The Relationship You Build Becomes The Treatment with Dr Elizabeth Francis

The best psychiatry doesn’t start with a prescription, it starts with how safe a person feels across from you. We sit down with Dr. Elizabeth Francis, Duke faculty, clinician, author, and APNA board member, to talk about what happens when you take Hildegard Peplau seriously in modern PMHNP practice: the relationship is not an accessory to treatment, it becomes part of the treatment itself.

We trace how rigorous psychiatric nurse practitioner training can integrate high-level neurobiology with psychotherapy, including the idea that the brain is experience dependent. Dr. Francis explains how repeated emotional experiences shape neural architecture and why “corrective” experiences in therapy and in the clinical relationship can help patients change patterns that feel hardwired. From there, we get practical about what makes a strong psychiatric mental health nurse practitioner: deep curiosity, humility, and the ability to hold complexity without rushing to labels.

Then we move into high-stakes environments and whole-person care. Dr. Francis shares what emergency department work taught her about building a therapeutic alliance in seconds through presence, tone, and calm confidence. We also talk metabolic psychiatry and why diet, metabolism, and brain health belong in everyday psychiatric assessment, including how patients respond when someone finally asks about what they eat. Her Alaska clinical rotation stories bring it all together through outreach psychiatry, ACT team care, long-acting injectable antipsychotics, and the reality that mental health can’t be separated from housing, trauma, and systemic inequities.

We close with personalized care in private practice, including hyperbolic tapering and shared decision making, plus the real-world impact of state practice authority on access and delays in care. If you care about ethical medication management, patient agency, and the future of psychiatric nursing, this one will stick with you. Subscribe to Peplau’s Ghost, share this with a colleague, and leave a review telling us what idea you want to bring into your own practice.

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_04 0:31

Welcome to the next episode of Peplau's Ghost. My name is Dr. Dan Wiesman. Thank you for listening. Thank you for joining us. I'm really thrilled to have our next guest here, Dr. Elizabeth Francis, who were just talking about this is a time of year in which a bit reflective about our time and graduation and in the month of May and everything like that. But I think she's graduated and she's done a ton of work since graduating from Duke University. So I am joined by my esteemed colleague, Dr. Sean Convoy, and Dr. Melissa Chapman Hayes, of course, is here as well. So Dr. Elizabeth Francis is a standout alumni, current faculty member at Duke University, a top-tier DMP, PMHMP program. She is an author, clinician. She's on the American Psychiatric Nurse Association board member and truly embodies what we hope that I will be one day as a PMHMP. She's done a great work in really marrying the roots of her emergency medicine experience and really look to kind of connect this with trauma,

Psychiatry As Art And Science

SPEAKER_04 1:31

schizophrenia, bipolar disorder, and so forth. So thank you very much, Elizabeth, for being here. So you've spoken, you know, a lot about this in psychiatry as being both an art and a science. And obviously, Dr. Peplow, Hildegard Pepplau, was very much a part of this as being, you know, integrating this and into the hope and such, and how this can be, you know, nursing is an art, it's a therapeutic process. So, how did your training, how did you get into this work? You mind kind of just catching us up where what kind of brought you to this place in your life?

SPEAKER_01 2:03

Yeah, I guess the question would be how my doctoral training at Duke, you know, helped blend high-level neurobiology with the deep human interpersonal art of psychiatric nursing. I guess, I mean, my coursework at Duke was difficult, as Sean, Dr. Convoy will will tell you. It was quite rigorous. But also, like what I and what I tell my students is as far as like psychotherapy and integrating that with neurobiology, I tell people that the brain is experience dependent. So we have those, like these repeated emotional experiences that shape our neural architecture. And we learned about this in in school. But how like psychotherapy and integrating that into my practice that can provide that, I don't know how to say it, like the corrective emotional and the cognitive experiences that can gradually rewire these maladaptive pathways. So being able to integrate all of that together is really important.

