she could physically do that, and that was very helpful for her. And the journal is in a style in which I really like. They have holding on to prompts and letting go prompts, so it allows people to see some of the beauty that occurred, the positives they gained throughout the experience, and the things that we want to let go of, and it alternates them so that you are not hammering in on the all of the things that were so overwhelming. You are actually finding the gratitude and finding the you know, the silver linings within what has thus far been the worst experience of your life that you haven't even been able to talk about.
Speaker 3:So I've seen some really beautiful things unfold, and that young woman in particular will be one of those that you never forget how it all happened my goodness, thank you for sharing.
Speaker 2:I just could feel myself physically like responding when you shared that yeah, yeah, thank you, christy, it's, uh, yeah, I mean it's, it's one of those things. I mean it's, it's um, I would say it's a privilege to be a part of someone's journey, but I mean, you know, the delicate time that you're dealing with these people has just got to be you know if it's something, and again hear your passion coming up through the screen or through the screen, through the, through the audio. It's definitely there. But the next question I'd like to ask it, cause you've kind of you know we talked a little bit about your different forms. You had CBT and narrative, which is great, and I'm sure you're kind of expanding on that too. But what about nursing? Kind of, how do you see nursing as as kind of you know, a leader in doing psychotherapy or you know even talk about within your program that you do work with? I mean, do you see? I mean, how do you see nursing being kind of just ideal as a profession for that work?
Speaker 3:Yeah, absolutely. You know, I think the vast majority of nurses enter the career because by nature of who we are, we are people who care right. So oftentimes that component is present, which is something you can't teach to people right. And so I think nursing as a field because it is so often that the person just has those natural elements of what it takes to understand the social cues, understand when it's time to push and when it's time to pull back, those things I think are what makes psychotherapy so successful, because if you don't know how to ebb and flow those, then you may lose your client pretty quickly. So I think, just you know, the general individuals that tend to lean into the world of nursing have some of those natural qualities that make a really great psychotherapist a really great psychotherapist.
Speaker 3:The other thing that I think and you know my passion certainly you know started off in the oncology world.
Speaker 3:But what I've realized now and I actually tell many of my patients to date that if I ruled the world I would have everyone go to therapy at least once every two weeks, because we all have something to process and talk about and of course I'm usually telling people who are still on the stage or they're rolling their eyes at the idea of, you know, going to therapy.
Speaker 3:But I think when you think about what I do in cancer, it is really relevant to all chronic illness and the vulnerability and fears that come with it, and I think that's true across the entire lifespan. But PEDS has always been my passion, so my deeper goal is to not only build what's happening on oncology here but also replicate it for additional pediatric chronic illnesses, because I think one of the things that is very relevant from a nursing perspective and delivering therapy in chronic illness is that we also speak the language of you know. We know what it is when you get stuck in the hospital for three days and we know what isolation means and we know like we can speak some of those like your blood gases were down. One is that I've tried that and I just need somebody who I don't have to explain what I've been through to just know they understand. And that's what happens here and I think that is something that nurses by and large can offer individuals, especially in the chronic illness domain.
Speaker 4:So then, thank you for sharing that. On the other side, do you have any concerns about PMH nurses using psychotherapy?
Speaker 3:And if so, what would those concerns be? You know, I'm not sure I have any concerns other than the idea that I know that programs across the country are really, you know, developing and making sure they're getting the right components in. The only concern I would have is that I think nurses have the natural skill sets to do this, but they need to be able to know how to do it in a structured way. You know you need the education, right? So, like I said, I think I was naturally implementing some things, but I didn't know the evidence behind it. I didn't even know I was doing some of the things, and so I think we have to be able to learn that and understand the impact that it has for people, because sometimes I think I was doing it and I didn't know the impact it was going to have, and it's possible that the impact was negative, right. And so I think that learning the skills and making sure that we have the correct training to do so would be the only concern.
