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Interview with Taylor Barragan, LMFT by Vidur Malik, LMFT, Director at Large
Vidur: Could you please introduce yourself and the work you do?
Taylor: I'm Taylor Barragan. I am an LMFT and a psychiatric mental health nurse practitioner (NP). I work most frequently with conditions like anxiety, depression, bipolar disorder, and adult ADHD. I’m primarily working as a therapist right now, but in the summertime I plan to relaunch my practice with an approach including medication management integrated with psychotherapy, as well as complementary interventions and lifestyle recommendations tailored to each patient's unique needs. Personalized treatment will be guided by the patient's history, specific lab results and grounded in evidence-based medicine.
Vidur: What originally inspired the shift to pursue the psychiatric nurse practitioner program?
Taylor: It was a culmination of things. Around the time I got licensed, my husband moved to Ohio for nursing school, and I found myself so interested in everything that he was learning. I was asking him so many questions. At some point he was like, ‘you should just go back to school.’ Around that same time, I had a few therapy clients that had tried medication and within a couple of weeks, they were not as anxious and could actually tap into the emotions or insights that they couldn't previously access in session. I realized that was like the missing piece for this client. I wanted to know more - why did a provider make that decision with that medication or how are these other lifestyle things impacting how effective that medication is?
I just really love school too. Part of that I think too is having ADHD myself. School provides a structure, and I like learning. I interviewed some colleagues who were psychiatric nurse practitioners and after researching how I could integrate my background as a therapist, I decided to make the leap.
Vidur: What type of work do you envision doing with your background in therapy and psychiatry?
Taylor: I have some clients that would prefer to see one provider for medication management and psychotherapy in an ideal world. What's coming down the line in the summer is relaunching my practice to include medication management.
But if somebody is already working with a therapist and that is established, I would love to be able to better collaborate with therapists and make that a cornerstone of how I practice. I don’t think school provides enough training on how to collaborate with a patient’s psychiatrist or psychiatric nurse practitioner. I also don't think that medical schools or psych NP schools do that very well either. There is often confusion about things like “What cadence should we be talking on? How should that communication go? Who leads that? What are we reinforcing in each other's work because this is our common goal for this client?”
Vidur: What are some ways clinicians can maintain relationships with psychiatrists and ensure coordination of care?
Taylor: It can be really hard to get a hold of psychiatrists or psych NPs. They may not have a direct number. I think that there's just a natural grittiness to the beginning of even making contact, and that takes a little bit of persistence. That gets difficult too because then you might spending a lot of time trying to get a hold of this person's psychiatrist outside of session that you’re not necessarily getting paid for. So you can reserve that time in the session with the client, because it is really important. You can use one of those sessions as a case consultation with the client there.
You can also talk through the main concerns, what you’re working on, and what would they would like you to reinforce during sessions. Getting an understanding about if that client is prescribed something, why that was the choice, and side effects that you should be looking out for. And if you are noticing that somebody is having side effects, being able to have a secure way to send a message to the provider.
In addition, psychiatric providers may only be seeing a client once a month, and then sometimes down to once every three months. So as the therapist, you're getting way more face-to-face time with that client than the provider is most likely. I don't think that everybody involved oftentimes appreciates just how much insight the therapist has; if somebody's doing well or not.
Also, if somebody is not sleeping well and they are on a medication that can cause issues with sleep. The psychotherapist can ask, ‘Hey, did you talk with your psychiatrist or psych NP? Can you take that in the morning?’ Just understanding how you can play a role in reinforcing things, being able to report back key things that you discussed with the psychiatrist.
Vidur: It sounds like there is a lot more insight clinicians can provide to psychiatrists than we might realize.
Taylor: So much, like sleep habits and quality, medication compliance, or substance use. If somebody is having side effects from a medication and they don’t like taking it but don't want to tell their psychiatric provider, it’s important to have the conversation with the patient about how important it is to let their provider know. It’s importance to reinforce, “Hey, we’re all on the same team. Your provider should know how you’re feeling about the treatment or they have no way of knowing what is or isn’t working.”
I think that's where things get really messy. Patients may be on a few different medications, and you can't tell if they've had an adequate trial of one because maybe they weren’t taking it because they were having side effects. If we had a better structure for how the therapist could feel empowered to help monitor and relay some of that information, it would be way less confusing and ultimately lead to better patient outcomes.
Vidur: Are there particular topics related to psychiatry that clinicians should like keep ourselves educated on in order to support our clients?
Taylor: Reducing stigma about medication can start just by referring a patient to a psychiatric provider. Patients trust us as psychotherapists, and reiterating that going to a psychiatric provider does not mean they have to immediately take what is recommended is really important. It just starts the process. I was talking to a psych NP a few weeks ago and she said that she always refers patients to psychotherapy, but not every therapist is willing to refer to psychiatry early on in treatment.
