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Hey folks, welcome back to the [00:01:00] podcast. Glad to be here. If you have been a listener for any number of years, you will know that I’ve had a few guests from the practice, Thriving Minds, which is in Michigan. I started with their owner, Dr. Aimee Kotrba, talking about selective mutism, and then talked with Bryce Hella about supervision and Andrea Roth about sleep and now I have another of their employees, Katelyn Reed, talking about intensive treatment models.
This is a fascinating conversation. It’s a model that I don’t think a lot of us probably adhere to, but after the conversation with Katelyn, it certainly got my wheels turning about what this might look like in practice. I imagine it will do the same thing for you.
A little bit about Katelyn, she is a Limited Licensed Psychologist and the Selective Mutism Program Director at Thriving Minds Family Services, they’re in Michigan. Through her work there, she specializes in treating children with Selective Mutism via traditional weekly therapy and [00:02:00] intensive therapy as well as group therapy models.
Katelyn is the current President of the Selective Mutism Association and co-author to the recent book, Selective Mutism: An Assessment and Intervention Guide for Therapists, Educators, and Parents: Revised and Updated Edition.
There is a lot to take away from this. It is testing adjacent, I would say, but certainly relevant for a diagnosis that a lot of us work with quite a bit, or diagnoses, I should say, selective mutism and other anxiety related disorders. Hope you enjoy this one and without further ado, let’s get to my conversation with Katelyn Reed.
Katelyn, hey, welcome to the podcast.
Katelyn: Hi, thank you so much.
Dr. Sharp: Thanks for being here. It’s [00:03:00] funny, I feel like I’m developing a pretty close relationship with your practice at this point, having had maybe four of you now. Is that right?
Katelyn: I think I’m the fourth. Yeah, that sounds right.
Dr. Sharp: Aimee, Bryce, who else?
Katelyn: Andrea.
Dr. Sharp: Andrea, that’s right. Yes, of course. The sleep episode. Y’all have star-studded staff up there. I would imagine it’s a pretty nice place to work.
Katelyn: It really is. Yes, absolutely.
Dr. Sharp: Thanks for being here. We’re going to be diving deep into this topic of intensive treatment options, which is super relevant for us on the diagnostic work that we do and different options for treatment for some of these kids.
Before we get into it, I’ll ask the question that I always ask, which is, why this is important to you and why do you care about this and why have you chosen to spend most of your life on this?
Katelyn: Maybe we should first define what intensive [00:04:00] is. So intensive, the way that I usually explain it to the families that I work with, it’s not called intensive because it’s inherently harder, but just more time intensive. Instead of taking a typical course of CBT, which might be 16, 20 visits spread out once per week, we’re usually squashing all of those sessions into the course of two days or two weeks.
And so the intensive offering brings a lot of clinical value, meaning we see a lot of kids make more substantial gains because we can thin out some of that warmup window, we can connect families with more folks who have expertise in their child’s condition, so we can get better access, improved [00:05:00] access to evidence based interventions.
That’s why I’m super passionate about it. I work in a pretty niche area in treating selective mutism. We get a lot of families who come from a pretty considerable distance to our clinic looking for that service.
For us, it evolved in a natural way. We had all these families who were saying, I can’t logistically make this work to come every single week, it’s going to be a six-hour round trip thing for us. It’s really evolved beyond that point. So it’s been pretty exciting to be a part of that.
Dr. Sharp: It is super exciting. I have a lot of questions about the logistics and how all this works, and that kind of thing. I’m curious about your background; did you start in a more traditional treatment model where you were doing the 16 to 20 session CBT thing or something similar?
Katelyn: Yes. Definitely, [00:06:00] pretty broad background in terms of lots of different anxiety presentations, always from a CBT exposure based model. But then the intensive model, for us, came from the need of the families that we were working with. We’re working with families who were like, I have to hop on a plane. I cannot do the weekly sessions.
And this was […] where it was a lot easier to work across state lines. We were finding we needed to be able to develop something that met the needs of those families.
Dr. Sharp: Let’s dive into that a little bit. I would love to hear more about the practice setup, how this is integrated in the practice. I don’t know if you were around when y’all made the leap the first time. I would imagine saying, hey, we’re going to do this week of intensive treatment [00:07:00] and hopefully, people come. How do you take that leap? Any questions around that material would be great.
Katelyn: We have several different intensive models that we offer at our clinic. I dug in a little bit to the research on what are some of the other folks out there doing? Although my practice is primarily in selective mutism, I realized that that’s not going to be your entire audience’s primary focus. So I want to try to speak to what is appropriate for those conditions too.
We offer three different intensive models for selective mutism. We also see school refusal. We’ve seen other more specific phobias with this model too. It’s something that we are growing more and more.
To answer your question about making that leap; my primary role is doing intensive style of treatment and absolutely, at the beginning, we would [00:08:00] get more sporadic referrals for this. And so I would try to squeeze those families in around my other sessions.
What that meant is that I had an insane amount of sessions that week. I was doing four or five hour days for the intensive and then still having three or four hours for my other clients that I felt like I couldn’t take a break from that week or whatever.
Even at the beginning, we were sharing our time. So they might work with me for the first four hours and then they might see Dr. Kotrba, who you interviewed some time back for the remaining two.
