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
When Pills Aren't Enough: A Candid Conversation with Dr. Tari Dilks on Psychotherapy's Vital Role in Mental Healthcare
What happens when the art of psychotherapy gets pushed aside in favor of medication management? In this thought-provoking episode, we're joined by Dr. Tari Dilks (taridilks@gmail.com), retired full professor and past president of the American Psychiatric Nurse Association, who shares wisdom from her remarkable 50-year journey in psychiatric nursing.
Dr. Dilks takes us through her evolution from mental health technician to licensed professional counselor to advanced practice nurse, revealing how the therapeutic relationship became her north star. "Psychotherapy is curative," she asserts, recounting a 15-year journey helping a patient with dissociative identity disorder achieve full integration—a powerful testament to therapy's transformative potential.
The conversation delves into the challenges facing psychiatric mental health nurse practitioners today, where employers often hire advanced practice nurses solely for medication management rather than comprehensive care. Dr. Dilks worries that the art of psychotherapy in nursing could disappear under financial pressures, despite research clearly showing patients benefit most from combined approaches.
Perhaps most moving is her candid discussion about working with suicidal patients when other providers refused. "Who does then?" she asks, sharing a poignant story about giving a chronically suicidal patient and her family "extra years" together. This perspective challenges us to reconsider how we approach risk, liability, and the true meaning of patient-centered care.
For clinicians, Dr. Dilks offers practical wisdom: develop an eclectic therapeutic approach, recognize when you need your own therapy, and find powerful ways to disconnect (like her preference for scuba diving where "nobody can talk to me underwater"). For educators, she emphasizes the critical need to help students experience psychotherapy's power firsthand.
Whether you're a psychiatric nurse practitioner, mental health professional, or simply interested in the therapeutic relationship, this conversation reminds us that beneath all our clinical tools and interventions lies the fundamental healing power of human connection.
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 number two welcome back everyone. Thank you so much for joining.
Speaker 2:Welcome back everyone. Thank you so much for joining Peplau's Ghost again another week and another fabulous guest that we get to talk to a little bit here on our Friday afternoon For us, kind of sending us into a glorious weekend that we hope is finding you in the same condition. So I want to say thanks again for all those who are listening and subscribing, commenting to our podcast. I think we're getting close to a thousand downloads, so I'm really excited about that number. We've been kind of coming out weekly here in 2025. We're going to take a little bit of a break. We're going to have a couple of weeks here. I'll be doing some traveling and so we'll have be coming back in a few weeks. So those of you who are desperate and dying for the next episode, hang on there. We're going to come back to you soon, but without any further delay.
Speaker 2:I'm going to introduce our next guest here, dr Terry Dilks. Dr Dilks is a well-established psych, mental health nurse practitioner Very similar to myself. She kind of came into nursing she was a therapist before she found nursing I always say found the light and just kind of stayed here and has been just an amazing professional and academic. I don't have much of an introduction for her, but maybe she can kind of share some of her experiences. But I will share that. She is currently a retired full professor and also was the past president for the American Psychiatric Nurse Association. So that is a big feat in my mind and takes a lot of things to do and, yeah, I'd love to hear some more stories about all the things that you went through in the APNA presidency and so, as I'm kind of moving into my own presidency and ISBN, so exciting and yeah so, but let me get started with our question right out the gate when did you first get interested in psychotherapy?
Speaker 3:Well, I started in nursing first, then went to therapy and then went back to advanced practice nursing. So when I was in nursing school a long, long time ago, we had a, we were at an adult psychiatric facility and one of our instructors decided to do some drama therapy with us and I was just like, wow, this is so cool. You know, this is. I wonder if this is something that you know I could learn to do at some point. And so that kind of piqued my interest there and, as I, you know, thank God for psychiatric nursing, because I didn't really want to be a nurse. I just, when I found psychiatric nursing, it was like, yes, I was home.
