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Hey, [00:01:00] folks. Welcome back to the podcast. I’m glad to be here with you and glad to be here with my guest, Dr. Rachel Loftin. Rachel is the Chief Clinical Officer at Prosper Health, a company that provides remote therapy and evaluation for neurodivergent adults. Rachel is a clinical psychologist and autism specialist based in Chicago, and she has over 20 years of experience in clinical and academic settings.
Many of you may have heard of Prosper Health. Like you heard, they do therapy and evaluation for neurodivergent adults, specifically, potentially autistic adults. And so our conversation today centers around the virtual autism assessment space and what Rachel and her team are creating over at Prosper Health.
I’ve heard some questions and discussion about Prosper, specifically on some other online platforms. I think this conversation will provide a lot of insight into [00:02:00] the process and give you a lot to think about in terms of the status of online assessment and best practices and things like that.
So we get into Rachel’s history as an autism practitioner and researcher. We talk about Prosper’s process for online autism assessment and how to bridge that gap between in-person services and jumping to fully online. We talk about bias in assessment. We talk about neurodivergence as a construct and many things. So there’s a lot to take away from this conversation, as always. I hope that you enjoy it.
If you’re a practice owner and would like a little support with your practice, I am happy to jump on and do a strategy session with you. So these a la carte hours where you can send me some information about what you’d like to work on and we just jump onto a call for an hour, dive deep and figure out as many things as we can, and I’ll [00:03:00] send you away with some little bit of homework and hopefully point you in the right direction. So you can go to thetestingpsychologist.com/consulting to sign up and book your call right from the website.
For now, let’s get to my conversation with Dr. Rachel Loftin.
Rachel, hey, welcome to the podcast.
Dr. Rachel: Thanks for having me, Jeremy.
Dr. Sharp: Thanks for being here. We got a lot to talk about. I think you’ve got a lot going on in your life that my audience is probably really interested in, so I’m grateful for your time. I know you’d likely have a full schedule these days, so thanks for being here.
Dr. Rachel: I’m happy to be here and share information. I hope it’s helpful to your listener.
Dr. Sharp: Yeah, [00:04:00] absolutely. I have a lot of questions for you and plenty for us to talk about, but we’ll start with my familiar question, which is, why spend your time on this out of all the things that you could do with your life?
Dr. Rachel: It’s always been important to me to look at where we are as a society, what we’re doing, how the world’s working, and figure out what I could do to make it better. I know that sounds incredibly naive, but if I look at my career at any point, that’s where I’m coming from.
For a long time, I’ve been focused on autism. It was always my professional focus. I have autistic family members, and it’s always been something I cared about.
I think neurodivergence more broadly is where we are in society right now and what we need to start looking at and thinking more about as we think about [00:05:00] doing the right thing for people, making sure that we have equity in society, making sure that everyone can access everything. It becomes increasingly important that we look at and think about neurodivergence. I think that’s what it means to me right now and why it’s so important to me to be putting my time and energy into it.
Dr. Sharp: That’s powerful. We’re right in the middle. I feel like the neurodivergence movement was like a slow-building wave. It started a long time ago -20, 25 years, something like that formally, but then it feels like over the last 4 or 5, maybe 6 years, it’s really gathered steam, and now we’re immersed in it.
Dr. Rachel: I think it’s so interconnected with other identities and other ways that people express themselves. And so I think as [00:06:00] we make progress in those other areas, neurodivergence is something that gets more and more attention. But yeah, there’s momentum now that I haven’t felt in my 20+ years of doing this work professionally.
Dr. Sharp: Yeah. So that might be a good place to start. I know I did the introduction in the beginning part of the podcast, but I think your history is important for people just to have a really clear sense of, especially what we’re going to talk about. So, tell me a little bit more about your experience with autism and what your careers look like up to this point.
Dr. Rachel: Sure. I’ll do that from a professional angle. I mentioned I have family members, and I can talk a little bit more about that, but professionally, I always knew I wanted to specialize in autism. So even going into my doctoral [00:07:00] program, that was already part of the objective.
I also was interested in adolescent girls, and I had some other specific interests in things, but autism has always been a big drive for me. Initially, I did school psychology thinking that, as we thought back then, autistic people are young people and there are kids who need diagnoses.
So, I started off with school psychology. I did that at Indiana University. They had a really strong special education program. I was able to work closely with people there, like Sam Obeng, who did great autism research and learned a lot, and start there.