Initially it was just however we could make it work schedule wise. At some point, we were getting enough referrals that it made sense for my position to evolve to that. So I don’t see barely any regular traditional cases anymore. I [00:09:00] do primarily intensive and then I also do some testing.
Dr. Sharp: Nice. As far as the details around this; just very curious how this works; how many intensives are you doing across the course of the year? Is it multiple times? Is it a one shot deal. What’s this look like?
Katelyn: I would say it often is a one shot deal. I might work with a family. They’ll come out for four consecutive days. We’ll work for about five hours each day. It’s my hope through the intervention that not only is the kid getting the type of exposure opportunities that they need; so for treating selective mutism, that’s talking to new people and in new places.
I should note that with the intensive model, we can do the in vivo [00:10:00] exposure in a more successful way. We have more flexibility. If I have five hours, I can go to the park with the kid and we can practice talking to new children and simultaneously or just thereafter, we can go to the grocery store and practice asking for help locating items on our grocery list.
We can also go and order lunch together and practice ordering their meal in a full sentence. I can get the in vivo component pretty easily there. We’re getting the kids as much practice as we can get in a short window of time, but we also want to equip the parents of the kids that come with the skills and strategies that they need to be able to replicate this.
Because we’re targeting both exposure work with kid, parent training, parent practice, parent coaching; we’re able to, [00:11:00] for the most part, send kids away and they continue to keep up the exposure to work that they’ve been taught.
We usually do some school training, because of the nature of this particular diagnosis, we want the educators and the administrators of the school to have a better grasp of the diagnosis and their role in supporting the intervention efforts. When we can provide that wraparound service, many folks have the foundation of what they need to be able to continue to implement it on their own.
Some do come back. For us, that’s often switching between our intensive models. I referenced that we have three for selective mutism alone. We have folks who come to us for a clinic one-to-one intensive. They work alone with me. We start in the clinic to [00:12:00] establish speech, lay the foundation of our psychoeducation, do the assessment of their symptom profile for selective mutism. And then we progress into the community setting as well.
We have another version where we come to the child specifically in their school environment, usually and we carry out the same evidence-based interventions. Instead of training the parent, we’re training the school or the school social worker, the teacher, whomever are the stakeholders there.
And then we have a third model, which is our treatment camp. In the camp, we rent out a school and we time it to the beginning of the school year. The kids are in a group of other kids who are approximately their same age. It’s meant to replicate a school, so they’re being called upon and asked to read aloud and speak [00:13:00] in school scenarios.
So we might have someone who comes for a one-to-one clinic intensive because that’s where they’re at the beginning of their treatment. And then the following year, they come back for the camp because they had some good success. They want the new school year to start off strong so they apt to come back and do that instead.
Dr. Sharp: I’m so interested in the school model. When you say you rent a school, what does that mean? Are there actors? How are you staffing the school? How are you replicating a school environment?
Katelyn: We literally rent out of school. We reach out to a private school in our area. We have a standing relationship at this point with one school. It’s at the end of the summer. We have to deal with some of their clean up measures, [00:14:00] but otherwise the school functions the way that we need it to; there’s a lunchroom space, there’s a recess area, there’s a variety of classrooms and everything we need.
So then in terms of staffing, this is the much more complicated question. If we think about a school, there are principals, there are teachers and then there are behavioral aides. In the school, in our camp, there are directors or principals, each classroom has a teacher. It’s one of our licensed staff focusing in selective mutism.
And then every child is paired one-to-one with a counselor. The counselors, we recruit primarily from local graduate school students mostly in psychology, some social work, some speech pathology, some in special education programs. So things that are tangential to our [00:15:00] pediatric anxiety world.
We train them and then they carry out the intervention under the supervision and support of all of the folks who are specialized, who are in the room at all times too.
Dr. Sharp: Got you. This is fascinating. We mentioned the school refusal program, the selective mutism, are there others that you’re doing in the practice or other presenting concerns that are more amenable to intensive treatment?
Katelyn: Yeah. We acknowledge the school refusal part came a little bit later for us. Originally, we would just take what’s working for selective mutism, make some minor tweaks and changes and roll it over to the school refusal population.
What we found is that the intensive models worked well, but [00:16:00] we needed to adjust a little bit more than anticipated because if we just took four days and got the kid into the school for four consecutive days, that didn’t necessarily mean that they were going to have the same success the subsequent week.
There’s definitely tweaks and modifications from the different populations that we’ll see. We are only using this with anxiety at this point in time. And that’s what the research has been conducted on that, that I’ve been able to find.
One of the things that is complicated about the research is that there’s a variety of terms, so some are calling them brief, intensive and concentrated, some of them are calling them intensive group behavioral treatments. There’s a lot of different acronyms.
We’re seeing this start to be used with not only selective mutism, [00:17:00] social anxiety, school refusal panic disorder, and some specific phobias, separation anxiety, certainly obsessive compulsive disorder, which is, if I’m not mistaken, where this whole thing started, generalized anxiety disorder. So really a ton of utility with a pretty wide variety of populations.
Dr. Sharp: Sure. Do we have research on intensive versus typical once a week exposure? What’s that look like?