Speaker 3:And so my whole career but with very few interruptions has been in the field of psych, starting as a mental health technician and then moving my way up, you know, to a head nurse, to a director of nursing, to getting a master's degree in psychology which was focused on psychotherapy, and I have dropped into so many things. Louisiana decided to go with an LPC, a licensed professional counselor. I had not completed my degree quite yet, but I had all of the classes I needed to have and I had the experience. So I was licensed as an LPC for 35 years. I just gave it up a couple of years ago, so great fun.
Speaker 2:Awesome, I'm sorry about mixing up your timeline. I apologize for that, but very similar. Like I said myself, I had to come to nursing I guess I started off in getting my MSW and very similar to you kind of let the license go and, yes, thank goodness for psych nursing. So, yeah, so, thank you so much. Appreciate it and I am going to apologize again the second time. Maybe I'll do this a number of other times, but I didn't introduce Dr Sean Convoy from Duke, who's here, so we're going to hear from him next. So sorry about that, sean.
Speaker 4:All good. My friend, terry Dan, asked you a question kind of big picture about kind of your experiences professionally. I'm going to ask you to kind of focus your lens a little bit on an experience with a patient that kind of illustrated to you that what we believe here in this podcast to be the secret sauce of psychotherapy Was there, a unique experience that told you, oh my God, this is lightning in a bottle.
Speaker 3:It. Yes, I mean there were many, there were many, I mean there were many, there were many, you know, but the ones that stand out are the ones I did with folks who had disassociative identity disorder, you know, and so you had to pivot very quickly to different types of psychotherapy, that diagnosis. Of course, people either believe in it or don't believe in it. But once you've seen it, you've seen it, Psychotherapy is curative and that to me was an amazing thought that you know I could cure this person with their help, or they could cure themselves of dissociative identity disorder. And one of the ones I worked with for the longest took 15 years, but then she totally integrated.
Speaker 3:I hear from her periodically. She got a bachelor, no, an associate degree, a bachelor's degree and a master's degree while we were working in therapy. She had had to relearn some things because she had a couple alters that wanted to hold back and not let her have information like basic math. So it was. It challenged me in so many ways, you know. It was like well, like well, I didn't. I had never been trained in how to work with this, so I had to look it up, I had to research, um, but I, there was nobody who was doing that type of psychotherapy near, so it was. It burned me out in the long run, but man, it was good work terry I, I, I.
Speaker 4:I'm gonna bring this back to Dan and let him know that we just found the tagline for this podcast around the line Psychotherapy is curative. Yeah, yeah, let's kick it back to you, my friend.
Speaker 2:Thanks, sean. Yeah, no, can we kind of maybe kind of spend, because I know that's one of your areas of expertise is working with people with dissociative identity disorder you mentioned. You know you have to be very flexible in kind of moving your approach depending on the altar and things. Is there any you know like one or two forms that you found to be most beneficial? You have to be just a real kind of I was going to say magician, but you know kind of really have to be very skillful in kind of picking and choosing the form of therapy that works best for that individual at that moment.
Speaker 3:Right, right, my background is in Rogerian psychotherapy, so a humanistic approach, and for me that is the basis of how I interact with patients. You know, just this acceptance of who they are, where they are. And it bothered some of my patients because I wasn't directive enough, you know. So I wasn't going to fix them because I didn't tell them what to do. And you know, in humanistic psychotherapy you don't do that.
Speaker 3:And as I grew as a therapist, I added in CBT, emdr, you know, some other types of psychotherapy that you know that I just everybody is different, everybody that you see is different. So you can't have a one size fits all approach and you also have to recognize that you may not be the right person for that particular patient at that particular point in time. You know. So when I didn't fix this, the one that just keeps ringing back in my head, you know you're not telling me what to do it. It meant, you know, let's refer this person on to something else and somebody else. So, but the rewards are just incredible. The rewards are incredible with this.
