Therapy Beyond The Med Check by Dr Karan Kverno

Fifteen minutes isn’t a clinical encounter, it’s a timer. We sit down with Dr. Karan Kverno to talk about what gets lost when psychiatric care becomes a rapid-fire “med check” and what PMHNPs can do to protect the relationship, the assessment, and the person in front of us.

Karen shares her nontraditional training roots in stress response management, where behavioral learning, cognitive tools, and psychophysiology shaped a practical, skills-based approach to psychotherapy. We get into how biofeedback has evolved from bulky machines to today’s wearables, why heart rate variability (HRV) matters for calming the nervous system, and how simple breathing training can support stress regulation and trauma recovery. Along the way, we talk about the quiet power of therapeutic language, positive suggestion, and meeting patients where they are.

From there, we wrestle with the real balancing act: integrating psychopharmacology with psychotherapy while practicing evidence-based care. Karen breaks down how she uses current best practice guidelines, how telepsychiatry can reduce access barriers, and why stable medication regimens should create more space for meaning, goals, and day-to-day coping rather than dominating the visit. We also confront burnout head-on, including documentation burden and high-volume schedules, and we close with a bigger lens on advocacy through community mental health, prevention, and building resilience in youth.

If this conversation helps you rethink how you structure care, share it with a colleague, subscribe, and leave a review. What’s one change you’d make to keep mental health care more human?

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_01 0:31

I think we're recording. Welcome back, everybody, to a new episode of Peflow's Ghost. I am thrilled to welcome our new guest here, Dr. Karen Carvarno. It's one of those things we were just talking about earlier, too. It's like we're kind of feeling like getting the band back together. Hopefully, Melissa, you don't feel out of place by saying that, but uh, but it's it's great to see Karen. I've I've been working with Karen and I hope I can call her a friend and a colleague for a number of years here and and have you know been missing part of this podcast. You know, we're over 50 episodes at this time, so yay, Keplow's ghost. But we're but a big person that I've always wanted to have on the podcast is Karen. Karen from Our Time Together has done a number of things, started the PMHMP program at Johns Hopkins, went on to Georgetown and kind of got their program up and going and is currently, if anybody does any cyberstrocking like I sometimes do, she is retired for a couple more months, as she was just saying, and is heading back as a consultant to Johns Hopkins. So John Hopkins is lucky to have Karen in her capacity as well. So so thank you, Karen. And as I kind of hinted at, I am joined by ever-present Dr. Kate Molino and Dr. Melissa Chapman-Hayes. And so let's get into it. Some of these times, like I said, since we've known each other, Karen, for a while, I like to kind of, you know, I was saying this in our last episode, I like kind of origin stories. Can you recall the time that we first met? Or what do you recall kind of from our first kind of meetings together? And and and thanks again for being on the

How They Met Through Standards Work

SPEAKER_01 2:05

podcast.

SPEAKER_03 2:07

I I think we probably first met through NOMF, right? Yeah. The work we were doing that you were leading, actually. And Kate was involved and several of us, and we worked to update the or make recommendations, I should say, for the exactly.

SPEAKER_01 2:30

Yeah. Right. Yeah. So for those of you who don't know, and again, most of you listening probably do know, but NOMF stands for the National Organization, Nurse Practitioner Faculty. And uh yeah, it was kind of serendipitous. We got you know put together on this panel to update their competencies for the PMHNP education, which is kind of national standards for that. And then we got involved with ISPN and been on the board with the foundation and and kind of work in there too. So so I know this story, but I think our listeners would really enjoy this again, thinking about origin stories. Uh, you know, as your history of being a psych nurse and an advanced practice psych nurse, what got you interested in in doing psychotherapy and then keeping psychotherapy, which I know is still a part of your clinical work and and research that you do.

