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
How Curiosity, Not Magic Bullets, Helps People Heal with Marcus Evans
What if the most powerful tool in mental health isn’t a pill or a protocol, but disciplined curiosity? We sit down with Marcus Evans—psychoanalyst, longtime psychiatric nurse, and trainer at the Tavistock—to explore how a psychoanalytic lens can make care more humane for people living with psychosis, borderline states, and severe distress.
Marcus takes us from old asylum wards to modern outpatient clinics, showing how labels help as rough maps but fail as destinies. He explains why some patients act out when supervision eases, how a harsh inner critic and fragile ego can be mistaken for manipulation, and what staff can do to contain projected fear and shame without losing boundaries. We talk through the practical balance between medication and psychotherapy: when small doses open the door to therapy, why “therapeutic omnipotence” is a trap, and how multidisciplinary support—psychiatry, OT, family systems—creates the holding environment needed for real change.
Across stories and strategies, one theme repeats: people want to be understood, not processed. Instead of chasing a magic bullet or a perfect code in the DSM, Marcus shows how to read behavior as communication and build plans that pace risk, supervision, and discharge to the person’s actual capacity. It’s a grounded, compassionate approach that protects clinicians from burnout and helps patients feel less alone with their minds.
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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. Identifying challenging your beliefs. All the day of framing your mind, make the thoughts release. I discovery. Identify and challenge in your beliefs.
SPEAKER_01:I think we're recording. Welcome back, everybody, to Pepla's Ghost. I am your host, Dr. Dan Wiesman, and joined with our my co-host, Dr. Melissa Chapman Hayes. I am thrilled with our next guest here, Marcus Evans, another one of our international guests, which is great. And again, just withstanding before we start recording, really wanted to say thank you to sacrificing a bit of your Friday afternoonslash evening here to join us and uh and really kind of get to know you a little bit on this podcast. So thank you so much. Um I've got a quick introduction from Marcus, but I'm sure he'll be able to kind of explain himself a lot better than I will since he knows himself. Um but Marcus is um got a lot of vanished experience here. He's been uh practicing for over 40 years. Um I read that he's been in private practice in Beckenham, uh, which is in the UK uh since 1995. Is that accurate?
unknown:Yeah.
SPEAKER_00:No, no, no, yes, more or less. Yeah, more or less.
SPEAKER_01:Yeah, yeah. Yeah. I was I you know, I was gonna say it seems like these days um it's all BC before COVID. It's so there's it's been a while since you've been in private practice. So yeah, um you're an accomplished author. You've got a few texts uh out there that um I I'm happy to mention. I'm gonna feel free to correct me if I'm getting the title wrong, but the one of them making room for madness and mental health, and then one uh focused on gender dysphoria, a therapeutic approach for working with children, adolescent, and young adults. So um, so I don't want to kind of go too much into just the introduction. Again, just I I think Marcus is amazing and can't wait to hear kind of his story. And that's maybe where I'll start. Just kind of, if you wouldn't mind Marcus kind of taking us back in a time machine and just kind of what got you kind of on this path and what where did you start? What sort of life experiences kind of led you in this direction? So, and thanks again for being here.
