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
Psychiatric NPs Need Both Meds And Meaningful Talk with Dr Paula Alloca
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The fastest way to miss what matters in psychiatric care is to treat the visit like a transaction. We talk with Dr. Paula Allocca, director of a Psychiatric Mental Health Nurse Practitioner program and founder of an integrative functional medicine psychiatry practice, about how advanced practice can keep its soul while expanding its scope. Her story moves from an early love of people’s stories to deep CBT training, teaching and research, and then a pivotal decision to add medication management so she could better serve patients whose needs go beyond talk therapy alone.
We dig into the profession’s big transition from therapy-forward roles to prescribing-forward workflows. Yes, PMHNPs gain the ability to address biological well-being and to fight stigma by treating mental health as brain-based health care. But we also name what gets lost when “15-minute med checks” replace a working therapeutic relationship, especially in a world where AI and speed can pressure us to move too fast. The throughline is clear: without the therapeutic alliance, trust fades and lasting change becomes harder.
Functional psychiatry gives us another lens: symptoms are signals, not conclusions. Dr. Allocca explains functional medicine as systems-based thinking that looks for root causes, then shares how issues like gut dysbiosis and the gut-brain axis can show up as depression. We also get practical about training psychotherapy skills in online PMHNP education, what telehealth changes, and why eye contact and intention still matter. Subscribe, share this with a colleague, and leave a review if you want more conversations that keep psychiatric nursing relational, rigorous, and 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
Welcome And Guest Introduction
SPEAKER_02Well, welcome everyone to another episode of Peplau's Ghost. My name is Kate Molino. I'm an associate clinical professor and psychiatric nurse practitioner at the UCSF School of Nursing. My co-hosts, Dan Wiesman, Sean Convoy, and Melissa Chapman-Haynes, are on vacation this week. So I get the opportunity to have an amazing one-on-one conversation with our esteemed guest this week, Dr. Paula Alaka. Dr. Alaka is the director of the Psychiatric Mental Health Nurse Practitioner Program at Shenandoah University and received many of her degrees from Victoria Commonwealth University. She also founded Commonwealth Integrative Psychiatry and Functional Medicine, which is a functional psychiatry practice, and completed her dissertation with regards to a cognitive behavioral therapy intervention for women undergoing breast cancer treatment. So, Dr. Alaka, welcome to Pepla's Ghost. I'm so happy that you are here and that we get to have a conversation today.
SPEAKER_00Thank you. I'm so happy to be here. So really looking forward to this. And I've enjoyed several uh previous, you know, podcast
From Pharmacy Plans To Nursing
SPEAKER_00episodes. So this is exciting to be able to be part of this.
SPEAKER_02Oh, that's great. Thank you. So, you know, Dr. Alaka, one of the first questions I wanted to ask you about was actually about your educational preparation. You know, having a PhD and a nurse practitioner certification is a fairly rare combination. I'll I have that myself as well. So I'm really interested in what drives people to do that. So I wonder if you could speak a little bit to you know your your pathway and how you kind of ended up where you did. That's a that's a great question.
SPEAKER_00And be careful because I might want to ask you the same thing. So basically, as I I think that for me, my pathway actually started in childhood. I I was the person that kept saying to my mom, I want to talk to people for a living. And I didn't even really know what that meant, but I have been drawn to people my whole life. I've been drawn to their stories, I'm drawn to their challenges. And you know, sitting with people is something I think I've done really my whole life, right? Even in high school and whatnot. I didn't necessarily have a one friend group, but I found I was involved in many different friend groups. So as I graduated and then went to I went to Mary Washington College in Fredericksburg, Virginia for my undergrad, the first part of my undergrad degree, thinking that I was going into pharmacy, which is interesting that I eventually got an MP. But so I think that I came home one day and I was working at the pharmacy, standing behind the counter over Christmas, and I realized, oh my gosh, I can't stand behind a counter the rest of my life because that was the role at the time. And so ultimately said to the pharmacist, oh my gosh, what am I gonna do? My parents have helped me with this investment, and you know, now I'm stuck in what I'm, you know, I don't know what I'm gonna do. And he said, Hey, you should go into nursing. So I went, okay, great, good idea. Okay, not knowing even what nursing really involved. But long story short, that was the best stumble that I think I ever made in terms of, you know, sort of my career and you know, my educational pathway. So basically, I ended up getting my master's degree as a psychiatric mental health clinical specialist. And at the time at Virginia Commonwealth University, outpatient psychiatry, I had the amazing opportunity to work with several psychologists there who were deeply trained and knowledgeable about training others in cognitive behavioral therapy. So all of a sudden I realized I have found my love, you know, where nursing maybe felt sometimes a little awkward to me, because even when I worked on a bone marsplant unit, which is where my dissertation stemmed from, what I wanted to do was sit and talk with my patients, more so than, you know, administer chemotherapy or, you know, you know, those types of things. What I really found was my passion was sitting with them. So as I got my clinical nurse specials