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
Therapy Notes: What to Write When No One's Looking with Dr. Kate Wheeler
Ever wondered how psychiatric nurse practitioners seamlessly blend talk therapy with medication management? In this illuminating conversation, we're joined by Dr. Kate Wheeler (lovingly dubbed "East Coast Kate") who shares her journey of maintaining a vibrant psychotherapy practice even after retiring from academia.
Dr. Wheeler offers a candid look at her approach to therapy, particularly her specialization in EMDR for trauma patients. With refreshing honesty, she explains why she prioritizes psychotherapy over medication management: "My goal is always to get people off of stuff rather than starting a medication." Her practical insights on patient screening, managing therapeutic relationships during extended absences, and documentation practices provide valuable guidance for practitioners at any stage.
Meanwhile, Dr. Kate Melino ("West Coast Kate") provides a fascinating contrast with her work in a home-based primary care setting. Her approach to therapy with homebound adults, many facing end-of-life issues, demonstrates how narrative therapy and existential approaches can be adapted to serve unique patient populations.
The conversation takes an enlightening turn when the hosts discuss documentation requirements, with Dr. Wheeler candidly sharing her preference for process notes over insurance-driven progress notes in her cash-based practice. This sparks a valuable discussion about balancing clinical needs with regulatory requirements.
Whether you're a psychiatric nurse practitioner looking to incorporate more therapy into your practice, a student wondering about the practical aspects of psychotherapy integration, or simply curious about the intersection of talk therapy and medication management, this episode delivers practical wisdom from clinicians who've successfully navigated these waters.
Want to learn more about bringing psychotherapy back to psychiatric practice? Subscribe to Peplau's Ghosts for more insightful conversations on advancing psychiatric mental health nurse practitioner 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 Kendra Delany
Email: Kendra@empowered-heart.com
Dr Melissa Chapman
Email: mchapman@pdastats.com
Yeah, just my take on things. My answer number two Alright, we're recording. Decrease until they cease. It's not a discovery. Identify a challenge in your beliefs, all right we're recording.
Speaker 2:Welcome back to Pep Lau's Ghosts. Great to have another episode here, Super excited about our guest here back a first time here for Pep Lau's Ghosts to actually bring back a guest. But before I get to that maybe create a little suspense here I am continue to be joined by Dr Melissa Chapman Hayes and Dr Kate Molino, who we will call, probably a little bit in this podcast, West Coast Kate, and maybe that's a little sneak peek on who we've got back.
Speaker 2:But it's exciting to have Dr Kate Wheeler, who I will say I lovingly call my East Coast Kate. So thank you, kate, for coming back to talk on Pep Lau's Ghost. It's exciting to kind of have you and your perspective and your leadership here and, you know, keeping the psychotherapy a part of the role of the PMHMP and such. So I think what we were talking about right before we started recording is maybe kind of sharing a little bit.
Speaker 2:This is going to be maybe a how-to podcast, so how to do psychotherapy within the practice, and I know both Kate and myself do some psychotherapy within our clinical role and Melissa can maybe kind of jump in and kind of make sure that we don't get too jargony and things like that but also helping us kind of, you know, understand some of the questions that obviously on a podcast we can't ask. So so, kate, maybe I'll just kind of throw it to you and just kind of maybe get you going. You know, for you, you know thinking back or thinking kind of even today, you know I know you've you've retired from your academic role but you still maintain a clinical practice. You know, why did you want to keep that? Why did you want to kind of hold on to those patients and still still do psychotherapy, and and, and what is the? What is the pragmatics of keeping that practice or part of your daily, weekly live going?
Speaker 3:daily, weekly live going. Um well, I didn't think at all about stopping that because I really enjoy it and have liked psychotherapy you know my whole career and I didn't want to see more people than a few days a week. So I have about 12 to 15 patients a week, a lot of them, you know, I get a few referrals, but a lot of them have been with me for a while. So it's just to me it's fun. And, to condense, it is even more fun because the days I don't have people, it is even more fun because the days I don't have people, I'm just like happy, because I'm like what am I going to do today, which is such a novel feeling. Since I've been retired, I never had time and I always felt like I wasn't doing stuff that I was supposed to do and I was always trying to. I don't want to say get out of stuff, but if you're in academia, everybody wants you, please be on this committee, do this, do that. So I think it was time for me to retire because I was getting crabby about that and then I was like um, realizing that wasn't fair. You know to be um trying to get out of stuff. So, anyhow, yeah, what did you say? So I, there wasn't never a question of not continuing to see my patients.