SPEAKER_00:So, as an 18-year-old, I didn't really know what I was going to do and who would pay me for doing anything. So a bit of a lost soul, and um quite good with people. So I I trained as a psychiatric nurse. That was in 1980, or over 45 years ago. And during the course of the time on the wards, um the thing that I learned the most, I didn't learn a lot from school, but I learned quite a lot from seeing the patients and from staff that I admired and the way they would interact with people. But I found that the biological model, I'm not against medication or I'll say something about diagnosis in a bit, but but it didn't really explain to me why I was um seeing patients who were quite disturbed and had been for a very long time, sort of living in their own world. And I came across a psychotherapist. This is when I was about 19, working on one of the back wards. These are the old um asylum wards with people who've been there for years, and he was trying to think about the patients and the patient's behavior, and I got interested, and I started to this is Concertain, a very long story, but I started to read Medeline Klein, didn't understand much, but I intuitively thought she was talking a lot of sense, and then um I qualified as a nurse in 1983. Um I worked, I I eventually ended up running a day hospital when I was quite young, and then a parasuicide service. But all along, um probably 1985, I started to do psychotherapy trainings. I trained at the Tavistock, did an introductory course, then an intermediate course, and uh decided that I wanted to change as a psychotherapist, and luckily um managed to persuade the Tavistock to accept me for a four-year adult psychotherapy training. I was working at the Mawsley at the time, so I was seconded. When I finished that training, they were criticized by a report in which they said they didn't do enough about for nurses, and they did a lot in terms of training. It's the sort of national psychotherapy training institution, and they do a lot for psychotherapy, but not a lot for um practicing nurses. So they headhunted me, basically, and I was employed by the Tabas that was the first nurse in something like about 1986. You know, National Health Service was the national service that is um um run by public institutions. And why I said I've been in private practice since 1996 is I've had a small private practice lot running alongside my major job, which was um, as the chief executive of the trust, said, Look, I want to set up a nursing discipline, and you are to set up trainings that would be offered to nurses working in psychiatric and general settings, actually. And that's what I set about doing, and that was in about 1996, after I qualified as an adult psychotherapist. Wonderful. My passion, um, actually, I've sort of um written three books, but and I've got a fourth coming out. Two are on gender dysphoria, what one is coming out called Um Identity and the Foundational Myth. But the second book is called Psychoanalytic Thinking in Mental Health Settings, and it's a book designed for sort of interested psychiatrists, psychiatric nurse, psychologists who are interested in looking at what psychoanalysis has got to offer psychiatric settings. And that is really my sort of passion. So I I I work as a psychoanalyst, I'm a fellow of now trained as a fellow of the Institute of Psychoanalysis here in Great Britain. Um but what I'm known for is the application of psychoanalytic ideas to, say, patients with borderline personality disorder or psychotic patients, partly in treatment. And I was fortunate in working in the Tavistock, I had a sort of clinical setting where I could take on patients that wouldn't ordinarily be seen in private practice, um, people with a diagnosis of paranoid schizophrenia or anorexia or personality disorder. So I'd see patients, and then I'd, you know, do my best to try and understand them and see if what I had to offer helped. And then I would consult to frontline nursing staff in psychiatric settings, inpatient units, hospitals, and consult to them in terms of saying, okay, let's talk about a case and let's see if I've got anything to contribute. And what I'm saying really is the two dovetails. So my clinical experience of working with the patients was then um helpful when thinking about what uh community psychiatric nurses were faced with when dealing with someone who's self-harm or cutting on a Friday afternoon. And that's really what I've been doing um since, I don't know, about 1990. Um, plowing the same furrow, working clinically, but then consulting to psychiatric settings.
SPEAKER_01:Wonderful, Marcus. It's it's hitting home to a lot of things, um, you know, reflecting on my own life. You know, mentioned, you know, just being 18 and kind of lost. That's kind of where I started to. I I just joined the military and because I was really lost and didn't know what I wanted to do uh with my life and found the military, like you said, kind of paid for um, you know, room and board and everything for a while. And uh yeah, and then and then you were kind of working in a day hospital, which is something that I've done as well and has been really kind of meaningful and impactful for me too, because the the day hospital, formerly called the partial hospital program, was so nice in that you could do the therapy and kind of the medications, because it was an outpatient uh practice. I don't know if that's kind of what your experiences was. So we didn't have kind of psychiatrists that are prescribing them. I mean, they were just seeing them once every three months or something. So so the real work was psychotherapy. And so that was really where I cut my teeth and and really kind of learned to help people without a prescription pad. So so yeah, that thank you for sharing your story. That's been uh, like I said, just could hit home a couple areas. So I wonder if Melissa has any questions at this time.
SPEAKER_02:Yes, thank you. Um I really enjoyed hearing about your background and the dovetailing um of those two areas. And I wanted to ask a question that kind of builds upon how you've written extensively about working psychoanalytically with psychosis. Um, so often some well, sometimes that's a population um that's seen as you know beyond talking therapy. What have you learned from these patients about the value and limits of uh psychoanalytic understanding?
