Peplau’s Psychotherapy Playbook with Dr Fatima Ramos-Marcuse

Someone reads your clinical notes and decides a child is “beyond repair.” Years later, that same kid is thriving, making art, keeping friends, and living a life that proves prognosis is not destiny. That tension between labels and lived outcomes drives our conversation with Dr. Fatima Ramos Marcuse, a developmental psychologist and board-certified psychiatric mental health nurse practitioner, as we explore what actually heals in mental health care.

We start with Hildegard Peplau’s legacy, including Dr. Marcuse’s memories of meeting Peplau and learning psychotherapy through a now-famous photocopied manual. The thread running through it all is simple but demanding: stay with what the patient brings, track the relationship, and help a coherent story form instead of chasing scattered symptoms. If you care about psychiatric mental health nursing, therapeutic communication, and psychotherapy skills for PMHNPs, this is a grounded look at why the interpersonal process still matters.

From there, we get practical with attachment theory, including ways clinicians can listen for attachment patterns without turning them into pop-psychology labels. We talk earned security, why insecurity is not automatically pathology, and how one steady relationship can be protective. We also tackle the real-world squeeze between psychotherapy and medication management, including when meds are helpful, why effect sizes matter, and how to keep care holistic. We close with lessons from mental health systems across countries and what they reveal about training and models of care.

If this conversation helps you think differently about diagnosis, attachment, or the therapeutic relationship, subscribe, share it with a colleague, and leave a review. What part of your practice most needs more time for the relationship?

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

Transcript

Welcome And Guest Introduction

SPEAKER_05 0:32

Welcome back, everybody, and welcome to another episode of Pep Lao's Ghost. Really excited to have our guest here. Dr. Fatima Ramos Marcuse is here with us, and she is a PhD developmental psychologist and a board certified PMHNP. So I'm really interested to hear how those two experiences and educations really kind of come together on this podcast. As always, I'm joined with my eternal friends, Dr. Sean Convoy, Dr. Kate Molino, and Dr. Melissa Chapman Hayes. Fatima, it's an absolute honor to have you here. I think we wanted, I wanted you on this podcast as soon as I heard, and I forget the chain of events that actually kind of connected. Somebody said, You should get Fatima on your podcast. She actually met Hildegard Pepplau, and I was like, holy heck yeah, that's uh that's so awesome that we had, you know, so many people who have actually met uh Hildegard Peplow. So so if you wouldn't mind, maybe that's where to start us, you know. You know, in your experience, you know, how how was meeting the founder of this podcast, the namesake of this podcast? How did that shape your life and and what's what kind of memories do you have? So take it from there.

SPEAKER_01 1:42

All right. First of all, I want to say that I'm really delighted to be here with all of you today, and just delighted to be talking about Hildegar Paplau and psychotherapy. I did get a chance to meet Hilda several times at conferences in the 90s. I studied directly with one of her students, Dr. Suzanne Lego at Columbia University, and she and Dr. Paplau were in constant contact. I believe those letters are in either in the archives or the, I believe there's a Paplau Museum in California, and that's where those might be. But I was in awe of meeting Dr. Paplau. And essentially, you know, because in graduate school I learned how to do psychotherapy using her manual. And there was a funny story about her manual, which was a Xerox copy, and they were a hundred pages. And before the first day of graduate school and before starting our work with our individual client, we were to read this manual. And for some reason, I thought the pages were, the cover pages were missing or something, but apparently there is a copy of it in Virginia, Catherine Kane attested to it, and it's a Xerox copy. So maybe I had what I had on how to do psychotherapy. And so I was in awe of meeting this amazing icon who started the master's program in psychiatric mental health nursing that allowed a lot of us to become clinical nurses specialists. So I was prepared to be a CNS and graduated with a master's in psych mental health nursing, then had to wait until I had enough clinical hours with patients and supervision to become eligible to sit for the ANCC exam. And by the way, before I even started the program, Columbia, I also had to agree to have my own psychotherapy. So I needed to agree to be treated in individual and in group. And so I was very excited. I was working in inpatient psychiatry at New York Presbyterian Pain Whitney Clinic. And in those days, and I'm really dating myself, we had intermediate lengths of stay, and people stayed months and months in inpatient care. And then if they needed longer-term care, they went to Westchester, which is another hospital in New York where people stayed longer than a year. So I had been introduced to long-term mental health care and psychotherapy, and had essentially had been previewed to case presentations and professor rounds where primary nursing was practiced and where nurses were very much encouraged to do not psychotherapy per se, because we weren't master's prepared nurses, but to do one-to-ones with patients and to document as such. So that was my background. I was very excited about that. And that's how I went to Columbia University. And I was very much ready to do my to engage in my own treatment as well. So it was kind of like what it's like to be on the other side of the couch. And I'm really grateful for that. I know our program was very, very small, then there were about eight people, but I believe they were 10. And two people did not go on because they one refused to take sick patients. So we had to first work with patients who were psychotic. And, you know, Hildegarp Paplal developed her theoretical model in interpersonal nursing, essentially from working with inpatients in hospitals like Bellevue and other state hospitals. And she was very much influenced by Harry Stock Sullivan, who was an interpersonal psychotherapist. So, you know, back to uh how I met her. I don't even remember much conversation with her except that she told me that she danced with Bowlby, John Bowlby. And he, of course, is very important to me because of attachment theory much later on. And she said he was an amazing figure. And I was very excited about that.