Speaker 3:But you know, I'm at the University of Iowa and not only have we come, you know, so far in the moment, I first met Dr Wiesman, but now I'm faculty over at the College of Nursing as well, teaching people about the amazing world of being a nurse practitioner, and what I see is that, at least at Iowa, that's being focused on very much is we have, you know, a PM, and HP has the skill sets to do this. They have the training and we have the ability to integrate it into our practices, but we need to be sure that people aren't integrating it into practice without the training behind it, and so that would probably be the only concern that really comes to my mind.
Speaker 2:So I guess I'm going to Venmo you $20 for the plug. I appreciate that.
Speaker 2:Yeah, no, it's been fun to kind of keep getting to know you as you move into kind of a faculty role here too. So again, appreciate all your time here. Just kind of maybe finish up with a question. Pull out your crystal ball. What do you see as the future of using psychotherapy within the role of the PMHNPs? Maybe you know what opportunities are there, what barriers continue to be? You know, what do you see from your vantage point and your population that you serve?
Speaker 3:Yeah, oh man, the opportunities are so big, right. If you rewind, 10 years ago, I didn't know that nurses did psychotherapy. I didn't know that any of this was a thing. I was finding gaps and doing things over here medically, and now it's like the future can be so bright. Gosh, I don't know. I mean, I think as long as programs structure in the appropriate training or give individuals guidance on how to get additional training beyond school so that they stay savvy in their skills, I think what you will see is that right now it seems to me I don't know if you remember this, dr Wiesman when I was in school I was like, wait a minute. Are you saying that I can actually, in the same visit, acknowledge the service time I have spent on both assessment, medication and therapy? And I think that while maybe PMHPs are coming out of programs know that I'll tell you right now.
Speaker 3:I had to teach the Department of Pediatrics what codes I needed.
Speaker 3:I had to teach them that I are going to be able to teach the psych mental health world that, while we still need all of us to holistically care, we have been a missing link for a long time. You hear me say that around here a lot, because what I learned as I was structuring this program was a psychologist has different ways that they're able to provide services, you know, submit things to insurance companies. A licensed independent social worker has different ways and a nurse practitioner has different ways. Chime in on all of our top tier skill sets right, using your scope of practice to its max, and be able to create what then becomes very sustainable programs. Because the number one thing that the institution here was concerned about, with me moving into the mental health space, was that there was no way we would be able to sustain it. We, you know it would be something that we would be able to sustain it. We, you know it would be something that we would have to have grant funding, and that actually has not been true at all.
Speaker 2:That's great. I mean again that that highlights your again. I think people just feel your passion. But you have, you're driven, and so people pick up on that too. But I definitely have to go back. You know, if, if, if anybody says you know, the future is so bright, they got to say I got to wear shades, and so that statement just has to be said. Anybody listening with a birth date, with a one nine in front, you get it. If not, then you probably need to go Google that. But but yeah, no, I like how you said this, chrissy.
Speaker 2:I mean all the, all the disciplines need to be complementary here. I mean there's plenty of work out there. I mean Dr Sean Convoy, who's part of this podcast times two, that's what he's. You know there's no need to kind of compete for the patients. I think that you know patient A is going to maybe do well with a psychologist, patient B is going to do well with a social worker, patient C is probably going to do well with the PMHMP. So it's our job to kind of, you know, line those patients up to find the right providers. But we're all doing the same work. We're all kind of on this fun ride.
Speaker 2:But again, thank you very much, christy. It's been a pleasure. I wish we had more time. Maybe we can come back for a part two, who knows? But thank you so much again and thank you all for listening to Pep Lau's Ghost. Get ready for another episode coming to you soon and feel free to subscribe, like and comment. We do listen to that and we do like hearing from you. So have a great day. Thank you again, dr Foster, and take care everybody else.
Speaker 1:Thank you. Reframing your mind negative thoughts release these cognitive distortions decrease until they cease. Yeah, gotta discovery Identifying, challenging your beliefs. Reframing your mind negative thoughts release these cognitive distortions decrease until they cease.