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
Similarities Within Differences: A Conversation with Dr. Beth Phoenix
Dr. Beth Phoenix, the 2023 APNA Psych Nurse of the Year and APNA past president, shares her insights on psychotherapy in nursing practice, challenging traditional views and advocating for a more flexible, pragmatic approach that extends beyond the conventional "50-minute hour" model.
• Group therapy empowers patients through connections with each other rather than solely through therapist interventions
• The impact of universality—discovering you're not alone with your problems—is profoundly therapeutic in group settings
• 69% of advanced practice nurses combine psychotherapy with medication management
• Nursing leads in flexible application of psychotherapeutic techniques across various healthcare settings
• Psychotherapy doesn't require a full 50-minute session—effective techniques can be integrated into briefer encounters
• The "fixer" mentality from acute care nursing must transition to a facilitator role in psychiatric practice
• Advanced practice psychiatric nurses should claim more ownership over their psychotherapy skills
• Evidence-based psychotherapies have a strong track record and should remain integral to psychiatric nursing practice
Subscribe to Peplau's Ghost for more conversations exploring the intersection of nursing practice and psychotherapy.
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. It's not a discovery, identifying a challenge in your beliefs or framing your mind.
Speaker 2:I think we're recording. Welcome everybody to Pep Lau's Ghost Another exciting episode here. As we move through the summer, hopefully you're enjoying some warm weather wherever you may be, but really excited to have our next guest here, dr Beth Phoenix, who's going to be here and sharing her views on using psychotherapy and kind of her general experiences. And such Really pleasure to have Dr Beth Phoenix here on this podcast. She's, you know, one of the trailblazers as I may hopefully not offensive, but a living legend in my opinion within the psych mental health nursing community.
Speaker 2:I took a couple notes before we got going. So she was the president of the APNA, the American Psychiatric Nurse Association. That was back in 2012 to 2013. So did some amazing things there and has actually in 2023, I forgotten, it's amazing, I thought this was just last year, but 2023, she was nominated and voted for to be the APNA Psych Nurse of the Year. That's huge. I mean just to kind of think of all the psych nurses, you were number one in 2023. So great. And again, hopefully. If you don't know Dr Beth Phoenix, maybe you can look up her bio. She's very well known around the University of California, san Francisco, where she did a lot of her training, was a program director there for a while too. So again, thank you very much, dr Beth Phoenix, for joining us, and I'll just kind of get us going and talking about our favorite subject, psychotherapy. So when did you get interested in psychotherapy as a concept or as a skill?
Speaker 3:When did you start to notice that was something you wanted to devote part of your most of your life to.
Speaker 3:So, you know, my history was is a little different than a lot of people you've interviewed on this podcast, because when I was in graduate school in the late 80s, the director of my program was, you know, I was in the CNS program and the director of my program did not think that psychiatric CNSs should be trained in psychotherapy. She thought that, you know, nursing was focusing too much on what she called the worried well. You know, nursing was focusing too much on what she called the worried well, and that she really felt like we needed to focus more on people with severe and persistent mental illness. So the focus of our training was really much more on psychosocial rehabilitation for people with severe and persistent mental illness mental illness and so, you know, a big part of that was, you know, group. It delivered in groups. So that's when I really first got really interested in groups and, you know, started to understand how important it was for nurses to have skills in leading groups.
Speaker 2:Great. Do you know what was about groups that was so fascinating or you know, or was just part of the program and you just got kind of got the bug and it bit you.
Speaker 3:Well, you know, what I really liked about, you know, use of therapeutic groups was that you know, the therapist didn't have to do everything. I mean, a lot of the therapeutic effect of groups is from group members' relationships with each other and what they learn from each other and how they bond with each other and how they bond with each other, and I just found that to be kind of a more empowering, you know, form of support for people, because as a group leader, most of what you're doing is facilitating people's relationships with each other.
Speaker 2:So that was something that really appealed to me and kind of helping people benefit from the wisdom of the group. Yeah, no, that's great. I don't know, and I forgot to again to introduce my co, I guess my co-facilitators as well Dr Sean Convoy from Duke and Dr Kate Molino from also California, university of California, san Francisco. But yeah, you know, before I became a nurse, I was a program director for the partial hospital program, which was primarily group based, and and I agree that was that's always been the relief of of doing group therapy is that you don't have to have all the answers and probably somebody within the group is going to have a better answer and a better way of saying it than ever I could. So I just need to make sure I don't get in the way of the process and I really like the idea of not.