SPEAKER_05 7:22

So so joke, joke coming. I mean, when he said figure, did he mean like a physical figure? Was she attracted to him, or was it more of the dancing figure kind of?

SPEAKER_01 7:33

I think I think in in what he did uh was yes.

SPEAKER_05 7:40

And well, and and the question I have too is do you still have that Xerox copy of that manual? Or probably didn't know it was so valuable when you had it, right?

Learning Psychotherapy From A Manual

SPEAKER_01 7:50

I actually don't think I do, but I could. I've moved so many times and I had a flood, so I've lost some work of people who have been influential in my life. So I don't know that I still have it, but I know Katherine Kane does at University of Virginia.

SPEAKER_05 8:10

That's awesome.

SPEAKER_01 8:12

Yes, I know where I get where to get it for sure. And you know, and essentially what I remember from those 100 pages were to focus on what the patient said and in the relationship. If a patient brought up something, then you were to really stay with that and help the patient create a full story. And I think it was very orienting and at times really difficult to implement because at times patients want to go all over the place and talk about a hundred different things. They want to tell you about this and that and that and this, but you were supposed to like refocus them back on whatever it was that week that they were very upset about, and you were to ask about their thoughts and how they felt in a certain way. And I think it was really amazing how over time, and we had to follow the same patient over time, how people really changed in the times. I didn't even have to ask questions. They already said, Oh, I know what you're gonna ask next. What do I think and how I feel?

SPEAKER_05 9:28

That's great. Thank you, Fatima. I'll pass it over to Sean.

A Child Case That Changed Everything

SPEAKER_04 9:33

All right, hey my friend. So, first of all, I want to say I I share your academic experience as uh as an initial CNS evolving to psych. And I I trained at UVA with Katherine Kane, so uh we have some similar connections there. As I was listening to you talk, I I kind of see your academic training in developmental psychology and advanced practice psychiatric nursing as this really fascinating mix. It's like this professional bully basis, right? It's just really, really rich. Why don't you think about that bully base that you're gonna do your formal training and then you've got a lot of experience in long-term psychiatric care, acute psychiatric care? Can you think about a case or a scenario in your practice to de-identify that let you know that wow, psychotherapy is kind of like this lightning in a bottle, right? I I know this works, and here's my evidence. Can you can you share that story for us that crystallized your appreciation and passion for this?