degree, really found that this was exactly what I was supposed to be doing. This is what I meant when I told my mom I wanted to talk with people and had some amazing psychologists who trained me, who helped support me, and really found that to be so valuable, realizing then at that point I probably wanted to teach others. So at the time, they had just started a non, they called it kind of a non uh clinical, non-bench science, you know, sort of a PhD approach, where they allowed me to go over to the School of Psychology and get some of my courses. So it was a pretty cool degree at Virginia Commonwealth University where they let me sort of kind of create this psychological approach, you know, to building on my clinical nurse specialist degree. And really, my faculty were all clinical nurse specialists, so they really found that to be very interesting as well. Too, as I got into that, got into teaching, got a chance to really do some amazing grants, do some different things, but soon sort of just felt that complete yearning to go back to, you know, patient care. And at the time, they had just introduced the nurse practitioner degree. It was so new. I mean, everybody was nervous about it. They were trying to get it launched. And lo and behold, I thought to myself, I probably should go ahead while I'm here in the school, get a postmaster's as a nurse practitioner. And again, I think it was one of the best sort of accidental steps that I took. Maybe not accidental. I knew I wanted to do it, but at least it was a step that I hadn't fully planned to take. But won't lo and behold, it really has sort of, you know, created, I think, sort of a full circle for my the work that I do. And a lot of it was is because as a cognitive behavioral therapist, primarily, you begin to learn pretty quickly that there is an amazing amount of work that you can accomplish doing using CBT. We know that, right? But the the other piece of that was is I still found out if I was sitting in front of a patient with mania or sitting in front of a patient with psychosis, CBT was not going to be a useful tool. So I really saw medication management then as a sort of again that full circle moment where now I had a full tool belt and could really work with a lot of these, you know, patients and make sure that what the patient need was that's where I could sort of help sort of, you know, uh support their their clinical and health goals and needs.
SPEAKER_02So yeah. That's that's incredible. I love how you really just spoke to how you came to decide that you needed sort of med management skills to augment your psychotherapy skills. Often we're talking about the opposite when we talk about nursing and and this role. So I think that's so interesting.
SPEAKER_00It it is. And now that you say that out loud, and I'll also say, while it's interesting, I'll also say I think it's very important. I I don't think we can, I think we run the risk of letting go of those psychotherapy skills if we're not careful. And that's why a podcast like this is so valuable. That's why the work of ISPN is so valuable, because we have to really make sure that we're, you know, we're really sort of continuing to sort of practice that foundational piece of who we should be, you know. And I think Peplau would probably agree with us on that one.
SPEAKER_02So absolutely.
What Psychiatry Gains And Risks
SPEAKER_02And so I wanted to dive into that a little more. You know, you spoke to how you completed your master's degree as a CNS and then later came back for the NP credential. And so you have really, you know, lived through this field during a very important shift from a more therapy-focused role to a more, you know, prescribing focused role. And so, you know, I'm curious, like, what do you think when you think about our advanced practice psychiatric profession, nursing profession, what do you think that we gained in that transition? And what do you think that maybe we gave up?
SPEAKER_00That's a really good question. I think what we gained is we gained the opportunity to also participate in sort of the biological well-being of our patients, right? You know, in that, although I'll tell you, we do know CBT will change brain function. We know it changes, you know, how a brain, you know, pathways are created and generated and, you know, and whatnot. So I I think that what we gained is an ability to speak to the patient's whole brain instead of, you know, maybe just parts of the brain. And I think it also allowed us to start talking with patients about the fact that this is these are brain-based, you know, health needs. And, you know, we really want to make sure that we uh be continue to sort of, you know, you know, move away from anything that you know increases stigma. You know, we want to continue to sort of open the door to where seeking mental health needs is just as commonplace as seeking, you know, primary care for diabetes is the example we use a lot, right? You know, so but it's it should be, it that should be the case. And what did what do we stand to lose? I think what we stand to lose is really just what we've already mentioned, is that the absolute importance of the therapeutic alliance, and I think that a lot of people started looking at their uh opportunities really from maybe a dollar-based position rather than from a therapeutic alliance position. And you know, the 15-minute med check sort of even became adopted, I think, by a lot of NPs. And so I make sure with students that I talk a lot about the risk of that and making sure that we avoid that. Because if we lose the therapeutic alliance, first of all, in this in this new emerging AI, we lose our opportunity to gain and develop trust and gain and develop truly sort of a therapeutic, you know, alliance and an opportunity to create lasting change because you can create, you know, change for anybody, but will that change be lasting? You know, it's only when you sort of add looking at the studies, only when you add CBT to whatever medication management is being used.