SPEAKER_00:Yeah, I mean, obviously, when I was 19 and I came across Manily Klein, I thought, you know, um patients in psychotic conditions could be cured by psychoanalysis. That's not that's not what I think now. Um what I do think is that there's two things. One is that my experience is that some patients very ill can benefit from having someone who's trying to understand, you know, what it's like to be in their shoes. So one guy who I saw and wrote about, you know, was very isolated, living in a world of his own a lot of the time, and felt terribly humiliated because he wasn't so psychotic that he was sort of completely living in his delusional world. He was aware that he didn't fit in, he's he was, you know, nearly 50 years of age and had nothing to say about politics, or so he couldn't join in with conversations. And one of his problems was when he caught sight of just how unwell he was, he would become you know very shamed and start to feel quite suicidal because that insight was painful. In fact, I called the papercats 22 that he's sort of looking for insight, but the insight was was too painful to bear. And, you know, I would struggle to understand some of the time, the world that he lived in, but he felt he got enough out of the sessions, and I obviously understood enough from time to time that he he kept coming and he really valued it. Um but I wouldn't say that um psychotherapy is for everyone with a severe and enduring mental illness. But what I do feel is that even you know the the even patients in the most disturbed states of mind hope to meet staff who are curious and interested in who they are and what their symptoms mean. You know, if they're met, you know, they can be right in rather schizoid, cut-off state, and then they meet meet a system that can be rather schizoid and cut off. Because let's face it, being with patients in disturbed states of mind is disturbing and um staff can withdraw behind very procedural ways of thinking. And I always assume that the patient wants to be met by staff who are interested in who they are, and I think psychoanalysis gives a lens for thinking about that. You know, the patients do all sorts of is in a bizarre state of mind or may act out in violent ways. And I'm always encouraging the staff to think, yeah, but who is the person behind that presentation? Because there's something driving this, and if one could get an angle on that, then in a way you find a sort of different way of relating with the individual. Um so anyway, long answer. So I think that psychoanalytic thinking's got a lot to contribute to thinking about patients, even if they're not in psychoanalytic settings or treatment. Try and humanize the sort of contact. And also, you know, you get into repetitive patterns, don't you? Of, you know, the patient's on special observations and is in danger of harming themselves, but then they go on weekend leave and they come back quite happily, and then you withdraw the special observation and the patient acts out. Now, sometimes staff find that very perplexing. Of course, you would, it doesn't make any sense. But if you understand that the patient feels they need to have people worried and concerned about them because they can't manage themselves, then to some extent they've got to sort of keep the sort of maximum amount of um supervision and oversight because they feel frightened without it. And they worry if they think, okay, you're well enough to be to go home at the weekend, you must be okay. And then they feel that the support's going to be withdrawn, and then that provokes a sort of regression and acting out and one thing. Well, that that can be really helpful to members of staff who are struggling to understand why the patient is is repeating these sorts of destructive acts. Yeah, this is just an example.
SPEAKER_02:I I appreciate the examples and particularly the humanizing aspect of it that you brought in. Um thank you.
SPEAKER_01:Yeah, and and I I really like the idea too. Is you like you said, if you can offer a frame for people, I think that that helps you kind of, like you just said, Melissa, kind of humanize and just kind of understand that person a little bit better. And and that depth of understanding, um, you know, from my experience, you know, again, going back to my days working in a partial hospital program, for me it was more kind of uh we incorporated a model of dialectical behavioral therapy, which was kind of, you know, at the time kind of revolutionary to think of that people who were harming themselves, you know, weren't doing it just for attention. I mean, there was this constant, real cynical kind of um view that it was just for attention seeking. But but again, kind of take a step back and look at their pain in a different lens, uh, I think, and and then offers you a way to help them, I think is the other thing. Because I think you spoke to that as well as I think a lot of nurses in the on these units want to help. They all, you know, they they got on the unit, they look for these jobs because they want to help, um, but then they get to these environments that, you know, sometimes aren't conducive to the the most therapeutic processes as well. So um yeah, it's also you know reminds me of, I think last time we recorded, um, Dr. Sean Convoy kind of said, you know, it's uh more about your um your zip code than your DNA code. Um and so yeah, your environment has such a dramatic impact on uh on how you behave. And so thank you for sharing those and and and bringing those things up too. I I guess when you were talking about it. Just one other thing.