SPEAKER_01 10:29

So I have several cases, but one in particular is of a little girl that I treated since she was four years old. And at the time when I treated her, I was already psych nurse practitioner in the CNS and a developmental psychologist. And so I'm sort of eclectic, but I used play therapy with her. She had traumatic events involving a problem in daycare at age four, where she was left outside, and the caregivers thought that one of the parents had picked her up and they hadn't. And then she also had a mother who was psychotic on and off. Okay. And a very good father, I thought. So I followed this case for several years, and I actually saw her recently. She's now an adolescent in high school, living with her father. Her father, her parents were together when I started treating her, but then they got divorced. And now she has a stepmom that she really likes, and she's doing okay. But at the time when I started working with her, she was quite disturbed. And in fact, this case went on to court, and there was a forensic psychiatrist involved who saw this young patient as completely psychotic from my notes. And, you know, I did release my notes to the court and thought that she was disturbed beyond repair. And I thought he was completely wrong, you know, that in play therapy, she did in her play did manifest some disturbing things, but she also had a lot of positive attributes to her and resilience, and had an amazing father. And I thought she was, she had a positive attachment to the father, and likely a positive attachment to the mother when the mother was not so fragmented. Okay. But this case, to me, over the years, because this kid has been fine, she's an amazing artist, she's doing really well academically, she has peers, she does have some anxiety and all that, but she's done amazingly well when, you know, we could have looked at her, and in the beginning, her mom did take her to several providers: neurology, developmental pediatrician, a GI doctor, all these other people because she was having a lot of different symptoms, and ended up bringing her to me without the father knowing. So that caused a lot of conflict. And this kid, by the way, and I treat people in multiple languages. So this kid's mother speaks Portuguese, and the father is American, and so she was brought up with dual languages, had spent some time out of the country, and there were at times issues involving, you know, well, the mother takes the kid out of the country. So a lot of back and forth conflicts and disruptions and dysregulation and whatever. But looking at this kid from age four to age like 15 now, she's done remarkable. And by the way, even after I stopped treating her for a period of time, she had come back so that my students in psychotherapy from Columbia University would treat her, would also do some family work, did some work with the mom, did some work with the dad. So the these this family has been in my practice for many, many years. And I think, you know, they're not amazingly perfect, but they're also not, you know, condemned to what the psychiatrists had suggested.

SPEAKER_04 14:55

I I so appreciate that. And when you were talking in my mind, I thought about we sometimes in clinical practice, arguably, sometimes informed by the medical model, we tend to embrace the negativity bias. And what your story tells me is that you valued pieces or positive childhood experiences just as much as you did aces or adverse childhood experiences. So thank you for that.

Attachment As A Clinical Tool

SPEAKER_02 15:18

Thank you. And my next question for you piggybacks on what you just shared, Fatima. And I love how you said that Papalau danced with John Bowlby because you have also danced with John Bolby, maybe not physically, but intellectually, right? So, my question for you, given all your research and work on attachment and you know, parent-youth relationships, we would love to hear your thoughts on how psychiatric nurse practitioners can better use their knowledge and understanding of attachment as a tool for healing within a therapeutic relationship.

SPEAKER_01 15:54

That's that's an amazing question, an amazing preposition. I had developed a course at Columbia University that was at the doctoral level, a master's and doctoral level called Developmental Psychology for Psychiatric Nurses, or something like that, or developmental across the lifespan, something like that. That course has gone away, and essentially they have created a course for MVE. So people coming into nursing from other disciplines and they get a master's degree, and they're so they're there can't they can be prepared to take the RN exam. Apparently, the attachment content is still in that class, so that was the way I had brought in attachment into the program. But I present on attachment a lot at conferences, and of course, the research that I've done in attachment is only showing up in psychology journals. But I've been working on other manuscripts that I've not been able to submit into nursing, but I'd like to. Sometimes one. But give me five adjectives for each caregiver that was had a main big influence in your life. And then tell me five stories about each adjective. So, you know, they might say, My mom was kind. So I say, tell me a story that illustrates how kind your mom was. And so then, as a therapist, you can kind of evaluate those stories for coherence. Are they coherent? Do they make sense? Or are they about something else? Like my mother was kind. Well, she was kind, you know, she was a nurse and was always administering to people, but not, you know, but they don't say they're talking about themselves, right? So the story should be relevant to themselves. Or people sometimes go off in tangents, or they say, I don't remember. So you can kind of, you know, you do have to have some training and understand the various aspects of attachment. And also just because you might be insecure, avoidant, or insecure, anxious, or ambivalent doesn't necessarily mean that that's pathology. Okay. Pathology is disorganization typically. And even people may have insecure attachments, and even some disorganizations can actually work toward positive security in therapeutic relationships. So there's something called earned security. I don't know if that answered your question.

SPEAKER_02 20:17

Absolutely. Thank you so much. Those are such excellent practical examples for yeah, I appreciate you sharing that.

Keeping Therapy Central With Meds

SPEAKER_03 20:23

I'll pass to Melissa. I was gonna say, could we just talk about attachment for the whole episode? Because I have follow-up questions, but I actually have a different question. So just noting that for the future, you are a strong advocate for integrating psychotherapy with medication management. I want to make sure we we touch upon this. Since Peplaw viewed nursing as a quote, significant therapeutic interpersonal process, how do you ensure that the nursing or human therapeutic aspect doesn't get lost when the clinical focus shifts toward pharmacological interventions?