SPEAKER_02So absolutely. Thank you. And I I want to just uh our co-host Melissa Chapman Haynes has joined us. So welcome, Melissa. And I will pass the mic to her.
Lessons From A Venlafaxine Trial
SPEAKER_03So I'm the non-nurse, and that's gonna come through with my question because I think I'm gonna mispronounce uh medication that I'm not as familiar with. Okay, you can correct me. So you worked on a multi-center venilexifene.
SPEAKER_00Venil venilfaxine, yeah.
SPEAKER_03Venilfaxine, yes.
SPEAKER_00You guys really did your homework. This is great.
SPEAKER_03I was going through iterations of how to say that. Okay, say it one more time. Venillafaxine. Venillafaxine.
SPEAKER_00So you work called effects, right?
SPEAKER_03Oh, okay. So you've worked on those affects her trials early on, and now, of course, you run an integrative functional medicine practice. So we were wondering, what did you see from inside that trial infrastructure that moved you toward a different way of practicing?
SPEAKER_00You guys ask amazing questions. I think what I saw in that. So the funny thing is what we used to advertise that study was this headline. And believe it or not, we put it in the sports section because we found men were probably more prone to generalized anxiety disorder than women. So we made sure we put our ad in the sports section and we sort of put it with sort of the the heading, Are You a Warrior? Because that's one of the kind of the hallmark symptoms of somebody with generalized anxiety disorder. And what they were basically sort of testing, and now we've really come to understand that SNRIs, serotonergic and noridinergic, you know, re-uptake inhibitors, actually can really help with some of that anxiety. So I think what I really learned there again is that we we want to get to the root cause. And if a serotonin agent isn't gonna be the right prescriptive approach to treating something fully, can we think along other lines of what could be going on chemically, biochemically in the brain, you know, where we want to make sure that we're addressing additional, you know, sort of uh or or looking at additional approaches to try to treat symptoms as efficiently and effectively as possible.
SPEAKER_03Nice. Thank you. I love especially how you advertise to get to who you wanted to reach. That's very creative. That's so creative.
SPEAKER_02And and you know, Paula, as a follow-up to that question, I think, you know, sort of integrative psychiatry, functional medicine is becoming more popular, more people are becoming aware of this approach.
Functional Psychiatry And Root Causes
SPEAKER_02For our audience, could you explain really what you know functional psychiatry is? And we would love if you could maybe think of a patient example, the someone you've worked with, and how you kind of walked through what was going on with them to develop this type of treatment plan. Okay.
SPEAKER_00So so basically the interesting thing about functional medicine is, and I agree with you, I really do believe we're seeing a growth in the field of a lot of practitioners who are, and I'm just going to call it returning to our roots. Because when we all start with the three Ps and we all have pathophysiology, in essence, that's really what we're learning when we talk about functional medicine. So, no, so we're not just addressing, you know, sort of, I'll kind of call it the the you know, pharmacologic sort of biologic component of the brain, with where we're talking about neurotransmitters, but we're also being reminded of what systems are are operating underneath the surface that are maybe dysregulated, disrupted, because we all learned that once one system is slightly dysregulated or disrupted, it's going to often lead to another system sort of becoming dysregulated. So in functional medicine, instead of looking at sort of an organ, we think about systems that the organ operates in. So we might talk about GI health, we might, and that will be the example that we're going to go to. But we we also talk about things like I remember when I first studied it and I was able to go and psych the sort of psychiatry wasn't sort of being included just yet in that. So it was really pretty medical sort of oriented. But there were a few psych NPs who were taking the course who said to me, You're never going to look at psychiatry the same way again. And I think that they're absolutely right. And so basically, functional medicine is that appreciation for the pathophysiologic aspect of what's happening in the body. And then our work is to just as we say always, you know, we're doing that thorough assessment. We're using the therapeutic alliance to open the door to where therapeutic communication is sort of taking place. We're able to begin to understand all of the different components. And you're looking sort of for the root cause because you can say depression and I feel depressed, my mood feels depressed, I feel down. And that can be all kinds of things, right? That could be