Speaker 2:Always in my program I told my students you're not a group leader, you're a group facilitator. I like that idea. You don't lead the group, you just facilitate that conversation and, like I said, just try to get out of the way when you can. So all right, I'll turn it over to Sean.
Speaker 4:Yeah, great opportunity. We were talking about this before we went live about. You know how we would necessarily operationally define psychotherapy. Do you have any thoughts about that?
Speaker 3:I do, you know, because I think people have a lot of assumptions about psychotherapy.
Speaker 3:I mean, I think people think 50 minute hour, they tend to think of individual therapy kind of exclusively. So I decided to do a little AI experiment. So I asked the Google AI thing to find like six definitions of psychotherapy and then summarize the common elements and this is kind of consistent with my observation. So I don't think any of this is hallucinations. But some of the things that you know were common were, you know, that it involves communication, interaction with a trained professional, focus on thoughts, feelings and behaviors to address a variety of mental health and emotional challenges, coping skills and problem solving, value of therapeutic relationships and a safe and confidential environment. And so none of that is a 50-minute hour, none of it is a particular, you know, type of psychotherapy. So you know, I think often the way we think about psychotherapy is a little bit too narrow and, as we'll get to later on in this conversation, I think this is important in thinking about the ways in which advanced practice psychiatric nurses are leaders in psychotherapy.
Speaker 4:Yeah, it almost sounds like, if I understand you correctly, you're kind of saying that psychotherapy is consumed within the discourse of the therapeutic relationship.
Speaker 3:Yeah.
Speaker 4:Cool. Yeah, I'm going to take you more directly towards a practical experience. Was there one particular experience that you had as an advanced practice nurse that kind of gave you the bug that, wow, there is something magical in this psychotherapeutic process with a patient Can you identify and share the story with us.
Speaker 3:Hmm, hmm you know, nothing's coming to mind. I mean, I've had so many of those experiences throughout the years. I mean I think one of the things that really struck me, you know, because I've done a lot of kind of psychoeducational kind of groups, is the impact of universality, when people find that they're not alone with their problems. Because you know, I did many, many, you know kind of psychoeducational groups on depression and I can't tell you how many times, you know, when we were kind of doing our checkout and you know people were talking about what they got from this first session of the group, people would say I did not realize there were so many people that had the same problem as I do and I always thought depressed people were kind of downers. But the people here seem pretty cool, they have great senses of humor and they seem pretty smart, and so you know that was something that, that that really impacted me. That it's not, it's a kind of a simple thing, but it really makes a big impact on people.
Speaker 4:That's awesome, I hear. I hear tales of Yalom's curative factors coming into this conversation.
Speaker 3:Oh yeah, baby.
Speaker 2:Hey, this is Peplow's ghost not Y. Lau's ghost. I think he's still alive too. I shouldn't have put him in the grave like that. Sorry.
Speaker 5:So you know, Beth, I'm wondering you mentioned that you've, you know, done a lot of psycho education groups and I'm wondering for our listeners out there if maybe you could elaborate on, sort of, were these groups focused on a particular topic? What types of settings did the groups that you've run take place in, like? Give our listeners a little bit of an overview.
Speaker 3:You know, for a while I was doing them in a kind of community-based residential treatment. I've spent several years doing primarily groups in a stimulant drug treatment program. I did many years of psychoeducational groups and a big health maintenance organization. So the focus of the groups I mean obviously in the substance abuse treatment program the focus was on substance use recovery. I did groups, a lot of groups, on depression, anxiety, adhd, insomnia. I think I did a couple on anger management. So you know a lot of different foci but kind of, I think, similar strategies or skills that these groups focused on.
Speaker 5:Yeah, thank you, and you know, I think, going back to what you said earlier about how sort of what I would term these common factors in psychotherapy are so important you know so much of, I think sometimes we get really bogged down in the details of exactly what type of techniques we're using. But important to kind of pare it back and maybe going back a little bit to Yala, you know what are some sort of principles or guiding lights that you have used in your groups to facilitate change.
Speaker 3:Well, you know, I think a real important role of the group therapist is to really help people in the group make connections with each other, because I think that's where a lot of the therapeutic benefits of groups come from. So kind of helping people see things that they have in common or things that they may have a common problem, but kind of different ways that manifest for different people. One of my colleagues kind of talked about a big focus of groups being able to identify differences within similarities and similarities within differences. You know universality, just people in a lot of contexts, you know feeling that they're part of a group. You know, for people who've been socially isolated, that value of group cohesion you know I think can be very therapeutic. You know the way people learn from each other. It's kind of like, oh, you know that person has struggled with the same problem as me and they tried this and it worked for them. Maybe I should try that. So, you know, I think a lot of those, a lot of those things you know are very impactful.