Katelyn: Yes. First of all, some of the research is we’re comparing this intensive model to weightless controls or we’re comparing them to non-treatment receivers. We also do have head to head comparisons with intensive versus regular form CBT, and [00:18:00] the research is telling us that we see comparable gains; effectively no change in effect size from the traditional model of CBT but that the gains might be achieved more quickly.
So if you take 20 sessions and you squeeze them into one week, then you’re going to achieve more in that one week. We see some extra benefits that is like a return to more typical daily functioning in a quicker trajectory.
We see some of the studies when there are comorbidities, we’re seeing more reduction in the comorbid symptoms. So if there’s comorbid depression, we’re seeing a change in that as well, even though that wasn’t the treatment target.
The other thing, and this is out of the selective mutism research specifically is that we’re doing immediate follow up, [00:19:00] so we’re redoing some of the initial assessments immediately after they complete treatment. We’re seeing nice gains, but then we also have been following up these same families three, four months later and we’re seeing even more substantial gains. So the families are learning, they are practicing, they are implementing, and the kid continues to make progress outside of the treatment, which is really exciting.
Dr. Sharp: Yeah, absolutely. I think that’s the thing that we’re always concerned about is how these interventions endure and if they generalize. This is great.
Let’s get into more details around this whole process. I’m curious, where are most of the referrals coming from at this point, are they internal from your practice? Are they external from others in the city, state, country? Where are these referrals coming from?
Katelyn: By and [00:20:00] large, they are coming from other families that we’ve worked with already. So it’s word of mouth in that way. I think the selective mutism side of this, because there’s so few specialists, there’s a lot of dedicated parent groups online and folks are doing a really good job at trying to connect families to resources because they themselves struggled to find resources.
Mostly, we’re getting the referrals in that way for the selective mutism side, but for the school refusal cases, we’re getting more of those referrals from the partnerships with schools that we have put into motion. The school social workers are passing us as a [00:21:00] resource to these families.
Dr. Sharp: That’s fantastic. And then what happens once they get referred? I would imagine there are some kids who are a pretty good fit, some are probably not a good fit. This falls, it feels like so far outside the typical referral stream or selection process.
I would imagine if you admit a kid, so to speak, or accept maybe, and then they’re not a good fit, it’s even worse because you’re spending so much time with them. How’s the selection process work?
Katelyn: It’s really unique. It’s hard to predict what the presentation is going to be like once the kid gets here. Because they’re coming for such a long window of time and often from a considerable distance, the stakes feel really high. [00:22:00] We want all of our clients to have success, but when someone’s put a lot of time, energy and money into this service, the stakes feel higher.
Anyone who expresses interest in an intensive, we start with a 15-minute screener call. They give us a quick snapshot of their symptoms from the preliminary phone calls to our team. And then we talk them through benefits and potential difficulties with the intensive model.
We write them an estimate for our services, I know we are planning a little bit later to talk about some of the unique costs and insurance components to this too, but we write them an estimate for the services. We talk a little bit about what types of treatment goals are most appropriate, and that helps us to narrow into either this is a good fit or [00:23:00] I think we need to try something else first before you can consider an intensive.
Sometimes this has to do with their symptom profile or the severity of their symptoms but sometimes not. What I mean by that is there are kids for whom they look incredibly “severe” on paper. The behavioral questionnaires that we give show effectively no communication with anybody outside of their family, we get them here, and they’re incredibly responsive to intervention. They speak with me or my colleagues relatively quickly.
There are other kids who look “mild” on paper, and are slower responders. So it is really hard. And because clinically, you have to make very fast [00:24:00] decisions about the treatment that you’re providing, you don’t get a few days or a week in between sessions to plan what’s coming next, it all does make for it to be a little bit more complex trying to find who is the right fit and why.
So even kids who sound more severe could be a good fit. In fact, if we look back at the key tenant of prolonged exposure, giving someone the long enough of a window that they need to fully engage in the exposure and feel some of that reduction in anxiety such that they’re able to check that little progression off their list, sometimes these are kids who really need the four or five hours in one sitting to finally get to a place where they can have success speaking with a clinician. They have not made success or gains at home, even with [00:25:00] CBT clinicians, specialists in selective mutism because the session windows themselves are too short.
So yeah, it’s hard. We want to get them on the phone calls, we want to get a sense from the families on what types of things the family is struggling with right now, and also what the family’s knowledge itself looks like referring to effectively, have they already gone through some treatment? Did the parents understand more of the diagnosis and some of the treatment strategies or are they fresh and are hoping to get an immersive experience for themselves too?
Dr. Sharp: So you do the 15-minute screening, you figure out, you said there is some component there of deciding if someone is a good fit for individual versus group.
Katelyn: Yes, exactly.
Dr. Sharp: Talk me through that.
Katelyn: [00:26:00] In clinic school where we come to the child’s school or they come to our group, and that also takes place outside of our office and the school, but here in Michigan. So effectively, if we are concerned that it’s going to take more than two hours for the child to establish speech with our clinical team, then they probably are not going to be the great fit for the group model.
So our camp, like many camps focusing on selective mutism, we have lead in requirements, meaning we want to meet the kid before the camp starts officially, so usually they come out a day or two before. We meet with them and we establish speech with them, and we want the kid to speak at least one word to myself, let’s say, and that one-to-one counselor that we pair them with so that we know some of those hierarchy levels have been checked off before we throw them into this [00:27:00] group.