depression, it could be anemia, it could be hypothyroidism. And so you're really looking for what system is dysregulated, and then therefore that's the system that I want to treat. Whereas I think, and sometimes more we'll say sort of a mainstream approach, we use a lot of now we've really gotten into a lot of algorithms, right? So if a person has a certain set of symptoms and maybe even say they score high enough on the PHQ9, we might say, aha, this has to be major depression, and therefore I'm going to treat this condition with, you know, an SSRI, an SNRI, you know, something along those lines. So a good example would be really just that, in that I had a patient who come to find out, didn't mention it sort of in their initial evaluation when you go over some of the medical pieces, and they were being seen for major depression. And while they had had a history of it in college, they were now in their late 50s and had not had any depressive episodes in between those two. So what we sort of agreed on was that, you know, we're gonna we're gonna start with an antidepressant. So I believe in a, you know, really kind of an integrative approach, right? Where we're taking what we know and understand, you know, from research in terms of benefits, and then we're sort of bringing it into the functional medicine model. I didn't throw the baby out with the bath water, if you want to say it that way. And so as we really got into it, we started recognizing that there was probably some, you know, some gut dysbiosis going on there, you know, really. And so get, you know, helping this individual sort of, you know, do some testing, diet testing, allergen testing, you know, then sort of gut restoration sort of strategies. We really discovered that by treating the gut, we actually were treating, you know, this depression. So, so what was the root cause of that depression? Right. You know, it's it's sort of mind-boggling when you start to think about it. But now the whole gut brain axis is very well known. Actually, you know, they discuss it in NEI. And, you know, that it's, you know, so as anytime it becomes more mainstream like that, you're just so excited because again, that's where I think mainstream and functional get to really sort of highlight the importance of something for, you know, improving patient care. Because while, you know, you you you I believe you never want to use a medication unless it's warranted. So if if treating gut is going to really bring the change that you're looking for, then, you know, lo and behold, maybe you don't need that SSR, especially in somebody who hadn't had a recurrent episode. Now, if there had been a lot, several recurrences along the way, I think I would have thought differently about that. But in the meantime, you know, it just let us create a lot of change by really addressing, you know, nutritional support, you know, addressing adding probiotics, you know, and doing some of these things that actually really did make a pretty significant difference. So now that's a case study. So, but we do know we have studies on on this now.
SPEAKER_02So that's an that's such a fabulous example. And I think it's also really illustrates, I think, how nursing can really shine in this in this approach because it's very much aligned with what we have learned about, you know, nursing assessment, nursing process, and addressing all the spheres of a person's life. Yes. Yes.
unknownYeah.
SPEAKER_00I love talking with the students, for instance, at Shenandoah about uh formulation, right? Because I think that's exactly Kate what you're getting at is that we are, we are, we want to think about all the pieces. You know, we used to joke when I first got into nursing that nurses were the sponges of healthcare, you know, and that we had to absorb the responsibilities of all the different disciplines that we worked with. So, you know, maybe we were a little bit social worker, a little bit psychologist, a little bit of the physician, you know, and sort of we had these pieces. And so how wonderful now that nursing has really been able to grow into this really amazing profession, amazing profession. I tell people thinking about nursing all the time, do it. It'll be the best thing you ever did. Because you missed this part, Melissa, but I shared I was supposed to go, I thought I was going into pharmacy is when I first started, and then kind of realized I'd made a maybe it wasn't going to be the thing for me. Great profession, not for me. But I'm so glad that I I've I'm so happy I've been on this journey of nursing because it has been an incredible profession to be part of.
SPEAKER_03It goes in really nicely to our next question, actually.
Teaching Psychotherapy In Online Programs
SPEAKER_03So, you know, you direct a PNHMP program that runs online and shares curriculum across partner institutions. And then psychotherapy is a relational, supervised, watched, and be watched skill. So, what does that look like to do that virtually?