Stress Response Training And Early Career

SPEAKER_03 3:17

Well, I I have to go way back for that. I my first job out of nursing school was in a neonatal ICU, just because it was across the street and they had an opening. And it was pretty stressful. And I I recall maybe before I got out of school that they passed around a brochure and there was a program at the University of Washington in Seattle that was focused on the management of stress response. In fact, that was what it was called, the management of stress response program, headed by a Dr. Helen Nakagawa, who was one of the first Japanese American nurses in this country after World War II. And thanks to one of the faculty at in the University of Colorado that welcomed a whole group of Japanese Americans into their program because it was it was still close to the time where people were in camps and things, and it wasn't it was kind of new for them. But anyway, so I I kept that in mind, and when I decided to leave the NICU, which was after my first year, I went to well, I took a stop for a couple of years in Wyoming because I skied a lot, and that was fun. But then I was still heading to Seattle, and I got there in the early 80s. I had a full ride. This was a time when the country was realizing that psych NPs could be very important in promoting access to mental health care. So I joined her program and took that as my major, the management of stress response. So it was a non-traditional compared to today, where we have psychiatric nurse practitioner programs. Well, back then there was no psychiatric nurse practitioner concept. And even the psych CNS was new. I'm one of the first cohorts of, I was in one of the first cohorts of psych CNSs. So my training was really uh, I would say behavioral focused, behavioral learning. And uh Helen had started a stress response clinic at the University of Washington, and the students, and there were a few of us, but we ran the program. So we saw patients, we were trained as biofeedback psychophysiology experts, and I was one of the first cohorts, first nurses to be certified as a biofeedback therapist. So it was behavioral in the sense that we focused on uh what people could do to reduce their stress. So we they could do things like monitor their their triggers and make changes in their behaviors, and they could also learn to perceive uh internally what was happening in their bodies. So with the the instrumentation, we can measure uh muscle tension, we can measure skin sweat, which is used for lie detectors, and we can measure or skin conductance, it was called, and hand temperature, and we could teach people to regulate, we could teach people how to calm their nervous systems through the vagus nerve, and we know that's very important, and uh and then we taught all sorts of relaxation techniques, lots of imagery work, lots of uh desensitization sorts of training. So it was behavioral, but it was also cognitive. And I even remember our textbook was called Helping People Change. And I still think that that's kind of my core is helping people change, people who have a problem that's stressing them or that's resulted in some sort of trauma, and then working with them to understand it better, to understand themselves better, not necessarily at a level that you would with analysis, but just in terms of you know, ABC, you know, what what is the antecedent? What what are you thinking? What are you doing? Yeah. And um, so that's that's my background in therapy, and that's what I've done. I I would say that after I was I was recruited from Colorado, no, from Washington State out here to the DC area in in the 80s, and the group that I ended up working with was called the Medical Illness Counseling Center in Chevy Chase, Maryland. And we saw people with all sorts of serious illnesses and chronic pain, and we treated them with mental health strategies. I was a biofeedback therapist there. We had two psychiatrists, we had physical therapists, I think. But we worked with people to help them cope with the tremendous stress of illness.

SPEAKER_01 9:22

Yeah, thanks, Karen. I think I remembered most of that story. I don't remember the uh skiing in Wyoming, which is uh we could go down a rabbit hole there and talk

Biofeedback Then And Now

SPEAKER_01 9:30

about. But uh, but you know, the one of the things that come up, and excuse my negativity with biofeedback, but just thinking kind of how times have changed, my experience of biofeedback currently is like using a lot of computer imagery and things like that for people to kind of, you know, it's if there's a visualization of their heart rate or their skin galvanization, as you were talking about too, and things. What was the the vi was there any visual components back in the 80s when you were first training, or was it more of just kind of yeah, what was it like, I guess, kind of back in the day?