They have to speak to their counselor, around eight or so other kids and eight or so other counselors, they’re being called upon in a group, the demands and the hierarchy steps become just much more challenging. So if we’re concerned that the kid’s not going to speak at that window of time, then we might say, with an intensive that takes place one-to-one in our clinic would be a better fit.
There might also be times where we have a kid who is doing really well with their home clinician, they’re starting to speak in community situations and they’re having more success within their extended family. Things are moving along in everywhere except the school. At that point we might say, hey, we can come to your school or you can come to our [00:28:00] replicated school where we can give you the talking scenarios that meet the kids’ current needs.
It’s a lot about what exposure opportunities do they need and how quickly do we think they’ll be prepared for some of the more advanced goals.
Dr. Sharp: Got you. Okay. I would imagine there have been situations where you maybe made the wrong choice for whatever reason when you missed it, in the good direction or the not so good direction.
Katelyn: 100%. From a good direction, if we have someone who we expect is going to be more challenging to work with, but they make really substantial gains, that’s not so bad of a situation and we can adapt and adjust to that pretty easily.
We can find much more challenging goals. We can adjust to that really easily. It’s [00:29:00] harder when we overshoot what we think the kid is capable of, and then they have a harder time in whatever program than we expected
Dr. Sharp: Sure. That does make sense. Let’s talk more about pre-treatment part. I would love to hear more about how you prepare the families for this experience; what that looks like, what you’re telling them, how much are you couching the anticipated effects or results.
I have so many questions about how to prepare families for this experience, because I would imagine they build up pretty high expectations for something like this. I’m curious how you go through that specifically.
Katelyn: I’m [00:30:00] always interested at how many families that I work with who are baffled that they’re, one of the comments that I hear frequently is I thought I was going to have flown all this way and my kid wasn’t going to talk for four days, that’s a really common sentiment. I think, yes, they’re cautiously optimistic and willing to put some money and time on the line to make that bet. I think they’re generally quite worried that the kid is not going to make really good gains.
There’s some setup that we like to talk through for the family what to expect. So for us, that means we go through a day by day. On day 1, you’re going to arrive. I will direct you right away into our playroom space. There’s a camera system set up in there. I am just [00:31:00] trying to get a language sample of what your kid can do alone in my office but with you as parent.
I want to see what their language looks like at baseline so that I have a sense of where I’m starting and what I’m starting with from a treatment strategy perspective. That’s what the direct observation portion is going to look like.
After that, we’ll sit down, me and you parents, we’re going to talk about your observations, my observations, what those mean for treatment. We’re going to set some more defined goals together. I’m going to ask some additional questions about the paperwork that you shared in advance and your kid’s symptom profile.
And then usually we take a break for lunch and when you come back, the rest of that afternoon, we’re typically focused on those early exposure goals in my practice; establishing speech with me. And then I want to give your kids some psychoeducation about why we are going to be [00:32:00] asking them to do these things.
Some families find that they need a little bit more information for the kid so I’ve made two social stories that they can pass along, edit and adjust there like we’re going to go to Michigan. Are we going to fly? Are we going to drive? They draw it out on their pictures.
We’re going to be earning prizes for working hard on being brave. Here’s some prizes that I would like to earn so they can work on that together. That we’re going to meet Miss Katelyn. She’s going to help us be brave. We’re going to get to practice in different places. Where are some places that I want to practice? That’s some of the education that the families will give to the kids.
Education for the families is incredibly important. As we’ve built this out more and [00:33:00] more, we’ve found that we don’t want families to come totally novel because it’s really hard to establish speech with a kid who doesn’t talk to new people unless we can keep them talking to someone that they do speak with.
So if we can keep them talking to their parent, then we have an easier way of edging into that interaction. That’s a more comfortable exposure hierarchy for many kids than having to start from the ground up and work on saying sounds and doing all these things with an unfamiliar person.
And so we do need parents to be, I certainly don’t expect them to be like expert level clinician, but I do hope that they have some preliminary information. And so because of that, [00:34:00] we created a little video bundle that helps prepare the families for the experience.
There’s an introductory video that describes the condition and the basics of our intervention. There are videos illustrating us demonstrating the strategies that we’ve gone through and coded. So at the bottom the family can see, oh, they asked this question and here’s why. They waited five seconds for the kid to produce a verbal response.
They can see the strategies live, but we also have videos of us doing things wrong so that they can go through and make the point to be thinking critically about the types of questions they’re going to be asking and how to elicit speech.
Since we started doing that, I have certainly found that the families come a little bit better prepared [00:35:00] for what their role is in supporting things and also more realistic expectations of this is what my kid might be capable of. Of course, it varies from child to child.
Dr. Sharp: Of course. Okay. This is so nice to hear concrete details about how you tackle some of these things with families.
As far as the kids, you mentioned the social stories and some information around that. I feel like I have to ask, it seems like it’d be hard to convince a child to participate in something like this; having had a daughter who had some school refusal and now is working through some OCDish kinds of stuff, I know firsthand, getting kids to engage in exposure is challenging [00:36:00] sometimes. How do you talk to the kids? How do you navigate if they get there and then don’t want to do it? What’s that whole process look like?