Speaker 3:The challenge now is I just took a long vacation. It was a little over a month, maybe five weeks and then you know telling people I don't see people that are in crisis. Usually my folks are like just kind of normal neurotic, anxious or depressed people so, and I always have somebody that covers for me. You know, somebody needs a med refill or they do have a crisis, but I don't think I've ever had anybody had a crisis while I'm gone, so I'm not worried about it. But they all came back, you know, on top, so exciting, because you know I wasn't sure how that would play out in terms of you know the transference and you know who would be annoyed that they were abandoned.
Speaker 3:But you know, if you talk about, you know how did it feel to not come. You know for the past month and you know explore that it's much better to put it out there than to just pretend like that elephant isn't in the room. Do you know what I mean? Because people that have abandonment issues are going to be, you know, feeling that. So that's always interesting. Not that you have to apologize for it, but, I think, getting their take on the whole thing, and most people were like pleased that they did so. Well, you know they and nobody quit because of it, cause I thought, well, they're going to see that they don't need to come anymore, hell with you. But um, they all hung in there and, um, you know, there was not a problem.
Speaker 2:Um, so that that makes me remember one of my um uh mentors that's retired recently. She said she knew it was time to retire because she was on a plane and had started somebody on depakote and the patient was calling her urgently to try and get that something about the medication that was having a side effect or something. She was like, okay, that's, that's too much and time to go. So I think that kind of speaks of that. You get get a little cranky and just kind of done with things. But maybe talk more about that, because I think that's one of those sticky things in practice too.
Speaker 2:When we want to take vacations, self-care is very important and, like you said, that's kind of an extended time away of five weeks, which is amazing. But how do you handle those patients that maybe struggle with that countertransference and don't think you can? You know they won't survive for five weeks without you and how do you, how do you plan for that? Or how do you kind of you know address that you mentioned, kind of they did survive and they they learned from it. But do you do any prep work on that or kind of get them?
Speaker 3:ready. Well, I ask them you know I'm gonna'm going to stay to that day, you know. And then I tell them way ahead of time and then you know, ask, reminding them again and asking them how they feel about it. And when I was in analytic training, most of the analysts always took August off, so it was just like not a question. And yeah, so you know, I think it's surprising, there I had more I don't know pushback, maybe because I didn't know what I was doing. But also I may have been seeing people with more serious problems than I see people out of my home. So serious problems, then I see people out of my home. So you know, I'm not like seeing people with significant psychiatric problems, serious mental illness. So that probably makes a difference to where I was in analytic training. I was just seeing, you know, folks that came into the clinic and some of them with you know, big attachment disorders. So I think that probably made a difference too. But I think preparing people and just using their response is kind of grist for the mill, saying about it and tell me more about how you feel, and not to be, uh, you know, afraid of getting anything negative back. You know, because everybody. We all like to be liked and maybe they won't like you, you know, because also it could stir up envy. You know who are you to get to take all this time off and you know I'm struggling here, so but anyhow, I was pleased that you know that wasn't an issue. I have a very good person that covers for me.
Speaker 3:As the years have gone on, I do less medication and more therapy and my goal is always to get people off of stuff rather than starting a medication. So, and I don't prescribe that many like Depakote or mood stabilizer or an antipsychotic Okay, I'll do an SSRI, but I'm not I don't really no offense like reading psychopharm articles. I'd much rather read a psychotherapy article and I think if you're going to do a good job, you've got to keep up with the psychopharm and I don't want to keep up with the psychopharm because it's so boring to me, the psychopharm, because it's so boring to me. So I just stick with mostly the therapy piece. And then you know, somebody needs a refill. My colleague takes care of that and I cover for her when she leaves. She's a psych MP that you know lives nearby.