SPEAKER_00:I was just gonna say, you know, one of the problems is when we're confronted by things we understand, we can get quite moralistic or judgmental, isn't it? You know, that that often the patient's called manipulative. Now you're talking about someone's EUPD or borderline personality disorder. You know, that their whole my my sort of frame would be there's quite a fragile ego with a very judgmental superego, quite a difficulty tolerating anxiety or um conflictual feelings, and that gets projected very powerfully into the therapist or the nurse. Now, the the thing is is that and it it can sort of get under their skin. I wrote a paper called um being driven mad because the because the patient gets under your skin, and then there's a tendency to sort of react rather than sort of digest. And you know, to some extent the the patient may be controlling the discourse, but that's described as manipulation, whereas I would think it's to do with the how fragile the patient feels and how much they need a certain sort of containment, and of course, they may either seduce or threaten if that is threatened to be taken away, but it's it's more to do with an underlying fragility and dependence upon the other's care than it is to do with uh manipulation. I mean, you know, one's got to keep an open mind about these things. I'm not saying, you know, with you know, with patients who've got perverse problems, then sometimes there is a wish to, you know, exploit, uh project guilt and exploit responsibility. It's not that it never happens, but it when we retreat to a sort of moralistic position as a first sort of port of call because we're frustrated, it's sort of unhelpful to the therapeutic situation.
SPEAKER_01:Yeah, well said. Yeah, I I want to kind of um maybe change gears a little bit, um, but can keep talking about this conversation. But it's, you know, again, another thing you've mentioned. Um, and and part of you know, why we generated or why we you know continue to do this podcast and what keeps keeps me going and really kind of energizes me in my work is that you know, this and I think we struggle with this. And so I'd just love to hear your perspective of you know, where do meds and therapy, you know, where where does that balance, where does that, you know, where does that dynamic kind of fit in? And um, because I think when you're talking about, you know, people you know who have psychosis, you know, it's not, you know, psychoanalysis isn't going to be for everyone. That's that's true. And and same with meds. And um, you know, I think uh Dr. Brooke Finley was on and and she said that she thinks that 70%, 70% of people on meds could probably come off of meds if they got into some good psychotherapy. But again, just from your perspective, Marcus, where do you where do you see that line and and where where does that for you conceptually kind of work?
SPEAKER_00:Yeah, I mean, my experience is that so, you know, I'd I'd be referred someone from the psychiatric service down the road to this specialist hospital, the Tavistok, which hasn't got any beds or day hospitals, it's just outpatient psychotherapy. And I would always say to someone with um, let's say, you know, diagnosis of paranoia schizophrenia, I said, look, I'll yes, I'll take you on, but I'm I'm gonna work with your psychiatric team. I'm I'm not, I don't want you to be discharged. Because if the patient breaks down, I'm gonna be phoning up the psychiatry. So I want that link to be continued. Now, some patients would accept that as the sort of deal, but others would say, no, I, you know, I want to get away from psychiatry. I feel it's stigmatizing. The problem for me was then we're I creating a setting as if I'm gonna say, look, I'm gonna be able to manage all your psychotic symptoms um on my own by just my understanding. Now, that to me is sort of therapeutic omnipotence um and actually makes the patient feel, you know, that they're they're quite excited that they met this omnipotent figure. So I I go. Did you coin that term?
SPEAKER_01:Did you is that your term? Or I love it. I meant that. But maybe you need to pay market. I don't know. Sorry, interrupted apologies.