Katelyn: That is definitely tricky and that’s one of the things that is discussed a lot in the research is how palatable is this to families. Specifically, this intensive, I’m doing this, I’m committing to this. I don’t have to try one or two sessions and see how I feel about it and I can just continue, we’re committing to the several day long experience.
The short answer is we try really hard to couch these practices into things that are really enjoyable and really fun. And then there’s a reward system in place as [00:37:00] well. It varies substantially depending on the age of the kids. So the young kids, a social story tends to go a long way.
Honestly, the younger children, if you do it well, you can get them through the first two exposures before they even realize that they’re doing exposure. And then you can do the psychoeducation, you can say, I’m wondering, on a scale of 1 to 5, how hard you thought it was going to be to talk to me today, and how hard is it actually?
Usually, they’ll report a reduction, from 4 to 2 or whatever. And so you’re able to say, look, you’ve already done it. Oh my gosh, I’m so proud of you. You’re already starting to see how this is working.
The older ones, we do provide some additional details. Obviously, parents are the consent providers, but we do provide a written [00:38:00] assent document that describes here’s what exposure therapy is, here’s why we’re asking you to do this, here’s what it’s going to look like, here’s your role, here’s your parents’ roles. We want you to do your best, that’s all we can ask of you.
We are also going to, as anybody who does exposure work would tell you, we’re going to make sure that we’re not asking you to do the things that are too hard. We’re going to have an inappropriate plan B or plan C at the ready.
Dr. Sharp: That makes sense. This is good work. So they’ve gotten there. They’re going through the whole thing. You did talk a bit about how parents are involved. Can you say any more about, what are parents doing during these four days that kids are training?
Katelyn: We need them for the exposure. We need them to establish speech but [00:39:00] then, like I said, these are predominantly families who live pretty far from us so we’re not able to see them on a regular basis. We do want the parents to learn the strategy.
Typically, the week starts where I’m at the helm. I am leading the exposures and I am coaching parents and telling them why I’m doing what I’m doing. We always save some time at the end of every day usually for a parent debrief, we talk about what went well, what didn’t go so well, set plans and goals for the next day, et cetera.
And then as the week progresses, the intention is to hand more and more over to the parents to say, okay, we’re going to go to the grocery store next. Here’s the grocery list. The first two employees that we talked to, I want you to tell them this and this. The kid’s exposure goal is to say, da, da, da.
And so [00:40:00] we want to be able to hand more of the exposure work over to the parents so that:
1. The family feels more competent in carrying this out.
2. That the kid doesn’t leave the intensive week thinking I only do that for this clinician or only because I was in Michigan, we want them to see the continuity as well.
Dr. Sharp: Okay. That’s fair. Gosh, what else? There’s so many details. What am I missing? Oh, what about the age range? I’ve actually wondered about that throughout our conversation. What kids are appropriate for this kind of thing?
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Katelyn: That’s a great question. We start with relatively young kids. I have a kid right now who I’m going to their daycare next week who just turned three. So quite young children. For selective mutism specifically, we need the kid to be in a school like environment for at least one month before they can get the diagnosis. So that limits things, so we’re generally not working with one and two year olds as a result of [00:43:00] that.
And then we work with teens as well and some even young adults whose symptoms negatively impact them in the community setting, but they understand what treatment looks like and are committed to it. So really wide range.
Dr. Sharp: That sounds good.
Katelyn: Most are early school age, though, I would say is our primary. That’s when symptoms are usually first apparent, it’s hard for teachers to assess these kids’ skills, and so there’s a lot of motivation to figure out how to support them more.
Dr. Sharp: Okay. We’ve hinted at the billing process a little bit. I am curious about that and the logistics; how this works. Is there insurance involved? Is there not insurance involved? [00:44:00] What does that look like?
Katelyn: We take insurance. We’re very clear to the families that we work with that insurance will cover some, but not all of the service fees. That’s because we’re still using the same 60-minute treatment codes; we’re not a hospitalization setting, we’re an outpatient clinic and so we’re using the same regular treatment codes that I’m guessing everybody else in this audience uses as well.
We do intake codes and we do some of the assessment codes for the direct observation time and then we write a report for them as well. So we’re using those codes too. Often how it works is because day 1 is primarily the assessment piece, we’re able to get most of day 1 covered from their insurance if they have an insurance that we participate with. [00:45:00] And then usually beyond that, it’s one treatment hour of the 4 or 5, and then the rest is patient responsibility.
I certainly wish that that would change because I think know from the research that prolonged exposure is really important and really necessary for some clients. We’ve got a growing research base to suggest that this intensive model is equally effective, interferes less with family’s lives and schedules and yet, that’s just not the reality of the billing right now.
Dr. Sharp: Sure. I imagine that you’re talking with families about this ahead of time to make sure they’re educated make right choices.
Katelyn: Correct. We give them an estimate that says here’s what [00:46:00] we found that your insurance will cover, you have a whatever percent copay or coinsurance or whatever. We give them a pretty close as we can get estimate to what their portion will be.
And then in order to be able to book their intensive time, they put a deposit down, because we’re reserving 20-something hours worth of time for a family at a window of time. So they put down a deposit and then we account for what we expect their insurance will pay.
Dr. Sharp: Right, that gets into questions about no show fees or canceled. What if somebody gets sick at the last minute, how do you handle something like that with when you’ve got 20 hours reserved?