Speaker 4:And you know, kate, I'm curious if you would describe a little more, because it sounds like you know you have, you know, been very intentional about the type of clients you want to work with and what your parameters are for working with them. And I imagine you have some kind of like screening process or, you know, conversation when they're first interested in working with you, about how a goodness of fit might happen. And I'm wondering if you could describe for our listeners a little bit about how you go about doing that.
Speaker 3:Well, I get, you know, a lot of referrals for EMDR or trauma. So it could be EMDR could could be like a very short-term therapy. It doesn't mean they're going to be. They might kind of really belong to somebody else. You know not my patient if it's from another therapist that's not EMDR trained and they just heard that I do EMDR trainings or something or I know how to do it I'll call them and we'll talk about it. I like it if the person comes just to me while we're doing EMDR and then they go back, because otherwise it just seems, you know, like they're going to come in and tell me what's happening and if they got somebody else they're going to go in and tell them what's happening. You know it's a kind of a waste to have two therapists. You're kind of updating on your activities and also it builds more trust than if you know I see them over time and make sure they're kind of together enough to do EMDR. So, assessment wise, I give everybody the dissociative experience scale to see you know how dissociative they are and not that that's like 100% accurate, but if they score, you know, like more than 30, then I'm thinking, okay, it could be, you know, complex trauma. This might not be like a once and done situation and maybe they just come in, they were in a car wreck and they want EMDR for that. But I want to know, you know, like, how much preparation do we need so this person doesn't destabilize with EMDR? So you know, we'll do some safe state and some imagery stuff and you can kind of tell from that.
Speaker 3:I've had people that you know don't even have a safe state. They, you know, it's kind of like oh you know, this, this might not be a good candidate here, and so I explain. If the person says like, you know, how long is this going to take? I tell them if they've had a lot of childhood trauma, it could take a while and I explain that to their referring therapist, but if it's just one horrible thing, it could just be a few sessions. So I'll get a sense from just.
Speaker 3:I don't spend a lot of time on the phone with the patient because I want them, you know, to be in person. I mean, I'll tell them what I charge if I don't take insurance, so I'll make that clear. If they don't have out of network provider benefits, well they need to find out about that. Tell them my fee and then you know, tell them if you know if they're still interested. You know kind of how to get here, but a lot of times they want you know me to say how long it's going to take or something. So that's where you know.
Speaker 3:I said, well, I can get a better idea once you come in and you know we discuss it. So then I try to, you know, get a pretty good history about what you know. Have they been in therapy before? What are they here for? What are they like? The question is, how are you going to know this therapy works? What's going to be different for you? So that's going to help us figure out some collaborative goals. So, yeah, if somebody comes and they weren't referred by, they're not in therapy, then you know that's fine. And you know I kind of do the same in terms of assessing. You know their stability. If they're on psychiatric medication, you know they. If they're on like a benzo or something, you know. I explain that if we're going to do you know when we're ready to do EMDR, they shouldn't take the benzo that morning, because we want them to be activated and I have them.
Speaker 3:I always give them some literature. I have a really good book I love. That was written a few years ago Every Memory Deserves Respect by Debbie Korn and she wrote it with a guy that's a photojournalist. So there's some fabulous pictures and it's like you could read it in an hour. So I'll recommend that if they're interested in you know, because he, the guy that the photojournalist, was the patient and Debbie Korn then writes after he says his thing in one chapter she then explains kind of what's going on. So it's like this you know dog and pony show thing that is so engaging I think. Um, it's. It's not that, you know, theoretical or hard for anybody to understand. So anyhow, they want but not everybody wants to read about it.
Speaker 3:So if somebody is, you know, actively in crisis, you know I had one girl come. She was had a car accident. She was really dissociated and she kind of walked in the office like a zombie and normally I don't see people that dissociative. But she was referred. A friend of mine knows this girl's mother and so my friend told me about her and I thought I could work with her because you know the supportive family she had and she had been a daughter of a bipolar mom who kind of completely ruined this girl as a child, not on purpose, but you know she was really raised under adverse circumstances. So I kind of knew the family history from my friend who was friends with them and so she, you know it was a matter of active.