SPEAKER_04 3:06

Yeah. Can can you do you mind kind of going back a little bit and just kind of sharing kind of maybe, and maybe I'm stealing Sean's question, but just really, you know, what sort of things drew you to this? I mean, what's what were

Personal Path Into Psychiatric Care

SPEAKER_04 3:17

your experiences like, you know, either personal or professional, that kind of seemed to make sense and kind of lined up to what you were doing at Duke and things.

SPEAKER_01 3:24

Oh, like why I became a nurse practitioner. Sure. And like why I did psychiatry. I had some personal experiences with family members really deeply struggling throughout my life that lived in the home with me. That kind of brought me into psychiatry in general, you know, throughout grade school and high school. So that's what kind of brought me into psychiatry in general. I witnessed suffering firsthand with family and friends, and I wanted to get into a field that I was passionate about and help alleviate that suffering from people that I think our society kind of casts aside and doesn't believe the best in or labels very easily and quickly.

SPEAKER_04 4:05

Well said, thank you. I'll turn it over to Sean.

SPEAKER_03 4:07

Hey, Doc. So as we've talked about a lot in the past, is I I tend to think of psychiatric nurse practitioners kind of being a genotype, and every psych NP

What Makes A Great PMHNP

SPEAKER_03 4:18

that practices and follows is a phenotypic expression of the genotype. Two questions for you. One will build upon the other. First question is if if you're forced to give your elevator speech to say what is your phenotypic expression of the psych NP role, what's unique about you and the way you think? How would you answer that?

SPEAKER_01 4:41

I would say I I am very, I'm infinitely curious, and in the clinical setting with my patients, my patients would describe me as humble and like I have a really high ability to tolerate complexity, both with just with the entire person. I'm I'm I have a very high tolerability of complexity, of the brain, of a psychiatric presentation, and including the whole person.

SPEAKER_03 5:14

Cool. Building upon that, and imagine, if you will, the ghost of Hildegaro Paplau hanging over your shoulder. What parts of your practice would she be particularly excited about?

SPEAKER_01 5:28

I would say my ability to create a safe therapeutic relationship with patients. I've had students tell me that, and I and I do believe this, that I'm pretty good with like meds. That's like kind of my thing. But also I think that my patients come back and refer to me and recommend me because of the relationship that we have, the therapeutic alliance. And like you hear that in school, you know, like I know you told us that Sean all the time. But in clinical practice, that is truly what I'm seeing time and time again. They trust me. And we just have I have good relationships with a lot of my patients.

SPEAKER_03 6:11

So those of you you right now you you can't see this because this is an audio podcast, but just imagine me smiling like a Cheshire cat. So I'm gonna pass it to my left.

Building Trust Fast In The ER

SPEAKER_02 6:22

Flattery, Sean. So Dr. Francis, I want to build upon that, you know, relationship building and think about a time in your life when you've spent a lot of uh amount of time in the emergency departments, um, which would make it challenging or a different challenge maybe to establish that relationship. You recently published some research on implementing substance use disorder in the emergency department. So in a chaotic, high acuity environment like that, the orientation or getting to know you phase of a patient happens in seconds. What did that teach you about rapidly establishing a therapeutic secure connection with a patient in crisis?

SPEAKER_01 7:06

I saw that and still say it's it's not just about like, yes, it's very highly dynamic and fast-paced, but it's not just about what you say to people, it's how you say it and like the presence that you bring into a room. You know, like a confident, I really try and mix like a confident presence with like a soft presence. Like they know that I get it, but that I'm like I'm infinitely present and they have my full attention, if that makes sense. So like while in the ER, you have to be quick and like I said, it's very just very fast-paced, but being able to bring that type of presence into the room is extremely important.

SPEAKER_02 7:47

You can imagine in an emergency emergency situation, you would want someone who has confidence and is decision-making while also having that solved for bulking presence. Thank you.