Speaker 2:Yeah, thanks, beth. I mean I'll say thank you too. I think you've come up with our title for this episode. I love that idea the similarities within the differences and the differences within the similarities. That's yeah, that's very just succinct and kind of really streamlining what we're doing here in this kind of. My next question, which I want to get into, as as you're, you know, one of the you know, stellar nurse leaders here, how do you see nursing, being a leader in performing psychotherapy or doing, you know, group psychotherapy and such?
Speaker 3:Well, you know, I think that nursing is a leader in kind of flexible application of psychotherapeutic techniques, often when we're kind of doing other things as well, like I. Actually, I was on the APNA workforce task force a few years ago and I actually went back and looked this up, but 69% of the advanced practice nurses that were surveyed said that they used psychotherapy in combination with prescribing. You know, and I don't know what those statistics are like for other prescribing professions, but I suspect that that's a lot higher. And you know I've heard people on this podcast like Kate talked about kind of modifying. You know I've heard people on this podcast like Kate talked about kind of modifying. You know, the timeframe for psychotherapy sessions based on the needs of the population. You know Chelsea Landolin was talking about how you can kind of incorporate cognitive restructuring into a brief medication visit.
Speaker 3:You know, I think nursing is a very pragmatic profession. You know, I think nursing is a very pragmatic profession. We kind of, despite whatever circumstances we're in, we kind of figure out how to do what works people to receive combination therapy, both medication and psychotherapy, which much, much research has demonstrated is the most effective for many different kinds of mental health conditions. And also because, you know, nurses are kind of ubiquitous across the health system, you know. It kind of allows us to bring psychotherapy into settings where it might not otherwise be like primary care.
Speaker 3:So I think that's an area where nurses are really taking leadership and I think I think it's kind of a matter of framing, because I think people sometimes kind of bemoan, oh, we don't have enough time to do appropriate psychotherapy. But I think I think you, you know you can apply psychotherapeutic techniques across a variety of types of interactions and nursing is not, you know, we're not like real dogmatic about you know any particular kind of psychotherapy. It's kind of like if it works, we use it, you know. So I think that that's something that we ought to be tuning our own horn a bit more about. You know our flexibility, our pragmatism and our ability to deliver effective treatment to people with a variety of different conditions across settings.
Speaker 2:Wow, let Dr Phoenix cook. That was great, that was amazing. Yes, I love it Because I mean there's so many things there that you just said I that just kind of really resonated with me. You know, just this, this idea of you know not having and you said this earlier too about you know, 50 minutes, you know session is is not the, you know, it's not the framework that we all need to be thinking about for doing therapy. And I know, when I really get kind of this prickly like no, it's, you know it's got to be an hour, that's what this. You know you only get good therapy one hour. No, I disagree. I mean I don't think it takes an hour to do therapy. It's, you can do it in a half hour. I mean, I don't know if you can do it in 10 minutes, but I mean there there is kind of nursing as a holistic science, very caring science. You're right, you know, if we find something that works, we go with it.
Speaker 2:But I wanted to kind of maybe follow up and ask a little bit of a question just to your thoughts on it, because I had this discussion just before we started recording that a lot of providers that I talked to you know they're doing therapy within their practice just like you mentioned that integrated, you know, med management, therapy type of role but they don't take credit for it, they don't count it. You know they don't count either for billing or they just don't say that they're a therapist and for something about that. And I think you mentioned that maybe they're scared to do therapy. But you know, is there something else that seems limiting to you, that why people don't kind of take that ownership that they are doing therapy? They just, you know, they just don't own it in a sense.