Katelyn: I was doing this at the beginning of COVID too, and so we did have to like, it was a whole thing.
Absolutely, if someone was sick or had an [00:47:00] exposure, we had to have a pivot plan, which really at that time was we will let you reschedule X amount of times and then otherwise, please don’t let us get to that point. Hopefully we don’t get to that point. We thankfully didn’t.
We have had kids who the family emails us frantically the weekend that they were supposed to fly out saying our service starts on Monday and my kid is throwing up and we’re not going to be getting on a plane. So that’s happened. We try to be flexible with that. There are things that happen.
It is really hard from the clinician’s perspective, because if someone has a no show for their one session because the kid is sick, you still have your full case load the rest of the day. You’re still making money. You still have things to do. You’re not paying for child’s care that you don’t end up using. [00:48:00] It’s a little harder with the intensive in that way.
Dr. Sharp: Absolutely. Oh my gosh, it’s challenging.
Katelyn: It doesn’t happen frequently though.
Dr. Sharp: Okay. Fair enough. Did you have to do any unique or direct or specific conversations with insurance panels to get “permission” to bill all of these non-covered hours, or that’s just the deal, we know insurance panels do not cover multiple treatment sessions per day.
Katelyn: Correct. No, but effectively how we write the estimate is we can’t submit these to your insurance. This X amount of time is not billable. In our camp, there are some of the service fees that are like, we rent out this space, we have to train other clinicians, we have to buy the [00:49:00] materials to be able to provide rewards every day for all of these kids. So there are some service fees that are never going to be sent to insurance. The insurance doesn’t even know they exist effectively.
And then some families are able to, let’s say, we’re out of network with their particular insurance provider, they will seek reimbursement and they’ll ask us for documentation to support that as well.
Dr. Sharp: Sure. Of course. What about the personal side of this? I’m just thinking times in the past, when I’ve done in-person events or multi-day events where you’re on for most of the day, how does one handle the emotional side like managing your energy, preparing, what’s that look like?
Katelyn: Yes, [00:50:00] that is tricky. First of all, it was a lot harder at the beginning when I didn’t have my schedule dedicated in this way, because if I was seeing other clients or leaving the camp and trying to go back and do an intake for something else that I had the next week, it is incredibly hard to keep up your energy and momentum and the sharpness clinically all that window of time.
I think now, because that’s pretty much all I’m doing in a single day, I don’t find that it’s much different from my other colleagues who might see five or six clients in one day, I’m just seeing the same client for five or six hours. So I don’t find that part now is much more complicated.
What is sometimes hard is, so the intensive format lends [00:51:00] itself pretty naturally to people wanting to come during times where their kids are off school, they have more flexibility scheduling wise. So in the summer, I might have back to back intensive weeks, and that is tough to be on it for so many weeks in a row.
When you’re writing a report for each of these kids and you’re having to score all their questionnaires, just as much as we want the families to prepare for their time to make it as effective as we can make it, we as clinician needs to be pretty well-versed on this kid before they arrive in my office. So that’s tough trying to keep over several weeks.
Dr. Sharp: Yeah, of course. I would imagine hopefully, you have some flexibility to say, hey, I’m only going to do three of these or something like that.
Katelyn: Yeah, correct. I do [00:52:00] try to schedule my time in that way. And then because each of these intensives, like I said, we do a school consultation after they return home and are settled as well, I have to budget sometime, even in the summer for flexibility to schedule those types of follow ups as well.
Dr. Sharp: Of course. Are there other, I don’t know if you’d say downsides, but challenges from more of a personal energy management standpoint or emotional standpoint with a model like this, things that are tougher to manage for you as a clinician?
Katelyn: Yeah. One of the things is the pivoting for the plan Bs and the plan Cs if things don’t go the way that you expect. What’s nice about this model with selective mutism in specific is that I can tell [00:53:00] pretty readily if what I’m doing is effective because the kid is talking or they are not talking. I see pretty quick results from the exposure which gives me the chance to pivot my strategy pretty fast if I need to.
Kids are kids, sometimes they wake up cranky or they had a tough exposure earlier and they’re feeling sleepy now and one thing that goes wrong can set the whole day back. It can really be a problem.
On the other hand, and this is why I love intensive format, if a kid has 5 successful practices in a row, we can usually get them to do a 6th [00:54:00] practice because what’s a 6th practice if I just talked to 5 new people.
Let’s say it’s a separation anxiety case, we just did that practice and that practice, I can do this much harder practice for a longer window of time away from my parents or from a further distance away from my parents or whatever the exposure task is because I’ve already had all this success. But if things aren’t going great on one day, it almost feels like the whole day can go downhill pretty fast.
Dr. Sharp: Yeah, I think that’d be pretty tough. We have all struggled with that even if we’re testing a kid and hanging out for 4 or 5, 6 hours a day and something goes wrong in the morning and it’s like oh, no. You just buckle up and pull out the tricks and hope that …
Katelyn: I think in some ways, that’s why there are so many parallels to the testing role and this intensive role of [00:55:00] schedule wise, we’re talking about a lot of the same variables, how much time you’re allocating for these cases, which hours you’re working with these kids.
I think that it’s a nice companion for folks who do a lot of testing and want to have some treatment cases but maybe don’t have the bandwidth in their schedule to do that on a regular basis.