SPEAKER_04 7:59

Yeah, this is great. Thanks, Elizabeth, for this perspective as well. You know, doing kind of, as we said before we start recording, a little bit of our online cyber slew thing. We've I found out that you have an interest in in metabolic psychiatry and you've published on this in part of your research. And for those who don't know, metabolic, you know, psychiatry is really kind of looking at your diet, your metabolism, ketogenic diet, and how this kind of affects the neurobiology process. Thinking

Metabolic Psychiatry And Asking About Diet

SPEAKER_04 8:23

about this and how we connect it to Hildegard Peplau and the whole person, how do you kind of integrate all those aspects within your appointments and how you care for people, not just, you know, focusing just on the metabolics, but also that relationship piece that you were talking about earlier too?

SPEAKER_01 8:38

Mm-hmm. So I ask all of my, and I always have before I got into like the meta metabolic psychiatry, which you know, I've been following the metabolic psychiatry field since 2021. I remember I was in Alaska talking to a preceptor about it when I was in in clinical. But I ask all of my patients about their diet, and I always have. And that's just part of like that whole person piece, right? Asking about like what their eating patterns are, what are you eating, which is a direct correlation with as far as metabolic psychiatry and that part of that umbrella is the ketogenic diet, those kinds of questions with patients and opening up that conversation about how that directly, you know, every your diet has a bi-directional relationship with your mental health and your brain health.

SPEAKER_04 9:24

Do you see that helping with that nurse patient alliance? Or some do people sometimes push back on that? Like, you know, I'm here to talk about my whatever, not my diet, and things like that.

SPEAKER_01 9:34

I don't, I wouldn't say I've had people push back. I've had people say, nobody's ever asked me about that before, which is quite infuriating in my opinion. But uh no, nobody's pushed back, but they're I think that they're surprised and curious as to why I'm asking. And I tell them there's there's very calculated and deliberate reasons why I ask you the questions that I ask you in a 30-minute visit.

SPEAKER_04 9:59

Thank you. Appreciate that.

SPEAKER_03 10:00

So, Elizabeth, you you cracked the seal on Alaska. So I got to ask you a question or two about that. So can you can you for the for the audience and recognize that the audience is probably 50-50 pre-licensed uh nurses who are aspiring to become nurse practitioners or established nurse practitioners in psychiatry? Can you give us your your your your elevator speech that describes what the experience was like in Alaska for you? And then speak to how that might have influenced the decisions that you make as an independent practicing nurse practitioner today.

Alaska And Seeing Social Determinants Up Close

SPEAKER_01 10:33

Alaska was incredible. It was the best thing that I could have done for my clinical experience. Something, you know, how it influences my current practice, I would say, is how like the the suffering that I witnessed there, just in ways that I had never seen before, just the profound suffering with the degree of mental illness, but also the lack of just like social supports was jarring and difficult to manage. And I would say now currently, how it just changed my perspective and how I practice, we cannot discuss mental health without discussing housing instability, financial stress, systemic inequities, trauma exposure, social isolation, the list goes on and on. But yeah, it was it was an incredible experience. I wish that I could go back and do it all over again.

SPEAKER_03 11:37

I'm gonna build upon that, Elizabeth. Can you spend a little bit more time just talking about your exposure to the ACT team model through

ACT Team Outreach And LAI Reality

SPEAKER_03 11:43

Alaska Behavioral Health Services?

SPEAKER_01 11:45

Yes. So essentially what that looked like uh was we would I would get in the car with my preceptor, like the company car, and we would go and he would be like, okay, this person we need to give their invega injection to. And they normally hang out behind the Taco Bell dumpster in an orange tent. Like literally, these were the words being said to me. And so I was like, this is my first day. And I'm like, oh my God, like, oh my God, this is crazy. Like, this is crazy. And anyway, we would go do that. And it was a very, it'd always be quick appointments. And these these were people that if you were on the act team, you either had bipolar one, it nor it usually was schizophrenia spectrum somewhere on that spectrum, is most of the patients that we saw. So that's just like one example. We would go into like the community centers where people would sleep and do their appointments there. But yeah, they were most of them were on injections, which is really good. I'm a big fan of the LAIs, but yeah.