Speaker 2:Yeah, I I have been fired more than once for a patient to wanting to be a little more directive and tell them what to do. Yeah, it is kind of a thing. It's a shift for people, right. They sometimes come in they expect you to kind of take all their problems and just kind of give them like a new car, Like you know, it's like I'm gonna give you a whole tune up and then you're gonna go out the door and you're gonna. It's a very, you know, some people it's a shift, Some to shift, Some people it's not. They come in kind of ready and knowing it's a. I think that's why I always like to say it's a great time to be a PMHMP, because, I mean, I think people have a better understanding than they ever have of the importance of mental health and taking care of themselves, so, so that's great. That eclectic approach is, yeah, very valuable.
Speaker 3:I told people I had several magic wands and a couple of crystal balls which I do. People I had several magic wands and a couple of crystal balls which I do and none of them work. You know, it's that we have to work together and I always see psychotherapy as a joint journey. Right, it's not being in the front, it's not being in the back, it's, you know, the guy on the side, kind of colloquialism, but that's what it is, what it is, you know. And other piece to that is learning not to take it home with you. You know, because you, you have that journey, you're privileged to be a part of that journey, and sometimes the stories can be overwhelming.
Speaker 3:And so, you know, one of the things that I've learned is I go back to therapy periodically, you know, because I really think that, you know, all of us need it at some point in time, but also to take really good vacations. You know, like one of my favorite things to do is scuba dive, and I tell people it's because nobody can talk to me underwater, right, I just hear these rhythmic bubbles going up. And so I think that's important for anybody who does psychotherapy, both of those things to recognize when you need to go back into therapy and now there's so much available. You know it's hard to go to therapy in the town that you live in because you know everybody, so but with the internet now and you know virtual experiences, that really helped me a lot the last time I went into therapy. You know it's important.
Speaker 4:Terry, I am thinking about. You know your lens, as both a clinician as well as an academic. I'm interested to kind of understand from your perspective. I mean, we all recognize that this is part of our skill set as advanced psychiatric nurses but we recognize intra professionally that's not necessarily always accepted, necessarily always accepted. Do you think we can kind of help fortify the next generation of advanced practice psychiatric mental health nurses to be able to kind of practice at the top of their scope where psychotherapy is as formidable a tool as their prescriptive?
Speaker 3:You know, I think that we don't spend enough time on it. I mean, I had a certain number of hours and that was with me kicking and screaming and saying this has to happen, you know, and I think the other thing is that our, our students Hopefully they realize it, that this is important. I used to have them get a self-help book because I couldn't make them go to therapy, right, and they worked through the self-help book and it was amazing how many students said that was the best part of the whole program. And one of them told me he didn't do the assignment. He said I didn't realize I'd have to look at myself. Well, you know, that's the heart and soul of psychiatric nursing is knowing who you are and knowing what it can do for you. So I think we have to be better at getting people engaged in it and finding ways to get the students involved in seeing the power of it, but also really telling them that because you have a license to do it doesn't mean you're qualified, that you need to go seek further certification and then practice it. You know a lot of our students.
Speaker 3:I don't know about y'all, but our students were hired to do med management. I mean, that's really the only thing that they wanted to do. I mean, that's really the only thing that they wanted to do, but it's so important, Even med management, you can incorporate psychotherapeutic skills and you may not choose to be the primary psychotherapist for a patient. I couldn't stop doing it, you know, I just, I just could. I tried to do the real quick med management visits and it was like no, no, no, I have to do the therapy part of it, at least get engaged a little bit in it. So I don't, you know those of us that have sought further training and have become qualified. I think that that becomes a part of who we are. And there's just, I was at an art class yesterday taking some watercolor classes, and this lady across the table said to me she said it kind of creeps me out that you're in psychotherapy stuff because I think you're just analyzing all of us. I'm sure y'all have gotten that kind of reaction before.
Speaker 4:I do, and I commonly tell them no, I'm really just considering what I am getting at Costco later. So the world does not revolve around you.
Speaker 3:Right, and I told her unless you're paying me, I don't do that.
Speaker 4:There you go. I want to just kind of highlight and elevate you made reference to the idea about, you know, students and nurse practitioners getting their own experience in psychotherapy. Thank you, thank you, thank you. I think we are the biggest cynics in the world. We don't think we could benefit from that which we actually provide ourselves. So thank you for that observation.