SPEAKER_00:But no, no, that's fine. Um, but the thing is, is that so um unlike some of my psycholytic colleagues, psychiatrists who worked at the Moorsley, which is our big psychiatric institution, who are very much against diagnosis full stop. I I'm not against diagnosis as a ballpark thing. I think it's helpful for in terms of understanding what the sort of lightly prognosis, look, you can't rely on um prognosis of diagnosis. Is it we we act as this is a science, it's more of an art, uh psychiatry. But you know, if you've got someone who's got a history of psychotic breakdowns, it's helpful to know it. I wouldn't feel it's appropriate to take them on in private practice. For example, I just don't have the setting. Um I you know, I've tried it, but that's why I would see people in the tavern stock because I have the support of colleagues. Now, the thing is, is that so I think the sort of ballpark diagnosis, you know, what are we dealing with? A psychotic condition, uh personality disorder or neurotic is quite helpful. The problem is, is when we become over-reliant, you know, it doesn't tell us anything about the individual. Also prognostically, you know, we we don't know who's going to become very redrawn and living in a delusional world of their own, and who's gonna actually be able to um get on with their lives and get a job and one thing or another. So um, but I anyway, so I'm I'm sort of I like diagnostic categories provided we're adding the thing that this is an individual, and we're interested in finding the individual. Do you see what I mean? So we're combining the two. Medication is also helpful when patients are in very disturbed states of mind. You know, they can't manage their own mind, they're bursting out of their mind, as you know, smashing up the ward or attacking their mother or whatever. And and I'm not going to give magical interpretations that are going to contain that. It wouldn't be realistic. The problem with the medication is we tend to idealize it, and we we act as if this is a sort of magic bullet which will get rid of the psychosis. Well, with some patients it does, and they recover from their psychosis, with others, you know that they live with a psychotic part of their organization for years, and they to talk as if we could eradicate a part of themselves actually persecutes them, and they feel like they're a failure because the medication hasn't worked. There must be something wrong with them. So I sort of feel that with the diagnosis and then the medication, the the problem is it's this it's so tempting to use it as a sort of magic bullet, which actually bypasses the fact that people need a lot more than just medication. They need, you know, if you've got a fragile eagle and you're prone to becoming psychotic, you need a rehab team and a good psychiatrist and someone who's going to support your family if you're lucky enough to be still in a family because they become your asylum. You know, you're going to need all sorts of things, not just um, you know, the the latest um antipsychotic medication. I they're all improving, by the way, but but they're not magic. Um anyway, so long answer to your question.
SPEAKER_01:No, Marcus, I think that's, you know, because I've seen people at the podium stumble with that question. Like, you know, when do you use medications? When do you use therapy? And I think I I think your answer is, I mean, again, going to be biased here, of course, myself, but I think your answer is perfect. I mean, it's yeah, we don't want to reduce people to just diagnosis or, yeah, some looking at a magic bullet as far as a pill to kind of take care of everything. So yeah.
SPEAKER_00:I mean, just I'll just say two other things. I mean, one is that sometimes, you know, a mild amount of antipsychotic medication can make the uh can help the patient bear their emotional pain and then they become available for therapy. So that that's one thing to think about. The other thing, the direction of travel in psychiatry, I'm a critical friend, I like psychiatry, but it's sort of going down a sort of road of becoming more and more obsessional with DSMs and ICDs, and like as if we could sort of pinpoint the precise, you know, sort of point on the scale that this this person is has got OCD. And I I think that sort of obsessionality is just not helpful at all. It turns psychiatry into this um this sort of this belief that if only we can get the science right, you know, we're gonna actually nail the the diagnosis and then the treatment and all our problems will be solved. It becomes so mechanistic and it doesn't relate to my experience of people who are uh suffering and they suffer in a particular way. And how do we help understand who they are and why and what their symptoms mean in terms of their attempts to manage their difficulties?
SPEAKER_01:Yeah. No, it's yeah, it's uh for me. I mean, even with myself from a day-to-day, you know, it's where does that line between whatever we would call normal and abnormal, right? You know, not diagnosed to diagnose, like you're saying, OCD. I mean, we're all a little obsessive, we're all a little compulsive at times, you know, it's not a terrible thing if we you know can manage it. But yeah, where is that line? You know, and and that's even for myself, that's you know, I have to do that self-reflection and say, hey, my which side of the fence am I am I waking up today on? So yeah, um, yeah. I think we're getting close on time. So Melissa, I think you got another question if you want to ask Marcus.
SPEAKER_02:Thank you. Um, so looking forward and thinking about the future of uh psychoanalytic nursing, um what advice might you have to offer the next generation of psychiatric nurses and trying to integrate psychoanalytic thinking into modern practice?