SPEAKER_03 12:40

Thank you. I uh before I pass this to Mr. I'll just share, you know, I our relationship with Alaska Behavioral Health has been kind of defining for our program. So we're super grateful for them. In my time and trips up there, as I provided support to students, I wanted to share something that I thought was really relevant here. That, you know, we we think about that population of individuals up there, disproportionately high number of people with serious mental illness, significantly high rates for substance use disorder, dual diagnosis presentations in one of the most austere environments in our country. And you can get lost in the realization that wow, there's so much illness here. But at the same time, one of the things that I got watching these patients is that's not all that that's there. These individuals find a way to continue to physically survive in some of the most austere places. And I keep thinking, wow, we we we don't want to just focus on what's wrong. We have to remind ourselves what's still right. I remember being in some of these less than austere places behind the dumpster that Elizabeth was talking about, where I was like, I don't know how physically this person is as good as they are. And then I worked with one of the preceptors who said, Yeah, I recently got a lab panel on, and their cholesterol is better than mine, and their blood sugars are fantastic. And I'm like, wow, there's something in here that we can build upon. So thank you for that, Elizabeth. I'll pass it to Melissa.

SPEAKER_02 14:02

Yeah, thank you. And keeping with that whole person perspective that has flowed throughout this conversation. In your private practice, you emphasize personalized care, including advanced practice like hyperbolic tapering to those looking to safely reduce psychiatric medications. This requires, of course, a massive amount of mutual trust and just deep clinical attunement. And then shared decision making. So, how does this highly individualized approach embody Peplau's vision of the patient being an active participant in their own healing rather than just a passive recipient of care?

SPEAKER_01 14:38

In regard to the one size fits all, or not not it's not a one size fits all with a hyperbolic tapering, I'm really passionate about that because we learn all about how to start medications, but not how to safely land the plane, you know, getting people off medications when it's warranted, because there are people that can come off of their medications, you know, after some time. So, you know, having that conversation with patients and explaining, you know, what the process would look like generally, you know, giving people options too, like this is how we could go about this. I really practice like and I teach my students to like to give people options. So this is one way that we can approach this. Here's one medicine, here's the risks and benefits. We can also do this instead of a medicine, or here's another medicine. Like I really try and give people like two to four, you don't want to overwhelm people with options, but evidence-based options and like let them decide. And I think, and I've gotten feedback that people really appreciate that because then it's like it's them deciding, but it's also like you giving evidence-based options of different ways that and I tell people we can get to the same, we can get to the same endpoint, you know, Zoloft or Lexapro, or you know, this supplement versus this, or this therapeutic modality versus this one. But this individualized approach and this, you know, the patient being an active participant in their own healing, I think that's what leads to the healing, is if they're the active participant. You know what I mean?

Hyperbolic Tapering And Shared Decisions

SPEAKER_01 16:02

Because I've gotten, I've had patients before tell me that the the provider just told me what we were gonna do, like, oh, we're gonna just do this medicine and this. And it's like that that's why they were in my office or another provider's office, that why they were switching was because they felt like they had no say. So it goes back to that therapeutic alliance, right?

SPEAKER_02 16:20

Developing that locus of control and agency has to be a critical component and them managing you know themselves in a new way in partnership with their therapists. Thanks.

SPEAKER_04 16:32

I love this. I'm gonna actually come back to the Alaska thing because I was thinking in my head, like that was such a great experience. And and when I saw that you had this experience in Alaska, I guess I had wrongly assumed that you lived in Alaska. But so so how does this did you? Are you from Alaska?

SPEAKER_01 16:48

Well, I wish I lived in Alaska. That would be a lot of fun. I very much considered it after I left, and so did my colleague that I went with. We were both very much considering it.

SPEAKER_04 16:57

So that's a I mean, it really touched you personally and professionally, it sounds like as well. But I guess, you know, take for me, since I'm not from Duke and and maybe a lot of listeners are not either. How does how does that experience come about? Do you do you get to did you find that experience? Sounds like Sean was part of that as well. So so how does that kind of come about as far as all through Dr.