Speaker 2:Yeah, thanks, I mean this has been great. I love this conversation where it's going. It's, you know, because it is. And one of the things I think that we have been for myself even kind of on my own journey just recently is beginning to think of psychotherapy not just as an intervention but also as a tool that we use for our assessment, we use for our outcomes. You know, it's a framework, it's the. I think, like you said, terry, it's just kind of how it's everything you do, I mean it's everything kind of goes through that lens, and I've had those kinds of experiences too. You know, you kind of talk to people and it's like oh no, I don't do psychotherapy, I don't communication, and so so I think we've been talking about this a little bit, but I've just kind of maybe kind of draw a finer point to the question. You know, are you concerned at all about psych, mental health nurses using psychotherapy in any way? Or maybe, what do you see as maybe the barriers of psych, mental health nurse practitioners using psychotherapy?
Speaker 3:the barriers of psych mental health nurse practitioners using psychotherapy. The barriers are the employers for sure, because really they're hiring psych mental health nurse practitioners just to do psychopharmacology. And then also whether or not we as educators get through to them about how important it is. The other thing is I have seen people who just decide they're going to do psychotherapy and they don't seek any further training. So yeah, I'm going to do CBT. Or, for instance, the drama therapy I was talking about earlier.
Speaker 3:I had a nurse that worked on an addiction unit that was doing that with the patient. She had no training, zero insight into what she was doing and of course she caused some ab reactions and she just shut it down, you know, and that is not fair to people. Or you have therapists or psych NPs that say, well, I can't work with this person, they're suicidal, I don't want to be responsible for them committing suicide. Well then, who does? You know? It's we.
Speaker 3:I had a patient one time that every person I consulted with about her said to drop her, said to fire her, and when she came to me she told me that, um, that she had been fired by every psych provider she'd ever had. And I thought, well, I told her, I said, you know well, I'm, I'm gonna work with you as long as you're willing to work, you know, and and for some people you know that willingness to work means they get stagnant for a little bit. And and that's kind of what she did. And I referred her to a therapist. She was one of the people I knew would kill themselves at some point in time, you know, and I referred her to a therapist who fired her because she was suicidal, you know, and was worried about getting sued for it.
Speaker 3:And the story I've told this story, this story, dan, you might have heard it already. She ultimately did kill herself, ultimately, and I worked with her for three or four years and at her funeral, both her husband and her father came up to me and thanked me for giving them those extra years. And so you know, it's kind of it's hard to have a patient that chooses to kill themselves, but it also is, you know, sometimes we just put it off for a while and that's okay. You know to be okay with that.
Speaker 2:Thank you, Terry, for sharing that. That's wow, yeah. And again, this is hitting home to me too. I mean, yeah, I've had a.
Speaker 2:I remember a psychologist I used to work with. She would say that I don't want to be that person's last provider and it's just kind of like that's an interesting way to frame the idea that you don't. Yeah, I mean you're going to take extra precaution or maybe you're going to kind of refer them out when things get too too deep and things that's um, that's interesting. And then I remember psychiatrists used to work with who wouldn't restart their medications because they overdosed on my medicine, Um, so kind of taking it as a personal affront that they overdosed on this prescription that they wrote, so, um, which I've never kind of, you know, it just doesn't, I guess, click with me and I, I love it. It is one of those things we talk to our students about this a lot is that you, you do this work. You're going to. It's not a matter of you know, if it's when you're going to, you're going to work with someone who, unfortunately, either very closely attempts to suicide or they actually complete it.
Speaker 3:So Right, and didn't that psychite? That sounds like so much a patient blaming to me. You know, I go on these kicks of whether they're compliant or noncompliant and I tell people, I told all my students, you know, when you get in that space, the person that's noncompliant is you, not your patient. You know, to reframe it, that there's something that we're not doing right to help them. We haven't figured it out yet, we haven't walked in their shoes enough to know what they might be willing to do. You know, and so it's. I really hate those words, you know, but I really think it's a challenge to us as providers that when we get that person that you know, we continue to work. You know why are we just dumping people off? Just because we're afraid of what they're going to do or that they're not following through with what you say they need to do?