Speaker 3:She was in really dorsal, vagal, shutdown, totally zombie like shut down, totally zombie-like, and it took a while to get her activated. But there was some trust there between me because of my friend and this family. So anyhow she, you know, I don't know why I'm talking about her, but she was. But I think because she was so bad off I was like, oh my God. So she got much better and I worked with her, you know, every week, probably over it might have been a year and she eventually I mean she was phobic of driving after she, you know, came to from the accident. So we worked on that and she eventually bought her own car and she's like spiffing around in this nifty car. So it was really fun to see her come alive and come into her own as her own person and yeah.
Speaker 2:So that's great and I know Kate you're, you know you've got a lot of expertise in doing EMDR, you've done some training and you know, if anyone's interested, definitely look Kate up. She can still, you know, connect you with someone to kind of get that EMDR training. So I love the kind of the formalized kind of just really focused on trauma, and that's kind of where your therapy is really kind of taking you. I'm actually kind of a little curious. I know I'll call her West Coast. Kate, you know, I know you're doing something. Do you have a process in which you kind of screen people for therapy? Because I know that's something that came up at a conference once. Somebody asked you know, when you see in a patient, you know how do you make the determination? Do this person need meds or do they need therapy, or do they need both? You know, and so, kate, do you have any kind of or do you just shoot from the hip, kind of like I do? Yeah, yeah, well.
Speaker 4:I'm happy to talk a little about that. So I work in a very different setting than Dr Wheeler. My current practice is on, actually as the psychiatric provider for a primary care house calls team, actually as the psychiatric provider for a primary care house calls team. So we, our care is for homebound or bedbound adults, so many of our patients are older, but certainly not all of them are, and so you know we drive around the city providing care to folks. So my referrals come from the primary care providers and so you know, when I started at this practice there was no sort of formal, you know, referral screening whatsoever. So it was always kind of a you know bag of surprises, whatever I would show up and get. But I did develop one, actually in consultation with we got access as well to a licensed clinical social worker who can also provide some therapy, not in home but over the phone. So the two of us work together.
Speaker 4:So you know, some things we wanted the primary care providers to let us know about in the referral was yes, you know, does this person have any previous psychiatric diagnoses, you know, similar to Dr Wheeler? Are they in crisis or can they be safely managed? You know, in an outpatient setting where you know I'm only part-time with the clinic, so there has to be safety there. You know, what type of therapy do you think they might benefit from, like time-limited or more of sort of an ongoing thing, like any goals for care? And then you know the social worker and I look through the patient's chart and then generally I will go out and, you know, do an assessment visit and you know, sometimes after that assessment visit I will say you know, actually I think you and the social worker will be a really good fit together. Or often I will take on, you know, that patient myself. And so for most of those clients I'm doing both medication management and psychotherapy, although it is mostly psychotherapy and it is given the patient population.
Speaker 4:The average life expectancy of a patient who enrolls in the program is about four years. So you know, so it's a lot of like narrative therapy, act. You know some CBT, but you know people are facing end of life and some, you know, existential type of issues. So you know, I've had lots of patients say to me like, well, I don't know about therapy, I don't want to talk to you about my mother. You know I'm 92 years old. That's old, you know, and I say, well, we don't have to. There's, you know, and I say, well, we don't have to. You know, there's lots of ways that we can work together.
Speaker 3:So, yeah, so that's, that's a very different type of, I think, you know screening and practice when your referrals are coming from a very particular source. Yeah, you're sort of like right at the thick of it. They're trying to figure out. You know what's going on, where I kind of have people that you know I feel like they're not. You know, I'm not like thrown into these situations trying to figure it out.
Speaker 4:Sure, yeah, and then Dan, I think you're kind of somewhere in the middle maybe.