SPEAKER_00:I I think one's always got to be skeptical of any approach, and I am passionate about psychoanalysis, but I think one's always got to be skeptical of anyone who claims in psychiatry that there's one approach which has got all the answers. That's again, that's not that's not my experience. Someone, you know, with a psychiatric psychiatric disturbance, they're gonna need all sorts of people. Occupational therapy is undervalued in my view. Um but um but I do think the psychoanalytic lens, which helps sort of um take notice of the symptoms and or the acting out, but sees past to who is this individual and what are they struggling with, and then to understand the way the the individual might go through the habitual patterns in relation to their carers and nurses and psychiatrist, psychiatrists, and often that can be very frustrating. So it's sort of it's got so many tools that can help um the nurses think about their patients, and for me it makes life much more interesting. You know, you're trying to sort of think, what you know, it's why I went into psychiatry is like what makes people tick? Myself, other people, why don't you know, why don't I do sensible things if I'm trying to lose weight, which I am, why do I keep having curries on a Friday night? You know, these sorts of things, as as you're saying, Dan, that we all struggle with. Well, it just it just makes nursing much more interesting. And you know, and it helps throw light on these sometimes frustrating patterns of behavior. Um, and I think it's unique in doing that.
SPEAKER_01:I love it. Yeah, I think you know, it's it it again makes me think of you know people I've talked to before and going into practice and you know, they're seeing 25, 30 patients a day and they're just doing medication refills, and and after a year or two, they just get burned out. I mean, they're just become kind of a dry husk of themselves, and they forget like just what you said, like they forget why they got into this, they forget the curiosity of getting to know that person, um, which again for me kind of fills my cup. And uh, so that's great. Any last words before we wrap up today, Marcus?
SPEAKER_00:Or no, it's nice to have met you both, and um more more power to your elbow. Yeah, we need more of this, we need more of this, we need it in the UK as well. I run a course, yeah. Sorry, I run a course with the Institute of Psychoanalysis, I'm trying to, which some Americans have come on, which is basically me talking about say psycholytic understanding of borderline states. And um, yeah, I mean, you know, and people are so interested. And you say nurses aren't that interested or psychiatrists aren't. Well, they are. Um, but you know, I sort of trying to talk to them about their experiences on wards, not not uh, you know, I try not to talk too much about my own clinical experience because it's so far removed, you know, the privilege of being with someone for 50 minutes, and by the way, they're a neurotic patient who's got a job and a family, and the nurse is dealing with, you know, someone who's um borderline personality disorder who keeps breaking up in relationships and then and then cuts and burns themselves. The nurse thinks that that's miles away from what I'm dealing with on the wall. So yeah, it's trying to apply the the sort of analytic thinking to psychiatric settings. Yeah. But you guys are doing the same thing, I guess.
SPEAKER_01:Yeah, no, I think, yeah, it's it's uh fascinating for me too. I think you know, there's obviously different healthcare systems um with the socialist NHS in in the UK, obviously more private here in the United States, but we're all struggling with the same thing. We're all we're all kind of struggling to figure this out. So um that kind of reassures me that I'm not doing too bad here because I'm I mean we're all struggling, we're all kind of on this ship sailing along in the in the universe. And so thank you again to to uh to Marcus Evans. And uh if you like what he says, got again. Lots of books, just Amazon is name. I'm sure you'll find plenty of text there. Um, but again, if you're interested also in getting involved, I'll set links to his website as well as other ways to get in touch with him. So thank you again, Marcus. It's been a pleasure to meet you and get to talk to you. And uh thanks so much. Take care.
SPEAKER_03:Pleasure to meet you back. Therefore, it's true. Work hard until those thoughts are finally leaving. So you can be you, uh they feel it, therefore it's true. Work hard until those thoughts are finally leaving, so you can be you, guided discovery, identifying challenging your beliefs, core beliefs with framing your mind, negative thoughts release, let it go. These cognitive distortions decrease until they cease. Guided discovery, identifying challenging your beliefs, core beliefs with framing your mind, negative thoughts release, let it go. These cognitive distortions decrease until they cease.