SPEAKER_03 10:02

It's very different now. When I started, we had huge machines with little dial things that you people could see. It wasn't very fancy at all. None of the video imagery. In fact, we didn't even have computers when I was in my program. So I had to pay someone to type my thesis. So you know, things have changed a lot in terms of the technology. Now, I mean, there are so many things. Biofeedback is just a window into our physiology. So you could say a bathroom scale is a type of biofeedback or a the thermometer. But now you have heart rate monitors that you can wear while you're exercising. You can you can wear heart things that measure heart rate variability. And I was part of the Association for Applied Psychophysiology and Biofeedback for many, many years. I was on their board for a while on the biofeedback certification board. But we so I got very involved in heart rate variability. And when I came out here, things were really starting to change. And we have like there are small monitors that you can purchase for a couple of hundred dollars. People, you can have your patients purchase them, and they just use a pulse ox sort of clip on the finger or on the earlobe, and you can train people to breathe in a certain way and shift their heart rate variability, and it's extremely effective in quieting the nervous system. That is, increasing heart rate variability is associated with calming the nervous system. When we're stressed, our our heart rate variability gets very compressed. So people can do that on their own, but I think as a therapist, as a psych NP therapist, a lot of it is how I am working with the patient. So I might say another thing that I was certified in, I'm not anymore, I just let it go is hypnosis. And that's just the use of suggestion in a way and imagery in a way that can have have a pretty profound impact when people are able to dissociate a little bit in a in a consenting way. You know, people have to want to learn that. But I do find that I use a lot of positive suggestions still. And it's not like you're going to do this or that. It's more like, oh, maybe this time could be different.

SPEAKER_01 13:02

Awesome. Thank you, Karen. That's great. I'm gonna turn it over to Kate. But that's yeah, that's good. Thanks.

SPEAKER_04 13:08

Thank

Access To Care And Integrated Visits

SPEAKER_04 13:09

you, Dana. Thank you, Karen. This is so interesting. You know, I based on everything you said, and of course, also as in your role as an educator, I'm curious, you know, what do you think is the greatest strength of the modern psych MP?

SPEAKER_03 13:27

The greatest strength of providing access, I would say. You know, I think we are in places that a lot of MDs are not, for example, in prison and less more disenfranchised communities, rural communities. So I think that's what we provide that is different. Otherwise, I think we provide similar services.

SPEAKER_02 14:08

I'm gonna move to asking a question about psychopharmacology with psychotherapy. So one of the greatest challenges for modern PMHPs is balancing the biological demands, and you've talked some about that with today, this with heart, you know, right, nervous system regulation. So balancing the biological demands, specifically of psychopharmacology with the therapeutic art of psychotherapy, something that Pepplo championed fiercely. You've written extensively on evidence-based practice and psychotropic management. So, how do you teach students or advise clinicians to maintain a holistic nursing-first approach when the healthcare system often pressures them to focus solely on 15-minute medication management visits?

SPEAKER_03 14:59

Well, the yeah, let me just answer the last part first. The 15 minutes I think is horrible. And I have seen it in some of the psych centers that I where I used to send students, and it's it's just not not enough. And it's not enough for psychoform, much less any kind of therapeutic interaction. But I I've worked in the Med Star system for 15 years, and I usually get a half hour, which it still isn't that long. However, it's enough for me to do follow-ups. I do an hour-long evaluation, I do follow-ups, and I tend to work with people with complex problems. So uh initially, people often have uh a choice, you know. Do you want to just focus on using therapy? Do you want, do you want some, you know, you could be treated with some medication. But for a lot of my patients that who have serious mental illnesses, the medications are a big part of their treatment. So you were saying the time constraints. Well, I think with follow-up, you know, once you get people on medication, you titrate to a therapeutic dose, and people are doing well on that. The focus isn't really the medication when they come back in. I mean, you see, you're saying that people need a refill, an adjustment, but mostly we're asking people, you know, what have you been doing and how have you been doing and anything new? And and you're you're working with them therapeutically. So I've I just my contract with Med Star was tied into the university. So right now I I had to transition my patients, which is really complicated after a while. Took me quite a while. But but my patients had been with me for five like up to 15 years, and I knew them very well. I knew their cats' names and their dogs' names and their kids' names, and you know, it's not a focus. I I don't think the focus is psycho farm, even when you're using psychopharm. It isn't the whole focus, but it is important for a lot of patients. And I I teach my students to use the best practice guidelines, and those are, you know, you have to look for the most updated ones and the ones that are from the professional groups that are the most, I would say the most respected for their practice guidelines, like the VA DOD, the Child and Adolescent Psychiatry Association, and the APA. They have pretty consistent guidelines. At least one of them usually has current best practice guidelines. I have them use the BIERS criteria, I have them learn all those structures so that they can go to those, you know, that because they have to keep up with it. They have to know that a textbook goes out of, you know, by the time it's published, there are going to be medications in there that are not listed. I mean, medications that may be very good that are not in that textbook.