SPEAKER_01 20:58

Amazing question. Amazing. And so I can tell you that in private practice, which I've been in private practice for over 14, 15 years or so, I am able to really stick to that, okay? Where I will do extensive evaluations, I will talk with patients who come for services about what is available that is evidence-based. And we could talk more about evidence-based, talk about the work of Jonathan Shedler, who's a very special person out there in the world of psychodynamic therapy. But essentially, I try to understand my patients from an interpersonal perspective and understand what they're what they bring to me. And I may not prescribe the very first time they come to see. See me, unless they come to see me after they've been under the care of another therapist, which is often the case. I do work with a lot of other colleagues who are psychotherapists and not necessarily nurses that I highly respect. And my colleagues know that, most of them anyway, know that I am a therapist and that I see people from a holistic perspective. And so we make sure that patients understand that medication isn't just it. And we know that effect sizes for treatment using just medication, let's say for depression, are kind of low. Actually, psychotherapy has better effect sizes than medication alone. I do prescribe medication. I think at times it definitely makes sense, especially if people are very, very ill with symptoms that affect their ability to function at school, at work, and family life, and they're just, you know, unable to function out there. And that perhaps psychotherapy has not worked for them, or maybe they're just coming in and they're like, you know, a minute away from being hospitalized. I don't particularly like hospitals these days. I try to avoid them as much as possible and try to, you know, up in the beginning, do more intensive outpatient care and often work in the team approach with other psychotherapists if I'm not going to be the psychotherapist in that case.

SPEAKER_03 23:50

Thank you. I appreciate that response.

What Global Mental Health Teaches Us

SPEAKER_05 23:53

Yeah, amazing how you've kind of carved out your own kind of really, you know, intensive, I think is a great word that you use. And so my next question kind of shifts a little bit to, you know, I didn't, I kind of failed to mention in our introduction that uh we kind of know each other through the International Society of Psychiatric Nurses. And I think you're the president of the foundation board this year. And so with this kind of, and you mentioned already your multilingual background, your experience kind of in international travels and and maybe even caring. I'm very interested in, I think, you know, in in looking at we're all kind of traveling around on this blue, you know, marble in space. And so, how can we learn from other people? So that's my question. In your in your experience, in your travels, you know, from other countries, other places on the planet, what how do people do mental health maybe better, or what do we have to learn from them? Maybe like a lesson learned, and maybe something even that they could learn from us.

SPEAKER_01 24:52

Well, that's an amazing question, and we probably need an hour to do that.

SPEAKER_05 24:56

Right, I know. Sorry. Yeah, I just got five minutes. No, I'm just kidding. So take your time.

SPEAKER_01 25:01

So I know Portugal very, very well because I'm from there and I've spent a lot of time there, especially last summer, because my one of my parents was very ill. And because my parents chose to go back in their elder years back to Portugal, and they both needed to see psychiatrists, neurologists, and all that. So I kind of am familiar with mental health. And I think they're using the medical model a lot. So they're kind of, I'm gonna put them back to where we were in the late 90s. You know, there's this pendulum that tends to swing from side to side. You know, when I first got into psych mental health nursing, it was like all psychoanalytic, psychodynamically oriented. We were doing some medication stuff and I was in research and all that, but that wasn't it. And then we're swinging the other way. And now, even talking to colleagues who are psychiatrists, they're really not just wanting to prescribe meds, they want to do more. I think a lot of people, even psychologists, want to do more. All of us in mental health want to kind of provide more holistic kind of care. I did work as a psychotherapist in Switzerland for a period of time, not as a nurse. They would not let me work as a nurse, but as a EU citizen, I worked as a psychologist because I have uh I had a master's in psychology. So I worked with neurologists and psychiatrists, and there they were doing psychodynamically oriented psychotherapy, and also in cases that needed medication, they did do medication. This is in the I moved back in 2010, so it's been a little bit of time. But I, you know, I learned a lot. I was for a period of time working on a manuscript looking at other psychiatric mental health nursing programs across the globe. I looked at Canada, I looked at New Zealand, Australia, Switzerland. I was actually going to teach in a MS program in Basel, and then I ended up moving back. There was a psychiatrist uh teaching there. And in England, so in England, and also the Ireland, mental health nurses are very different. They're not RNs like we are in the United States. Don't just, but it's just amazing how people manage to provide mental health care across the globe.