Dr. Sharp: Sure. That makes sense. That might be a nice segue into if folks out there wanted to, I’m about to say, give it a shot, this doesn’t seem like a thing you just give it a shot, there’s a lot of planning and organization. Can you identify even two, three steps to take if somebody is listening and they’re like, I want to do this. How do I do this?
Katelyn: I’m [00:56:00] talking pretty exclusively about exposure therapy and specifically about anxiety work so obviously, step 1 is having the competence in that. Like I said, our treatment camp, we draw upon mostly psychology students but we definitely have providers who are already licensed and practicing and looking to get more experience with the intensive model or selective mutism specifically. They’ll come and do the camp. They’re paired with a kid. And so that’s a great way to get a feel for the intensive model and also to do it with the guidance and support of our team.
And then I definitely, this is more applicable for the folks who are somewhat in proximity to our clinic, but we have a lot of folks who come in and shadow for the day or for two days which is a [00:57:00] mutually beneficial situation; they get the learning experience that they were hoping for, they get to participate in intensive and see all of the various components, the parent education and the coaching and the skills themselves, and I get another person for this kid to practice with that I need as well. I think that is probably the most effective way to do it.
Dr. Sharp: Nice. We should have talked about this at the beginning, but what is the role of assessment in this whole process?
Katelyn: We’re not doing structured assessments in the way that we would for ADHD or autism or things of that nature. It’s more of, does this seem like a good clinical fit for their needs. Like I said, we’re doing a lot of behavioral questionnaires. [00:58:00] Some of them are broad anxiety screeners. Some are much more narrow into the selective mutism symptoms.
Some are things that we’ve made ourselves that are just like, I find myself asking the same question about will your kids speak to this person in front of other people, only alone? Do they whisper? So more of check the box sort of scenarios. So all of that can be really helpful. With the older kids, we’ll give examples of SUDS hierarchies scenarios and we’ll ask them to help us to arrange them.
So as much as we can do at the onset to prepare for the treatment, the better. We have had kids who end up doing more comprehensive testing with us as well. They come in for the [00:59:00] selective mutism treatment and then we find either through the intensive treatment or posts that there are also indicators of ADHD or autism or whatever else.
There’s a concern about whether the child will speak with the clinician to be able to do the evaluation procedures. So sometimes they’ll come back to us because they were already able to have success verbalizing with us. Generally, it’s more of a direct observation and behavioral questionnaires.
Dr. Sharp: Yeah, that sounds good. I know we talked about the referrals and where the referrals are coming from. It sounds like it’s a lot of word of mouth, which is great. Are there other ways that y’all are actively marketing this service and getting those referrals through the door?
Katelyn: Yeah, we’re a part of [01:00:00] some of the organizations that support CBT and other evidence based practices. That’s something that we spend a lot of time collaborating. We speak at conferences and trainings and such like that.
We do a lot of collaborating with local schools and pediatricians; things of that nature as well. Most of the referrals are coming from other families that we’re working with and dedicated groups focusing on X, Y, Z diagnosis.
Dr. Sharp: Sure. I would imagine, once the ball gets rolling with something like this and people hear about it, then it gains steam pretty quickly. Do you have any sense of how many of these programs are out there in our country at least?
Katelyn: Oh, that’s a really good question. [01:01:00] I’m a part of the selective mutism association and there are a number of group treatment camps. At one point, I had a list of all of those. Of course, I don’t know those numbers off the top of my head now but they’re spread out.
Of course, that’s me being naive about the other areas of expertise; if you’re doing more OCD intensive work or panic disorder intensive work. I don’t pretend to know all of those groups either. I think that it’s more rare, but also even in the last 10 or so years that I’ve been doing this, it is exponentially growing.
And for the reasons that we started this discussion with; families are having trouble finding a provider that does evidence [01:02:00] based intervention and that has a specialty in their area of focus. It’s hard for them to get to regular treatment sessions or the regular treatment sessions are limited by some of the rules or the confines of that setting. If you only have one hour, it’s pretty hard to go out into any real life places to practice. So yeah they’re definitely increasing.
Like we said, with the research saying that it’s equally effective and then sometimes having extra benefits that the families and the kids are endorsed seeing, I wouldn’t be surprised if it continues to grow.
Dr. Sharp: Sure. I had one more question for you around this, but now it’s escaping me.
Katelyn: It happens.
[01:03:00] Dr. Sharp: Thanks. We’ve talked about a lot of things with this method of treatment. It’s really fascinating. I love the idea of diving in there and doing such intensive treatment. That reminds me of the question that I was going to ask, which is, liability and releases of information and that sort of thing. To be going out in the community and doing this in vivo work, what does that look like just from a logistical kind of paperwork standpoint?Katelyn: That is a really good question. I think we think about that; those ethical variables no matter if it’s intensive versus if it’s a non-intensive. If you’re doing anything where there’s potential risk of being overheard that there’s some extra complexity to that. So we include that in our informed [01:04:00] consent.
Especially when I’m having somewhat a shadowing clinician or one of our practicum students or a doctoral intern that’s coming in for a part of the time to support, I think most families are fully in support of having additional people join us. For selective mutism specifically, we need extra people to talk with. So there’s no ambiguity about other people are going to be involved in some capacity.