SPEAKER_02 18:38

Yeah, I can hear playing that tension between psycho farm and psychotherapy and therapeutic approaches. I can see just as you're talking how you interweave them as you're mentoring clinicians and teaching students. So thank you for that.

SPEAKER_03 18:52

And I like having students because I can have, and I during COVID, we started seeing patients through telepsych. And I live in the DC area. My hospital that I was involved with was in the Baltimore area where Johns Hopkins is located in University of Maryland. And actually, Dan, I started the program for University of Maryland way when the psych NP started. Dang, I forgot that. Sorry. So my contact with Medstar started when I was at University of Maryland. But anyway, so it's really it was nice for me to do telepsych and I was seeing a lot of patients that had mobility problems, either from physical problems or because of finances, you know, just the cost of getting around, not having a car. And so when I had a student, I could have the student follow up with any changes in medication, see how they were doing, you know, and I I like having students for that purpose, that we can focus during the sessions on things that the patient wants to focus on, the patient comes in with, and then we can still follow up with meds pretty closely if if I have a partner like that.

SPEAKER_01 20:13

That's amazing. Yeah, I think, you know, that's holistic care. I mean, that really kind of breaks down. I mean, it just knowing your patient's pets' names, I think that's uh above and beyond. And, you know, part of it too, right? I mean, I guess that's you know, that's a it's like a symptom of of what you how intimately you get. And I loved how you said it too. You were, you know, once you get them on their medications and they're pretty stable with their meds, it it's a lot of getting to know the person. And I think that so rings true for me as well.

Mentorship, Documentation, And Burnout

SPEAKER_01 20:40

So I'm gonna kind of take a little shift in our next topic. And and I think Melissa, you know, did a nice job of trying to transition us too. But Hildegard Pepplau was, you know, kind of a legendary mentor. I mean, we've had people who've met her. Um, have you ever met Karen Karen? Have you met Peplow before?

SPEAKER_03 20:55

I'm trying to remember. I don't think I ever met her. I may have seen her speak once or twice, but no, not yet.

SPEAKER_01 21:03

But so you may know. She was a you know, she was a quite a mentor to people and you know, push people to you know be better and get more education. And and your role as an educator, I mean, you've mentored many people. I mean, I I I would love you to think that you were, you know, partly a mentor, mentor for me as well. But thinking about that as you advise students and and you know, continue to be an educator, continue to be involved in academia, uh, one of the things we talk a lot about on the podcast is this idea, as Kate was talking to, the pressure of the 15 minutes and the med check and all the technology and all this kind of stuff is just kind of really putting a lot of pressure on mental health workforce in general. So, how do you how do you foster, how do you mentor people to to you know, to take care of themselves and and to make sure that they can prevent themselves from from burning out or or kind of suffering any mental health problems that they're trying to help other people with?