SPEAKER_05 27:40

Thank you for sharing that. It's I like I said, a loaded question, like you were saying in the beginning, you could talk on that for hours, but uh I'm just mesmerized by all your experience, and and thank you for sharing that a little bit. Uh, I want to be Fatima when I grow up. It's she's great. Pass it on.

Why Attachment Should Not Be Pathology

SPEAKER_04 27:55

Uh Fatima, I um I'm a reasonably okay psychiatric nurse practitioner. And one of the things that I learned over the years is that I have to follow the affects. So I noticed that when you were talking about attachment and Melissa was talking about attachment, both of your eyes lit up. So I'm gonna defer my question and pass it back to Melissa if she can ask another question about attachment.

SPEAKER_03 28:17

Yeah, I know our listeners can't see our faces unless Dan posts some clips, but I have a loud face, so I'm sure you could pick up on that. I wondered, I have so many follow-up questions, but I wondered if you could speak a little bit more to not pathologizing attachment, because it's as a trained as a psychologist. I certainly know John Bowlby and his work and had you know gravitated to it immediately in school. And more recently, it's kind of pop psychology as well. I'm a I'm this kind of attached, and that's how I am, or here's how to be in a relationship with someone who's insecurely attached. I just love to hear more from you on not pathologizing it, because of course you can work through it if that's not too broad of a question, or you can take that in whatever chunk is manageable for this podcast.

SPEAKER_01 29:04

I I completely agree. I think that a lot of us will actually have various attachments and types of attachments, and we may uh display those with different people that we're in relationships with. And some of that might be adaptive because of how the other person responds to us, and as long as it does not, you know, make us unhappy or or cause a lot of dysregulation, it's okay. It's okay. We don't all have to be completely securely attached, and within security, there's also a bunch of categories. Okay. I learned to code babies, and so there's just like a B and a C and the D1 and a D2 and the C1, and you know, and and also even with the adult attachment interview, you know, there's I think that at times looking at it in scales that are kind of go from more positive to negative, kind of on a continuum, instead of just putting people in little categories, because we don't fit in little categories. Even the DSM. I hate the DSM actually. People usually, I don't say that a lot, but I don't like the DSM. We don't, and our patients don't fit in those little categories. And I often say, This is for insurance purposes, or somebody says, I'm definitely this. Can I be this? And if I think, okay, that's reasonable, let's be that. But I that's not how I understand people through these pathological medical model categories. And as I said earlier, the people who have insecure attachments can become positively or secure through what's called earned security, and that can be with a teacher, there's a really large study in Hawaii because people didn't move around a lot. And you know, even if you have a positive, one positive relationship with someone that can be incredibly protective and can foster security. There are people who have partners, like romantic partners that have become their secure base, hopefully their positive secure base, right? And that have helped them have kind of like secure or positive kinds of relationships. And also, of course, with your therapist through a therapeutic relationship that can derive security and it should, right? Because a lot of people have not had that as growing up. You'd think that growing up you'd have people that you can depend on in times of stress or that they wouldn't fit inflict traumas on you, but we know that's not the case. But it's also a very, very small number of people that have horrendous disorganized attachments. Most of us are securely attached across the globe. So I think that's very positive. And it's not everything, because a lot of critics of attachment say, well, this is not everything. Of course, it's not everything. I also studied temperament. I think temperament or personality can make a big difference. The environment can make a big difference. So many things can make a big difference.

Final Reflections And Farewell

SPEAKER_03 33:06

I appreciate that dynamic approach and especially talking about attachment through relation. Thank you. And we'll pass it on to the next person asking the question.

SPEAKER_05 33:18

Yeah, do we have one more? We're coming up on time too. Does anybody I mean, yeah, we just would love to have Fatima maybe back for a second episode. Thank you again. Maybe we'll wrap it up at this point and just thank you to Fatima. Thank you so much for your time and your expertise. And it's been enlightening. It's been uh really for me, it's it's it's energizing. I I I mean, I just uh I think the words and the stories that you've shared here really are inspiring to me and hopefully they're inspiring to lots of people listening. So thank you all for listening here for another episode of Peplow's Ghost. We'll be coming back soon with another one and have another exciting guest as well. So thank you so much and look forward to hearing another episode.