Speaker 3:Yeah, like I, like I kind of indicated before I think the whole concept of psychotherapy has been mystified a little bit. That it's. I mean, I think when people think about that they tend to think of more in-depth psychotherapeutic approaches that are, you know, that you kind of do need a little bit more time for. But there's certainly types of psychotherapy and I think these are the types that tend to be most used by nurses, that you know that you can kind of integrate specific techniques into a variety of interactions depending on the needs of the patient. I mean, for instance, you know, if you're seeing a patient for med management and the patient's kind of ambivalent about taking medication and their adherence is not great, you can use a motivational interviewing technique like a decisional balance. You know what are the things that you like about taking medication, what are the things that you don't like. Kind of explore that to improve adherence or maybe to kind of figure out that you need to change your prescribing regimen. You know, and you know you can use, you know, cognitive behavioral techniques like cognitive restructuring. You know, maybe you're seeing a patient with a medical disorder like diabetes in primary care and some of their dysfunctional and distorted beliefs about diabetes are interfering with their adherence to that medication regime. So you know, I think there is this idea that somehow that there's kind of nothing between novice to expert and I just don't think that's how people learn psychotherapy. I mean, I think you can. I mean I'm really in a lot of ways kind of largely self-taught in terms of what I know about psychotherapy, because I didn't learn it in graduate school because, you know, it was kind of like the T word was, you know kind of not what was on offer there, but you know from, from kind of using manualized psychotherapy, I've I've kind of used like, learned how to use specific techniques. You know, I've kind of been able to refine that you know, using supervision and that kind of thing. So so I think I think having you know more of an idea of kind of building blocks you know we're going to teach you some techniques you can continue to learn more techniques and how to appropriately apply them after you get out of school, yeah, so that's.
Speaker 3:I think that's kind of one thing. Is this people having this kind of overly restricted idea of psychotherapy? I think the other thing is there's just there's not a real clear border between our normal therapeutic interactions with patients and psychotherapy I mean, like some types of therapy approaches, like supportive psychotherapy are very similar to kind of just the regular things that we do in any encounter with patients. Some of those you know techniques like you know encouragement. You know techniques like you know encouragement, advice, giving those kind of reality-based techniques. So I think some of it is kind of a framing issue, but I do definitely think that's something that we need to start claiming a little bit more. You know being able to identify, know being able to identify. Yes, I've established a psychotherapeutic relationship. I have you know, I've kind of done an assessment, I have goals involving psychotherapy.
Speaker 4:And I'm doing it and I should get reimbursed for it. I think, quite frankly, as you're talking, I'm hearing a manuscript come out about deconstructing the historical context, about how we operationally divine psychotherapy. Yeah, great idea. I agree with you, beth, that most of what I learned was watching those old videos from Carl Rogers and Aaron Beck in the 1970s, most of which are black and white. I learned more from them than I think I have in any formal classroom environment. I'm going to ask a question that I ask all of you three of you answer. I'm going to start with Kate, then I'm going to go to Dan, I'm going to finish with Beth.
Speaker 4:I'm currently teaching psychotherapy this semester in my summer semester, and this is kind of the most enjoyable time of the year for me because of it. I see a common pattern working with students, and if there's like one student in my cohort is listening right now, hello, I'll share that. One of the most common challenges that I encounter when I try to teach individual psychotherapy from the ground up is that there is endemic in the nursing role. Is this tendency to be the fixer in the nursing role? Is this tendency to be the fixer? And I'm constantly working with them to shed loose the fixer role, to transition to what Dan said earlier, the facilitator role, and that role is so well entrenched for traditional registered nurses and also primary care nurse practitioners that are interested in everybody's thoughts about how I can break through that fixing mentality, shifting to the facilitating, and I'll start with Kate.
Speaker 4:What are your thoughts, frank?
Speaker 5:Sean, what a great question. I also am teaching psychotherapy this quarter. So, yeah, we're in week three and this is one of their first specialty classes actually. So something I've been trying out and of course we'll see how it bears out over the term Um, something I've been trying out, and of course we'll see how it bears out over the term. But something I've been trying out is, uh, trying to make an analogy, I suppose, um, in terms of shifting the concept of what they're doing from sort of acute treatment to chronic disease management, um, and so calibrating the notion of what is success. You know, how do we set goals that are realistic, thinking over the long term, and I have found with some of my students that I can see the light bulb going on. So, yeah, that's my, that's my thoughts on that.
Speaker 4:That helps, dan what you got Brent.
Speaker 2:Yeah, no, that's, yeah. Great question and great answer, Kate I. What I will say is probably a little more pragmatic. You know, when we run into students that struggle with this and want to fix everything, we just tell them to shut up. I mean not so bluntly, right, but it's really about you know, bite your tongue, get comfortable with being uncomfortable of not saying something Because, again, like we talked earlier about that facilitator role of just kind of being quiet and letting them come up with their own solutions. Sometimes they do a fantastic job of that. So sometimes we don't have to have that magic.