Dr. Sharp: Got you.
Katelyn: One of the things that we do have to be careful about as clinicians is setting up exposures that involve novel people and not helping them to understand what their role is going to be without telling anything that is not okay to [01:05:00] say.
What I mean by that is I couldn’t go up and say, hi, I’m so grateful that you’re willing to help us. My friend here has selective mutism. They need to practice talking to somebody new. I can’t do any of those types of things.
It is an awkward social exchange if you have a client who’s not readily speaking to somebody new or the practice doesn’t go the way that you planned and you have to go back and do a plan B or a plan C.
There are definitely times where people will say, oh, are you family or oh, wow, is this your teacher? Having some stock statements at the ready how to navigate those situations.
I find, in terms of how I set those up, I don’t even say anything. I would just go over and say, oh, my friend is trying to decide between ordering the chocolate ice cream or the vanilla ice cream; would [01:06:00] you mind asking them which one they want?
And then I have to shoulder some of the discomfort of telling a grownup how to ask a question and hope they don’t give me too weird of looks. And then I move on with my day and hopefully, I never see them again or they don’t remember me.
Dr. Sharp: Right. You just have to go for it and get over it. Got you. This is great. This is fascinating. I love these out of the box practice models. I think it’s a great option for us just to keep in mind too, for families when we’re working with them.
Katelyn: Absolutely. I do some assessment and so being able to refer people to this model or the weekly model or both, being able to help families navigate what might make most sense for [01:07:00] them.
I’ll give you an example of that. We do get a lot of folks who are referred to our camp. Like I said, the camp goals are a little harder and a little higher because of the nature of the group model. And so there are times where we’ll see on recommendations reports, you really need to do a camp and that kid might not be ready for that camp or might not make as good of gains.
I think it’s an interesting thing to speak about because the research is increasing in this area and being knowledgeable about what exists out there, but also when we’re recommending service models for folks, having some of the background of who’s going to fit and why, and what does this actually look like in practice?
Dr. Sharp: Right. That makes me think, maybe we talk just a little bit more about [01:08:00] exclusionary criteria, so to speak. So if we’re in that situation to possibly make a referral, who should we maybe think twice before sending that direction?
Katelyn: Like I said before, until you see the kid and you see how they’re responding to treatment, it is hard to predict some of that. I think maybe the synopsis is like lots of comorbidities that might be a situation where a one-week intensive, I guess just being realistic about what the aims would be, like the scope of the intensive is going to be this and this goal. We’re not able to tackle all of these things in this one [01:09:00] week.
I think that that’s really important for families always to know is that this is not a curative week. Most people find that they learn a lot, their kid makes really good progress, they have what they need to continue to implement this as they move forward in their day-to-day lives, but it’s not curative. So being able to set the right expectations.
High comorbidities would potentially be a bit of a concern. In the camp model because we’re pairing kids, are matching kids into age cohorts, if someone has some developmental or cognitive complexities that would make it so that they have difficulty in that group being able to meet the needs of the education that we’re providing in the group, [01:10:00] that would be potentially a concern.
Certainly, this is not the type of model where folks, parents get to have a hands off scenario, they’re really immersed in this as well. I think that’s an important expectation that we would want families to have too.
Dr. Sharp: Yeah, that makes sense. Cool. I appreciate you talking through all of this. Is there anything else maybe that we’ve missed or you want to highlight before we start to wrap up?
Katelyn: No, I don’t think so. I really like it. It’s nice, I get to have mostly daytime appointments. It gives me the flexibility.
It’s great to not just sit in an office all day. You get to be out about in the community and doing interesting things. I get to go to [01:11:00] museums and parks and get snacks that I enjoy also. It’s a fun way to spend the day by and large.
Dr. Sharp: That does sound pretty good. You get out in the community, order some ice cream, apparently.
Katelyn: Exactly. Lots of ice cream ordering and/or other treats. That’s usually one of the first exposures we do, get some practice talking to somebody new, get the nice natural reinforcement of ice cream cone, win- win.
Dr. Sharp: It’s hard to beat that. Yes.
Katelyn: Yeah. So it’s really awesome work.
Dr. Sharp: It sounds like it. It’s got me interested in it. I appreciate sharing all of this with us. If folks want to learn more or connect with you, ask more questions; are you open to that? And if so, what’s the best way to get in touch with you?
Katelyn: Yes, definitely. Certainly, you can find me [01:12:00] on the clinic website. Our clinic is Thriving Minds Behavioral Health. We’re in Michigan. My email, is that okay to provide on here?
Dr. Sharp: Yeah, if you’re okay with it.
Katelyn: Okay. Yes, I don’t have a problem with that. My email is kreed@thrivingminds.info. Another great
resource, if you’re interested in the selective mutism side of things is the Selective Mutism Association. There’s some really great downloadable, printable resources there. We have a YouTube channel as well, some really awesome prerecorded talks for professionals and for families and caregivers. So really good mix of things.
Dr. Sharp: That sounds great. I appreciate it, Katelyn. Thanks for coming on and talking through this somewhat unique and cool treatment approach that could be relevant for a lot of us.
Katelyn: Thank you so much for having me. I [01:13:00] appreciate it.
Dr. Sharp: All right, y’all. Thank you so much for tuning into this episode, always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes so make sure to check those out.
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