Speaker 2:Yeah, maybe. I mean I was just gonna say that reminiscent therapy is yeah, I did some work in a nursing home once and that was that's so rewarding, that's yeah. So you don't need to talk about mother and get all Freudian on people, but yeah, it's so fun to kind of just bring that and really kind of support their positivity and things. But but yeah, my practice is more we call it a hospital based clinic and so, um, so yeah, you know thinking about you know what is my, you know screening process. It's thinking about you know what is my, you know, screening process. It's probably just at this point, you know, just because of my time and limited, I'm only seeing patients about a day and a half a week. You know it's just that I'm not getting a lot of referrals because I just can't, you know, maintain those kind of patients and getting a lot of referrals. But it really becomes down to kind of you know a therapist walking down the hall and saying, hey, I've got somebody interesting. I'm like, oh yeah, it sounds good. So you know, that's a real formal. You know a very highly evolved kind of screening process. Unfortunately not, but it but it kind of works, you know, and and and it gets into.
Speaker 2:You know, I think we've said this before in the podcast and you know, kind of my, my bend, I guess, is always that people that everyone needs therapy. I mean it's you know, why wouldn't you do therapy? You know, even if you're on six medications, I mean that's maybe maybe even more of a call to say you need therapy and things. So so yeah, and I and I appreciate you, dr Wheeler, kind of saying you know that this idea that therapy can actually maybe work people off medications, I know Dr Sean Conboy, that's his big thing of. You know therapy and polypharmacy and you convoy, that's his big thing of. You know therapy and polypharmacy and you know how that can be a real tool to kind of, you know, get people off too many medications and things like that. But but yeah, so I, I just have the bend. You know, if I'm going to do some medications with you, if they're not seeing a therapist already, I'm probably going to get into some therapy with them. Um, you know, kind of that integrative type of thing. You know, med management, psychotherapy appointments in which you can kind of do those multiple billing codes and things like that. So you know, and maybe kind of wrapping up today.
Speaker 2:You know again, kind of wanted to think, maybe just like a pragmatic episode here but you know, for each of you, what do you? Let's talk just about documentation. You know what are some of the things you know, kate. I know in your, in your textbook, you know you've got a whole chapter on this. So you know, maybe we're plugging your, your textbook again, which is great, but but you know in reality, what you know. What do you include in there for my? You know, this is something that I think students that I see in my program get really intimidated by. Like you know, what do I need to have in there? So you know, so I don't get, you know, called to the carpet and have to repay any monies and things. So so, kate, for you, what, what is you know in your mind, what are the kind of the essentials that you need to have in your documentation for your therapy patients?
Speaker 3:I don't have anybody like checking me or looking over my shoulder.
Speaker 2:Oh right, Because you're cash yeah.
Speaker 3:I'm like more interested in process notes, like I'll write about countertransference or a couple of notes about what we talked about and where questions that came up for me. But if it ever gets subpoenaed then I have to go back and do progress notes, not process notes. So I'm not the good person to, you know, be a role model for, because I really don't like doing the progress notes and I don't have to unless somebody wants them, and I'm not, you know, in a system that's making me so so tell me about what.
Speaker 2:What do you have to add to the process note to make it a progress note?
Speaker 3:uh, well, I do. You know I would do soap notes. I maybe one time somebody wanted something and it was a pain in the butt to go back and do all these soap notes and and I figured out you know sort of my template and I did do it because I had to, but you know that was probably the only time I had to. So I think about it in terms of is it going to be more trouble for me to do a progress note every session or is it going to be more trouble on the rare occasion that I get called for those notes and so I have opted to just do it my way, which is process notes.
Speaker 3:So I wouldn't tell students that, though you know I would tell them they need to do it accurately and succinctly for whatever their agency or, you know, insurance company wants, and I used to do all those insurance forms. So I understand it's a pain, but you kind of have to do good documentation. But I do it now more you know in terms of what I think the process is going on in therapy and you know if the patient, if I feel like we're getting someplace and where I need to go next, and then I'll put question marks for myself. So I'm not like thinking I know it all or I'll go look up something. So that's probably not you know. I would just tell you guys that.
Speaker 2:No, I appreciate it. I think that's one of those things. Again, I always try to tell my students it's not as intimidating as you think it is. Again, I think writing a note for medications is obviously much more intimidating and you know much more detail on the medical processes, you know review of systems and things like that. That's just not required, I don't think, for those kind of psychotherapy notes. So maybe I'll turn it to you, to the West Coast, kate. You know what? What do you think? What do you have in your in your notes that you know make it a therapy notes and and what do you add to that?