Speaker 2:You know saying I sometimes blame a little bit about TV and movie on this. Right, you see psychotherapists and you know famous, like you know Freud or something, and he says something that's just amazing and it comes right off the cuff and I'm just like, of course they. They spent like six months in a script room trying to figure out what this. You know how to say this, exactly right, so, so you're not going to come up with that every time, so, but that's that's when you were talking about this, sean. That's my initial thought is, you know, if they want to fix, they want to kind of say something that's magical and, you know, solves all their you know 25 years of trauma that they've been experiencing. That's just not going to happen. Let them. Let them kind of be there and again learn to get comfortable with that uncomfortableness of of biting your tongue and not saying anything.
Speaker 4:So yeah, Great, I'm going to take it to our elder stateswoman. What do you got, beth?
Speaker 3:Well, you know, I think I think you've really put your finger on something, because I think nurses by nature are action oriented and I think that that a lot of since you know, most nursing training at the pre licensure level is in acute care settings. You know you're not there to kind of negotiate goals with the patient, you're there to do stuff to get them better. And a lot of what you're doing is you are acting upon patients. But I think psych is, you know, except for people, when people are at their most decompensated. I mean a lot of what you're doing is really more motivational. And I think you're doing is really more motivational. And I think, like Kate was saying, that kind of gear shift from you know acute management to you know kind of long term, you know helping people learn how to manage their own conditions, I mean I think that's a real gear shift for people. Own conditions, I mean I think that's a real gear shift for people. So I think that has to be really called out, you know, just in terms of what people's role is in this kind of context.
Speaker 3:There was something else I was going to say.
Speaker 3:You know, I think also, sometimes you just have to, you just have to raise the issue with people of kind of their own need to fix people and that you know, as nurses it is part of our kind of ethical responsibility to you know kind of respect people's own, you know goals and desires. So you know I think sometimes people do have to kind of look at what it is in them determined to fix people, because that's a recipe for burnout in the long term because you can't fix people, people need to fix themselves and you can help, you can support, you can cheer on, you can help people learn skills. But ultimately you know people are autonomous and they, you know it's up to them. So I think kind of, yeah, that readjustment of what you think of that your role is is really important and that's why it should. I'm just going to throw another thing in here. That's why this advice that you should do your year of med search before you go into psych is not good preparation for going into psych, because psych is a different mentality.
Speaker 4:Well said. Before I pass it to Kate, I'll just say I agree, I appreciate everybody's feedback and I particularly connect with what you said, beth, because I personally think that carrying this fix-it mentality into advanced practice psychiatric, mental health nursing is an example of our unchecked countertransference.
Speaker 5:Absolutely. But as a former student of Beth's and later on her colleague, you know Beth wrote the mission statement for the PsychMP program at UCSF, of which an important part is that tolerance for uncertainty and ambiguity is something you must cultivate in your advanced practice role, which I think is so important, and I love that she would read that out loud at the beginning of every year. That she would read that out loud at the beginning of every year. So, Beth, I'll ask you our final question for today, which is you know, how do you see the future of psych MPs, advanced practice psych nurses using psychotherapy?
Speaker 3:Yeah, I think basically kind of continuing to do what we're doing now but taking more, claiming more ownership over it. I do think it's extremely important for psychotherapy to continue to be taught and for certifying bodies to require that psych and peace students get supervised clinical training in psychotherapy. Because students get supervised clinical training in psychotherapy, because you know it's basically you know it's basically part of the you know kind of toolbox that you have for working with people who have mental health conditions. You know, I think you know kind of being more intentional in terms of how we talk about psychotherapy and are the types of psychotherapy we use, how we use it, the skills you know, the skills we have, articulating that to the public, to payers. You know whatever, you know whatever.
Speaker 3:But you know, I think, kind of demystifying it for students. You know, giving students more confidence that you know you kind of start small, you learn some techniques. You know, you try them, you refine them, then you learn more techniques. It's not like some big jump from novice to expert. You know, I think those are some things that are important for the future. But because psychotherapy evidence-based psychotherapies have such a strong track record of helping people get better, it is crucial that it continue to be part of psych NP practice.
Speaker 2:Love it Wonderful, thank you, thank you. Thank you, dr DeBeth Phoenix, for being our guest here on Pep Lau's Ghost. Please look forward to other episodes that'll be coming soon. And again thank you, dr Phoenix, for just really helping us demystify this role of psychotherapy within the practice. So, all right, take care everyone and we'll see you in the next episode.
Speaker 1:Like, subscribe and comment. Please, bye-bye leaving, so you can be. You Got a discovery Identifying challenging your beliefs, reframing your mind. Negative thoughts. Release these cognitive distortions. Decrease until they cease. Yeah, got a discovery Identifying, challenging your beliefs, reframing your mind. Negative thoughts. Release these cognitive distortions. Decrease until they cease.