Speaker 4:Yeah, I agree, terry. I think in many regards the sequela of patient-completed suicide is better conceptualized as provider countertransference. Yeah, and that's an opportunity for us to kind of do our own work, to kind of get better insight and understanding mental health clinical nurse specialists over the years who said that you know, if you are, if you can't control outcomes, you're not necessarily independently responsible for said outcomes. That you know, at best sometimes we have the possibility of influencing patient behavior but we don't get to control them and if you can't control them you can't take disproportionate responsibility for that.
Speaker 3:Right, right, because it really hits home sometimes. You know, I'm sure you all remember the first patient that you worked with that killed themselves, and then thinking about what do you do with those emotions. You know what do you do and you're right, it's a kind of transference. It's I have failed in some way and and you haven't. This, this field. That's just one of the things in this field that if you, if you go through a whole career, like I realized recently I've been in this field 50 years today, or this, this year, yeah, um, if you go through it and you don't have a single person kill themselves and want you know that, I just I think that means you're throwing people off.
Speaker 4:You know, just to me, I'll throw this message out to the audience If you have not read before or when you're interested in this discussion, that Dr Diltz has taken us. A wonderful, wonderful book that significantly influenced my thinking around suicide is something called Night Falls Fast from Kay Redfield Jamison. She's kind of a premier thought leader in this area of understanding suicide and I remember in her book she talked about this idea that we try to take disproportionate control over the decision. Right, we recognize sometimes patients who are psychiatrically hospitalized. There's a peak in completions of suicide post discharge because we go from hyper control to no control. So her philosophy isn't necessarily to fight that control, it's just merely to shift the risk to the right to look for other opportunities before you make that declarative decision. Because ironically, as clinicians we try to take control of that decision and that's kind of a fateful decision because, quite frankly, unless we're going to view with them and keep them in the hospital for the rest of their life, we can't control that right.
Speaker 4:So, what you're talking about seems to be really kind of pattern after what I've read from Redfield Jamison. That's high praise in my book, my friend.
Speaker 2:Yeah, I'll just kind of piggyback. I mean it has a lot of thought for me too about, unfortunately and again, if somebody in the audience is listening to this as well, just take care of yourself. As you mentioned, terry, too, when this happens, again, as we mentioned, make sure you take care of yourself, because unfortunately I've had those experiences where the system doesn't very well take care of that provider. I've known again a psychiatrist who was working inpatient where a person was actually able to hang themselves in an inpatient unit and I remember kind of the administration and the system really came down hard on this psychiatrist and it was, and I just felt so bad. I mean I wasn't in a position to kind of offer much help for that person. But you know, it was one of my regrets a little bit of why I didn't kind of reach out at Olive Branch and say are you okay? Because this is, you know, obviously a personal journey. But then we have this professional idea of you know, how do we, how do we take care of this?
Speaker 3:And so, yeah, it's and the liability is, you know, is there and you know. So from a hospital system standpoint, they have to have somebody point the finger at right and it you can't control it, you know, you just can't control it.
Speaker 2:Yeah, and one of the things that shifted for me a little bit and you know, this doesn't this isn't the whole journey, but it is something that I think about now more often too is that, you know, only in psychiatry I feel like we blame the clinician or we blame the patient. You know, if we're treating like an oncology, you know we administer a chemotherapy, radiation. If they don't respond to that, we don't blame the patient. You know, maybe we do sometimes and say they should be eating or exercising more. But but really I mean we look at, well, they had the wrong chemo or they had the wrong radiation, or you know that just didn't, that type of cancer, just didn't work, yeah, yeah.