SPEAKER_00Wow, that is a challenging question to answer. So I think I'll say to you first. Foremost, we are an online program, right? That is the reality. But I think we all learned as we got on Zoom that you really can have a therapeutic alliance even over Zoom. Now, are there some you know, maybe some hurdles to get over with that as well that you maybe wouldn't have in person, potentially, right? But there also are some distractors that go away when you're strictly face to face, you know, and you're not seeing my entire office, you're not looking at my pictures and trying to ask me what they mean. And, you know, there there can be some really focused, concentrated eye contact, you know, and then sort of the establishment of sort of we're here to accomplish something therapeutic. And so I I believe that goes even into the classroom. So when you're training students and you're talking about psychotherapy, well, I will say we do do an immersion at the beginning where we bring them on site. And this is really where we launch them into with through simulation and whatnot. We we help them set the stage for their uh opportunities to establish therapeutic alliances with patients and help them practice that before they start their their clinicals. Then with their clinicals, we are able to place them usually within an hour or so of their where they all live, because I've had students in West Virginia, Maryland, you know, mostly from Virginia or from Virginia. So, but it's you're able to place them there. So between connecting all your dots and you know being able to ultimately sort of you know assess them, you have that ability to begin to understand whether they can form that therapeutic alliance or not, and whether then they can sort of master some of the therapeutic strategies and skills that are required for the different psychotherapies. So it's a a little harder to do, probably, and that's really why that's such a great question, but it is possible.
SPEAKER_03Yeah, as a you know, non-nurse, non-practicing, you know, counselor psychologist, I have found bringing people together once, even if it's once a year or just once, can go a really long way. Can go a really long way. And then I really also appreciate the point you made about the fewer distractions, because as a patient of psychotherapy, I've done it virtually twice with two different therapists, and I prefer it.
SPEAKER_00That's interesting, right? And some people do prefer it. But then there are we have those that say, you know, oh no, I only do it inpatient, you know, or in person, you know. So I, you know, I believe life is the bell curve, you know, and so right. So we have every, you know, we've got most everybody right there in the middle with us, but you know, we're always gonna have those who have their strong preferences as well, too. But, you know, and and look, I've had a couple of patients who have come to me curious like, could you really have a good therapeutic alliance on Zoom? And but this was a person who wouldn't turn their camera on, right? So, you know what I mean? So it takes eye contact. It takes eye contact, I think, to really establish that therapeutic alliance. So yeah, absolutely.
Peplau’s Roles You Can Try
SPEAKER_02And my next question really kind of dovetails on what we're just talking about. It's bring it back to our pod podcast namesake, Pebw. Her argument was really that the relationship itself, the therapeutic relationship, is really the treatment, what's happening between the nurse and the patient. And so, you know, Dr. Alaka, given your extensive experience and knowledge in the field and really how you center that in the work that you do, what is one thing that you would want a psychiatric NP who might be listening to this podcast to try in their next clinic day, if this is something that they want to build their skill with more?
SPEAKER_00I think that I would encourage them to probably look at the different roles that Dr. Pepplau outlined for us, you know, stranger resource, you know, and and and to follow those, to understand what they truly mean and to follow those, you know, because while a therapeutic relationship has to get established, it also has to become working, right? It has to get launched into a working phase. And I think that so many NPs do a good job still with maybe even setting or gaining that alliance. But if that alliance doesn't become a working, you know, relationship, you're really gonna miss, I think, the real ability to create change in that person sitting across from you.
SPEAKER_02Yeah, excellent advice. Thank you.
Iceberg Lesson For Future Practice
SPEAKER_02So at this point, we will move into our, I don't know that we've named this segment, Melissa, where we have our previous guest ask a question to our current guest. Oh, our previous guest on this podcast was Dr. Chris Vandenberg, and she has a question for you. I will go ahead and play that. Okay.
SPEAKER_04So thank you. Here we go, Chris.
SPEAKER_01Well, I'm gonna call you Dr. Paula. So, Dr. Paula, I have a question. I looked, did a little stalking of you and noticed that you have a long, wonderful career of integrating with psychotherapy and medication management and look forward to for them to have you on the podcast. My question is what is one lesson about psychiatric nursing or mental health care that you hope every student that you've taught carries with them 20 years into their practice?
SPEAKER_03Love it. Crystal ball question. That's so great. Let's hear what Paul has.
SPEAKER_00I think what I would like students to visualize and to keep in mind is that person sitting in front of them is, you know, using the iceberg analogy, right? They're a very complex human being. They've had a lot of life experiences. And if you can respect the complexity of who they are and address them as a whole, you are going to get a long way with making a significant difference in somebody's life.
Closing And Listener Call To Action
SPEAKER_02I love that. Thank you. Well, Dr. Alaka, it's been wonderful to have you on our podcast. Thank you so much for spending this time with us. We really appreciate it. To all our listeners, thanks for listening. Please like, subscribe, share, comment, etc. Uh, we'll be back next week with a new episode of Cup Love.
SPEAKER_04Don't forget, don't block in our way, but I do, no, this, don't take it. We have noticed it.