SPEAKER_01 17:16

Convoy there? He uh and and Duke has a relationship with Alaska Behavioral Health. So they will send a couple of students per per semester generally. Sometimes I think there's an application. I don't even remember how I got selected. There's an application. Did I do an application? Oh, I did. Okay. I guess I did an application and got picked to go.

SPEAKER_04 17:36

It wasn't too hard then either. You don't remember.

SPEAKER_01 17:40

I don't know. Yeah, it was in 2021. So yes, there's an application process, and they pick a couple of students to go. You stay in a in a townhouse kind of vibe in Anchorage, Alaska for four weeks, six weeks, eight weeks or longer, depending.

SPEAKER_04 17:55

Yeah, that's great. I mean, it's a it's quite a commitment, I would say. You know, I I think, I mean, I talked to a lot of students too who, you know, not to be too cynical of students, but you know, it's they complain sometimes about driving too far to their preceptor site. I mean, going, you know, really kind of halfway across the continent to to go to a site is that's quite a commitment. But I yeah, obviously see this happen again and again is that good clinical sites can really change your whole life. I mean, your whole perspective here. So thanks for sharing that with us. Now, in moving, you know, from student to now, you know, prof adjunct professor and on the APNA board, you know, maybe this is kind of a little bit of, you know, take a step back and kind of see, you know, you're young in your career, but like what's what sort of things do you hope that your students get from you when they kind of have those experiences, or or people who join APA and and see that you're on the board and see kind of the the trails that you're blazing and such. I mean, what are you hoping to be like remembered for? And what sort of things are you hoping to pass down to that next generation of PMH MPs?

SPEAKER_01 18:56

A couple of things. One is that it's really important. You know, I'm big on like pal policy, like advocating for better policies, like healthcare policies, because it kind of starts there, you know. And so getting involved is what I would say. I want people to get involved in whatever capacity that they're passionate about. It doesn't have to be the same things that, you know, I do. There's a lot of different ways to get involved and make an impact in that, whether it's like nurse practitioner autonomy or like different healthcare policy at the you know, local level, state level, federal level, etc. But also, arguably, most importantly, that like I kind of hinted at earlier, mental health conditions rarely, if honestly, if ever, likely not ever, exist in isolation from a person's like trauma, their relationships, their environment, their identity. And kind of tying back with like the therapeutic alliance, people, and this is like a spin-off of a of a common quote, but it's so true that these patients, these people will often, and I know this because of just personal experiences too, but and also feedback, but they will remember how exactly how they made them feel long after they forget the exact intervention. It wasn't the LexaPro that saved me. It wasn't, you know, this CBT, it was the way you made me feel. And so that's how I want to be remembered. Like, do people feel seen? Do they feel safe? Do they feel understood? You know, any sort of psychopharmacological skill that I have, you know, prescribing, you know, skill I have, it's it's uh all null and void when you compare it to something like that.

SPEAKER_04 20:45

So well put. Thank you. I mean, yeah, it's uh the analogy I always use is like building a house. You can't you can't build a house on top of a bad foundation, and the foundation is the relationship. And uh, and again, I think that's why people are drawn to to psychiatry and mental health is that they they like the relationship, but you like using, you know, they become the intervention yourself. You use yourself in the appointments and things like that. So very well said, Elizabeth. Thanks.

SPEAKER_03 21:11

Elizabeth, I'm gonna ask you one final question, and it really focuses about your local practice. Remind me, correct? You're in Kansas, correct?

SPEAKER_01 21:19

Yeah, Kansas,

Policy Advocacy Practice Acts And The Future

SPEAKER_01 21:20

Missouri, yeah, Kansas City, Missouri.

SPEAKER_03 21:22

That area around there, what is it like practicing as an advanced practice psychiatric nurse in terms of practice acts? One of the questions I want to start asking more regularly of individuals who are practicing is what are some of the unique challenges that you're experiencing? So as it relates to collaborating with physicians and the practice acts within your state, what are some of the challenges? What are some of the successes?