Depending on how severe somebody's symptoms are, early intervention is key. Research shows that for conditions like moderate to severe MDD, schizophrenia and bipolar disorder, the longer the delay in treatment, the more treatment resistant they do become. There is also much discussion in the field whether “treatment resistant depression” is actually a case of missed bipolarity, specifically type 2. So for patients who are seeking therapy for mild depression, for example, if symptoms are not improving and instead getting worse, it’s important to refer for an integrative psychiatric medication evaluation.
The other important thing is to remind patients to not start and stop their medication on their own. Again, therapists see the client so much more frequently than a psychiatric provider, so its important to encourage the client to discuss this with their provider and also update the psychiatric provider about any issues with medication consistency. Research on MDD, for example, shows that symptoms should be first treated to remission, and then continued at maintenance with the medication, and psychotherapy, for 6-12 months before tapering (Altamura et al., 2007; Altamura et al., 2008; Kato et al, 202; Paquin et al., 2022). So it’s important for patients to know that for everyone, medication doesn't have to be forever, but it’s really important to decrease stigma about taking medication, reinforce and provide hope for patients, and collaborate with their provider during treatment. Therapists should also be aware of new and exciting emerging treatments like esketamine, and rapid acting antidepressants that are not monoaminergic like conventional antidepressants.
About Taylor
Taylor Barragan, LMFT, PMHNP-BC, APRN, PMH-C is a Licensed Marriage and Family Therapist and Board-Certified Psychiatric Mental Health Nurse Practitioner. She earned her Master of Arts in Counseling Psychology from Santa Clara University and her Master of Science in Nursing in Advanced Practice Psychiatric Nursing from Case Western Reserve University. She is a member of Sigma Theta Tau International Honor Society of Nursing, Postpartum Support International (PSI), American Nursing Association (ANA), and SV-CAMFT.
With a focus on integrative and holistic treatment, Taylor's telepsychiatry practice, which will launch in Summer 2024, offers medication management, complementary and supplemental therapies, and psychotherapy services for teens and adults. As a Perinatal Mental Health Certified (PSI) provider, she has a particular passion for supporting neurodivergent parents through the perinatal period, from preconception through postpartum. Taylor also earned a certification as a lactation counselor to better understand the mental health impacts of lactation and related challenges during the postpartum period.
Taylor's expertise also extends to executive functioning challenges at work and during the transition to parenthood. Her strengths-based and relational approach integrates psychodynamic and cognitive-based psychotherapies, emphasizing enhancing daily functioning and quality of life. Taylor is committed to providing affirming, culturally competent care tailored to each client's needs.
Recommended resources for therapists:
Psych Meds Made Simple
Handbook of Clinical Psychopharmacology for Therapists
Clinical Psychopharmacology Made Ridiculously Simple
References
Altamura, A. C., B. Dell'Osso, Mundo, E., & L. Dell'Osso. (2007). Duration of untreated illness in major depressive disorder: a naturalistic study. International Journal of Clinical Practice (Esher), 61(10), 1697–1700. https://doi.org/10.1111/j.1742-1241.2007.01450.x
Altamura, A. C., B. Dell'Osso, Mundo, E., & L. Dell'Osso. (2007). Duration of untreated illness in major depressive disorder: a naturalistic study. International Journal of Clinical Practice (Esher), 61(10), 1697–1700. https://doi.org/10.1111/j.1742-1241.2007.01450.x
Bobo, W. V., & Shelton, R. C. (2010). Efficacy, safety and tolerability of Symbyax® for acute-phase management of treatment-resistant depression. Expert Review of Neurotherapeutics, 10(5), 651–670. https://doi.org/10.1586/ern.10.44
Kato, M., Hori, H., Inoue, T., Iga, J., Iwata, M., Inagaki, T., Shinohara, K., Imai, H., Murata, A., Mishima, K., & Tajika, A. (2021). Discontinuation of antidepressants after remission with antidepressant medication in major depressive disorder: a systematic review and meta-analysis. Molecular psychiatry, 26(1), 118–133. https://doi.org/10.1038/s41380-020-0843-0
Paquin, V., LeBaron, N., Kraus, G. E., Yung, E. C., Iskric, A., Cervantes, P., Kolivakis, T., Saint-Laurent, M., Gobbi, G., Auger, N., & Low, N. (2022). Examining the association between duration of untreated illness and clinical outcomes in patients with major depressive and bipolar disorders. Journal of Affective Disorders Reports, 8, 100324–100324. https://doi.org/10.1016/j.jadr.2022.100324
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