Speaker 4:Yeah, well, I'll touch wood because it hasn't bounced back to me yet. But so far you know what I include is time spent, obviously, the types of therapy or therapeutic techniques that I'm using during this session. You know generally the topics that we are discussing, without going into detail, which I think is can be, you know, a bit nuanced maybe for students, but I think vague is better for those billable notes. And then, of course, you do have to assign a diagnosis in order for it to be paid for. So you know if you can outline any types of changes and symptoms. That would be sort of a brief sentence or two. So I agree with Dan, I think the onus is much less on.
Speaker 2:Yeah, yeah, and I totally agree. I think the big thing that catches people that usually I don't put, well, it depends on the medication. Sometimes people do put time, but that is, you know, that is, I think, essential because again those codes require you to put how much time you're spending with a patient where EM codes you can bill by, you know, degree of complexity, and so you don't always need the time. So I think if that's a burden, then that's something that people have to get used to. The thing I always try to focus on too is, you know, trying to kind of in most senses I try to kind of, and, again, not always super great on this, so please don't audit my notes but it's you know I try to have a focus of how long this treatment's going to be. So so you know this isn't like forever treatment. You know this isn't going. I'm not going to see him for five years, or at least that's not what I'm planning on when I'm, when I'm writing the notes. So I'm kind of trying to reflect that they're going to you know they're eight sessions and then maybe make another goal to work on for another six, eight sessions. So so that's kind of that's besides what you said, kate. Yeah, that's kind of the only other thing I I think with my note and and again that's for me that's really easy just to kind of layer into an EM code and EM notes and so so again I, I again hope that's, you know, something that I try and I'm happy to share those kind of things If anyone's listening want to kind of reach out. You know kind of my template of what I use. I think like, like you, kate, I haven't been called on the carpet yet, so haven't been.
Speaker 2:And sometimes I do hear that I mean I don't know. I mean I actually was having a psychiatrist who is using a lot of, you know, em codes with psychotherapy and and got audited and had to pay back a bunch of money. So you do have to follow some format if you're billing insurance because they will kind of look at you. And I know I've talked to people at the University of Illinois at Chicago. They've had kind of random audits through different insurance companies. They see a lot of codes. They see a lot of those 90833s, that add-on code for psychotherapy. They see a bunch and it was strange because they saw it not just for one provider but like the whole clinic was doing it, and so they kind of swept in and kind of did this whole you know making sure that they are documented. And they were, of course.
Speaker 2:It's just, you know, I don't know not to bash on insurance companies too much, but you know it's a scare tactic to kind of make sure we stay in our lane, which I don't think PMHNPs stay in their lane very well, but that's a good thing, I think. Yeah, well, we're coming up on time. Melissa, I felt like we kind of left you out there. Is there anything that you're wondering or this conversation has got you thinking about?
Speaker 5:I can't speak to the practice, so that made sense to me. I feel like I was a listener today and that is okay. I think hearing about you know why a practitioner might not go through insurance which I kind of knew from friends who have also made that decision is helpful though. And what goes on in the on the backend. So I appreciate the conversation today. Thank you all.
Speaker 2:Yeah, it kind of goes into that. You know, staying in your lane, I think you know that's why a lot of people are going out into private practice and doing what you're doing. Dr Wheeler is just kind of really trying to, you know, do what you want to do, do what you know is going to be helpful to patients. So, yeah, you know, find your voice and make sure you stick with your voice and uh, um, that's the powerful thing here too. So, all right, well, we'll wrap up our never the guest here and so look forward to more episodes coming out this summer and, uh, thank you so much. Please like, comment and subscribe to the peplau's ghost and we'll see you next episode.
Speaker 3:Bye thank you for including me thank you you, Dr Wheeler.
Speaker 1:Take care Bye. Work hard until those thoughts are finally leaving, so you can be you. Guided discovery Identifying challenge in your beliefs. Reframing your mind. Negative thoughts release these cognitive distortions. Decrease Until they cease. Guided discovery Identifying challenge in your beliefs. Reframing your mind. Negative thoughts release these cognitive distortions. Decrease Until they cease.