SPEAKER_03 21:50

I I think it's a big problem, actually. And the the whole thing with, you know, more and more regulations and And computer systems where you have to check boxes. And I think that can make people less accurate because they're just, you know, in a hurry checking this box and that box for mental status. Where if you write it out, you really have to think it through. But so I usually, when I'm working with students, I have them write out their mental status exam so I can really see that they understand how to describe mental status, how to evaluate it. But I think that the burnout issue is huge. I I for personally it is. I, you know, I um if I'm focusing on patience seeing, and and this is bad, I know, but it'll show you I do half hour rather than 15 minutes, because I sometimes see up to 14 patients in a day, and I'm I'm burnt out by the end of the day, and I haven't finished all those notes, and I have to go back and spend another day or whatever to finish those notes. That is a burnout. I I mean, I I guess maybe people are turning to the the AI, listening in, writing the notes, but I don't know how that is. I haven't tried it. It's got its own issues, I'm sure, plus privacy concerns. Yeah. But I do think I do think we have a big problem with burnout. And I I I can tell you I've been there and I you just and P and I encourage people to take care of themselves. I'm taking care of myself right now, taking a little break. Good.

SPEAKER_01 23:52

Yeah. Well, I think it goes back to a little bit too of just getting to know your patients, right? I mean, yeah, make the joke again, knowing your patients' pets' names and things. I mean, you know, being a pill mill where you're just kind of you know refilling medications, I don't think is is why any of us gotten this work. And so that can lead to more just kind of dissatisfaction and and burnout, too. So thanks, Karen.

SPEAKER_03 24:14

And the meds are it's not simple because most problems are complex. And a lot of psychiatric or mental disorders are comorbid with other. I mean, it's comorbidities are common and it's the medication does take time to think through, but when you're with the patient, you you need to be able to help them decide and give consent. But it doesn't have to be the whole, you have to have time to hear what's what's happening today, or how have you been since I saw you, and what would you like to discuss? Otherwise, there's no relationship.

SPEAKER_04 25:05

Yeah.

SPEAKER_03 25:05

And that's Pebla about, you know, you have to see the person, hear the person understand what they're going through.

SPEAKER_04 25:16

Karen, I wonder if I could I just ask you to elaborate a little bit on that.

Whole Person Assessment Changes Treatment

SPEAKER_04 25:20

You know, you've talked about how you work with very complex patients. Many of us do. And I'm curious perhaps if you could think of an example where, you know, using this sort of whole person approach allowed you to learn information, you know, develop a treatment plan that would have been totally different had you only really stuck to the more sort of biomedical investigation of that person.

SPEAKER_03 25:46

Well, I I mean, I can tell you people that have had really incredible outcomes over time because they engaged in the process and they made decisions about what they wanted. And and I hope that I helped facilitate some of that. I mean, I can give you an example. I saw a young woman when she turned 18, she came to the clinic by herself, she was scared, her knees were jumping, and she had lots of uh symptoms of different things. You know, the differential included OCD, included depression, included uh GAD. She may have had some panic attacks, but she had trauma. You know, she came from a traumatic home situation, and that's why she came as soon as she could on her own. And over the years, she's just she's used me as a resource in a very good way when she was at college, when she went to graduate school. Now she's studying in a profession that is her passion, and and I feel really happy for her because I've known her since she came in as a scared kid. I have other patients that maybe came in with very complex problems. Let me just think of another example. Well, I have another, I another similar one, I won't say that, but say a patient that's been on ECT who gets bumped out of their system for whatever reason, ends up with me, and the person is still getting ECT. I don't quite get it. Oh, I know. Let me tell you about another person who came from another state, no record. Had the the only way I got her was she had a pulmonary embolism, and they took her off paliperidone, long-acting injectable, because that can trigger a pulmonary embolism, apparently. I didn't know that before. But as I evaluated her, I didn't see the psychosis. I couldn't get a history of a manic episode, and she's like close to 80, maybe 70, something. And so I waited. And I next time I saw her, I got her sister to come, and they told me about a time where she thought that Elvis Presley was flying in to see her at the airport. And it was a time when she was yet, excuse me, younger as a teen. I don't know if she was using any drugs. The history was still vague, but there was some altercations with the mother. She had a at some point there was a legal thing, and they put her on medication. And her understanding was that she had to stay on medication to stay out of jail for her life. Well, I looked on the records because she came back to this state where she grew up, and that record had been closed in the 80s. So I told her, you know, you don't have to take medication. Your case was closed. Well, she's fine, she's doing really well. She lives with her sister, she's not on medication. So I think it's how you don't, we don't, we shouldn't just assume that because somebody was treated by a health system psychiatrist, that they're gonna need all that medication anymore. Maybe they don't need it at all.