SPEAKER_01 21:49

So I'm right. I actually just lived in Missouri, but I live on the border of Kansas. So my practice and business, I have my own private practice and I do a W2 shtick. My I'm on the Kansas side, which is independent practice. So, like for my private practice, I don't have to have like a collaborative, collaborating physician, which is a it which is a win. I don't, and this is just my personal opinion, I don't disagree with states where you have to practice for like two years or something as a PMHMP first. I I don't I don't disagree with that at all. If anything, I would encourage that. As Dr. Convoy always told us and burned into our brains, at least into my brain, that I have to teach you how to practice like a psychiatrist in four semesters, which is true and scary and also very profound, which is why I do all the things that I do because I want to know what I'm doing. But also, that would be a big win. On I will say, on the Missouri side, it is not independent practice. And it is extremely difficult for people to get in and see a provider. And I also see, like for any sort of medications, especially controlled medicines, like people that have ADHD, for example, the the physician has to sign off on all of their everything, essentially, the medications, and it they see delays in care, but also delays in like getting their medicine on time. That would be the biggest thing that I would say that I see. Because I literally live on the border of both of those states, and they're vastly different with those laws.

SPEAKER_03 23:19

Thanks. I'll pass it back to Jeff.

SPEAKER_04 23:21

Yeah, that's um we we have mirror images. I mean, I I live in a border community here for Illinois and Iowa, and so my my wife and family grew up in the Illinois side of the community, and so that's where we live. But I jump across the Mississippi River every day and practice in Iowa because of the full practice authority. So so yeah, and and Illinois's gotten better over time, but uh, but yeah, that's the the fight continues as far as you know feeling that sort of restraint and such. So yeah, I think that the kind of wrap-up, maybe just uh if you wouldn't mind giving your perspective on where is where is the psych mental health nurse practitioner profession going? I mean, again, you're very well positioned, APA board, you know, on faculty and such to to kind of guide the profession. Like what's what do you hope is in the next five or ten years of of of what a PMHMP looks like or or maybe what you look like in five or ten years? Hard to say.

SPEAKER_01 24:14

I hope, well, I hope that I'm even more like I hope that I'm even better at my job in the sense of like making people feel seen and learning more about different treatments for mental health conditions, depending on what paper you read. It's like 20 to 60 percent of the time our medicines just don't work and 1% of research is spent on treatment resistance. And I hate that term treatment resistance, it sounds so hopeless, and I don't use that language with patients, but you know, learning more about I hope that the field is learning more about different treatments like the ketogenic diet, like spravato or ketamine or TMS or, you know, different interventions that are not medications. But also, you know, I hope that our field is going even more towards and away from, you know, there are some patients that are going to be five-minute med checks, and they that's just what it is, and that's fine. But also having our system set up where you get paid more to do a seven and a half minute med check and four of those in an hour rather than spending an hour with the patient. I think that that's an abomination. So I hope that the field goes more towards that and emphasizing that like the relationship between the psych NP and the person and the patient is not separate from therapy. It is the therapy. Does that make sense?

SPEAKER_04 25:35

Absolutely. Yeah, no, very

Closing Thoughts And Listener Callouts

SPEAKER_04 25:38

well said. Um and again, as we'll wrap up today, Dr. Elizabeth Francis, thank you very much for being here. Inspiring, I need to go write something down. I mean, it's just I hope people who are listening are feel as inspired as I am because I think the work that you do and the vision that you have for this profession is here to stay. So thank you so much for sharing that perspective. And uh those listen, those of you listening, look for a new episode. Heplows ghost coming out soon. Please again like, subscribe, send those comments. We want to hear from you as well. Please, we'd love to hear you know, people that you may want to hear from and then future episode. We're happy to hear it from that. So, all right, until next time, take care.

SPEAKER_00 26:18

We are nurses, the world can't forget.

unknown 26:20

We give our all, no regret.

SPEAKER_00 26:27

We are nurses.