Speaker 2:And sometimes they pass away right, I mean, and then so it's a very it's a lot of's, a lot of parallels in my mind and again, that idea that we may be providing the best care, the perfect care for that patient. Patient may not be ready, or or maybe we're not, maybe we're not the right person, maybe they they live in rural Iowa where they you know providers are 90, 100 miles away, and so, yeah, so it's one of those things.
Speaker 3:One of those things and you know, one of the things that COVID did do was it had hospital systems looking at how could they support their nurses or you know the people that are there, and so they began to provide a place for nurses to either have therapy or to talk about it or to try to work through those feelings, and I don't know that that has continued. But that was a real blessing for some of those nurses. You know, to have so many people die and not be able to do anything, you know, so to me it was a little bit of a parallel that we get with patients who kill themselves. But I hope that they continue that, because I really think that nurses, no matter what kind of nurse you are, that they need some support and they need to work through some of the things that they see with their patients.
Speaker 2:Absolutely yeah, their patients, absolutely yeah. I cynically say always when I and I've got several nurses that I'm currently seeing as patients, I would say nurses make the worst patients. But that doesn't mean we abandon them and kind of turn our backs. That means, just like you're saying, we need more services, we need to, you know, meet them where they are. You know kind of have those counselings for those third shifters and you know second shifters where you know it's, you know second shifters where you know it's, you know helping out. And again, I think telehealth has been one of those things. I steal this line from Sean Before telehealth, you know telehealth was a bus and if you didn't run on the bus you're going to get run over by it. Now it's. That's a foregone conclusion, right? I mean we're in that bus and that we're just trucking down the road with telehealth, which is in one of those silver linings of COVID in my mind.
Speaker 2:So we're kind of wrapping up on time. But I got one more question for you, terry. What do you see as the future of psychotherapy within psych, mental health, within nursing, and what's your crystal ball? You mentioned crystal balls that you've got. What are they telling you?
Speaker 3:I'm worried that it will go away. I'm really worried about that, that this know to me the psychotherapeutic aspect, the therapeutic communication, that's the art of nursing, and I worry that we're going to miss or get you know, be made to not do psychotherapy anymore because it's not financially viable. You know it, just as I worked as a therapist, you know I had these 50-minute hours and it was great, but I didn't make as much money as somebody seeing patients for PsychoPharm where they could see 15, 20 patients a day or more. Some people are being forced to do more, and so I'm worried about it. I'm very, very worried about it.
Speaker 3:It's, you know, pills are not always the answer. They help with some, but if you don't combine it with psychotherapy I mean, we know the research the research says that people do better with both, you know. And so how can we? I think we just have to keep beating the drum and telling you know, our nurses, that this is important. This, more than the psychopharm, is what's going to make, make or break you. Because if you don't have that, if you don't have those connections with the patients, they're not coming back, you know. So you lose the financial incentive there. I don't know if that made sense at all.
Speaker 2:But you know, no, yeah, thank you, I think that made perfect sense. I mean, it's, I think you're in, you're in good company here. I think we're all terrified of that kind of future of you know where does this go, I think, when you talk to people, though, it's, you know, as we get more into more AI and how AI is going to be incorporated into health care, I think we need to kind of continue to urge against this idea that we do get relegated to like a kiosk, this idea that we do get relegated to like a kiosk. You know, you don't just come into the office, or even on your iPad, just kind of, how are you feeling today? One to 10, blah, blah, blah. And okay, we're sending your script to this pharmacy. There's more to it than that. I saw that. Look, sean, that was a growl. I saw it. That's good, but yeah, it is. Yeah, thank you, terry. I appreciate this and I appreciate everybody kind of hanging on listening to this. I've gotten to some deep stuff and please make sure that you like subscribe, send comments.
Speaker 2:Love to hear from you and you know any future topics people want to talk about as well. Love to hear from that as well. So thanks so much and take care.
Speaker 3:I appreciate the invitation. Thank you.
Speaker 1:Thanks, sarah. Challenging your beliefs or beliefs frame in your mind, negative thoughts release. Let it go. These cognitive distortions decrease until they cease. Yeah, got a discovery.