SPEAKER_04 29:53

Thank you. That's such an incredible example. I just I love that you shared that. And it really speaks to sort of our role as well, the word that comes to mind is detectives.

unknown 30:04

Yeah.

SPEAKER_04 30:04

You need to look beyond the surface and really investigate more. I'm so glad to hear that person is doing well.

SPEAKER_03 30:09

Yeah, because I tried to get the records, I couldn't get the records. So the next thing was just to wait until I could really make a diagnosis. And I could not make a diagnosis of for a reason for paliperidone long-acting injectable. Yeah.

SPEAKER_02 30:28

Well, this is a good segue talking about advocacy, curiosity of patience, and going

Community Advocacy And Youth Resilience

SPEAKER_02 30:34

deeper. So thinking on the level of advocacy and professional advocacy, whether it's fighting for full practice authority or upholding strict ethical standards, it's woven into the DNA of psychiatric nurse history. So if you could rally the entire PNH and P community around one urgent issue or standard of care that needs collective voice right now, what would that be? And then how can that torch be carried forward?

SPEAKER_03 31:07

Well, I think you're right on with advocacy. And I think, well, I'm signed up to take a community resilience model course coming up in August, which is it fits with my background, but also it's addressing youth. We're going to be looking teaching teaching people that the community selects in the DC area how to reduce the stress and trauma in youth through this resilience model, which involves teaching people how to manage stress, for one thing. But I think that, you know, as uh as providers, we're paid to see individuals. But I think that as educators, we have to take one step back or two in the social ecological model, you know, it's the person, the family, the community, and really try to help the community reduce the risk factors for youth because I'm not a youth, I I I got my certification when it was called adult or family, and I'm an adult psych NP, and I did a postdoc in JEROSYC, so I'm really not at the end of the youth, but I think you know, by the time I see patients, sometimes they've had so much trauma that could have been identified earlier, and maybe some of their problems could have been prevented. So with my students, I really I've built I for Hopkins, I built build a community course, kind of an integrative care course. In fact, that's what I called it. And I had students working in their own communities, wherever they lived, uh, to identify some of the risk factors and then to address them. So it went over two semesters. And when I came to Georgetown, I started or I developed the same thing, only it was called community mental health. And it was different because I was working with the DC community, and I brought in Kim McClellan, who's who's been at ISPEN recently over the years and was a former student of mine, and she does community mental health. And so she'll be in the community, she'll be working with the students, and I think that that's how, as educators, we can have we can provide advocacy and help to promote better access, more equitable access, and reduce some of the early triggers or risk factors for mental health problems.

Closing Thoughts And Listener Invitation

SPEAKER_01 34:17

That's awesome. Thanks, Karen. I think that'll probably wrap us up for today. I'm feeling inspired. I hope others that are listening right now, I want to go set up a meeting with my community leaders right now and start making some changes. But but hopefully that fire that you were talking about there and can light some fires within some other people too. Thank you so much, Karen. This has been a pleasure. Thanks for being on the podcast and thank you for listening. I really appreciate all of you out there listening and uh getting a real faithful following here, which is great to see you at conferences and other places out in the community. Please keep in touch with us, suggest ideas, different people who should be on the podcast. Would love to hear from you. Please like, subscribe, and uh comment. So look forward to another episode of Pepsi Ghost coming up.