And then as I did that work, I did school placements, and I did hospital placements and so forth, I realized, oh, I really like this clinical stuff. This is the draw for me. So, I chose an internship and a postdoc that were more clinically focused. I went to the Yale Child Study Center, where there was [00:08:00] amazing autism research happening.
The way their system works is there’s only one autism fellow, or at least there was at the time. I don’t know how it’s changed. You get to be the autism fellow for 2 years. It’s just a real immersion. I loved it. I just soaked in whatever I could. That was amazing.
And then from there I went to the University of Illinois, Chicago. They had just gotten a huge autism research grant. I worked there with Edwin Cook on his genetics research, and did a lot of clinical work and lots of other stuff. I love that too.
But being a university, there was some shifting, shake up, and funding issues. A whole bunch of things happened at once where that position wasn’t too secure. So I branched out into clinical work for a while
because I didn’t know what was going to happen with [00:09:00] the university, and I had a baby, so I wasn’t taking any risks.
I found that I also loved the clinical work, 100% clinical. It was a big shift from these research projects and things, but I really loved it. While I was doing that, I found out that Rush University here in Chicago was going to start an autism program and I had some connections there.
People reached out to ask if I wanted to be part of that. So I was the Clinical Director when they started their autism program and helped get that started. I was there for a few years. I went back and did clinical work again for a little bit, and that’s where I was when Prosper Health reached out.
It wasn’t Prosper Health yet. It was a young business guy looking to see if this was something to maybe go into. He asked me [00:10:00] he wanted to pick my brain as an autism specialist and someone who saw primarily young adults.
I didn’t say this earlier, but the age range I focused on has just gotten older and older over time. When I was at Yale, I had to be in the baby clinic. So a lot of us, we’d see literal toddlers and babies. I’ve just only gone up through the age range over time and shifted focus based on where the needs were. We didn’t have clinicians with the expertise. So I became an adult specialist because that’s really what was needed, and I loved it.
I talked to this business guy. I’m not a business person. I’ve never had a very business brain, but I really liked him. I liked talking to him. I liked the focus of what he wanted to do. And so in talking with him [00:11:00] over time, it’s evolved into my full-time thing. So what I do now full-time is I’m the Chief Clinical Officer at a business called Prosper Health.
Dr. Sharp: Isn’t that wild? Did you ever think that you would end up in this position?
Dr. Rachel: No. I would’ve thought the opposite. I would’ve thought that I would hate it. I didn’t want to do anything. For-profit business, it seemed probably inherently evil. I just didn’t want anything to do with it. And so I’ve had a huge shift in that.
Dr. Sharp: Right. I have a lot of questions within that information that you shared, but I’ll go backward from the most recent. Tell folks what a Chief Clinical Officer does in a business like this and how a psychologist fits in.
Dr. Rachel: It’s a startup, and one of the interesting things about startups is you don’t [00:12:00] usually get a very detailed job description because everything’s getting figured out as we go. So what I try to do is poke my nose into absolutely everything because I think there’s a clinical component to everything we do.
I want to know about billing. I definitely want to know how people are interacting with our therapists and our psychologists. How are our operations; people are asking them for information, or what are they being asked to do, or required to do? I want to know about client communications; how are people interacting with our clients?
So I’ve got my nose in everything, but the most important aspect of my job is coming up with our approach for evaluation, our approach for therapy, setting those clinical protocols, making sure that what we’re doing is valid, making sure that our evaluations are also reliable, making sure that our therapy is effective.
[00:13:00] I also oversee research projects. There’s so little research in adults who are autistic. You know that I want to contribute to that research literature and also expand that, and if it’s going to happen, it’s got to come from me because people on the business side don’t care. Not that they don’t care about the people and they understand the need for research, but they’re just not the people who are going to make it happen.I think that’s most of it, but there’s just an unlimited list of things that can happen at time. So it’s a constant every week prioritizing and making sure that I’m putting my time and my attention on those things that are most important.
Dr. Sharp: Sure. That makes sense. I appreciate you diving into some of the history. I did that on purpose just to set a little bit of context because I’m guessing some folks are probably looking at this conversation through [00:14:00] a little bit of a skeptical lens, like, oh, here’s this online autism evaluation and therapy startup. What are they doing? Can this happen online? What’s the clinical fidelity here? So I wanted to outline all that to let people know that you do have the background and the chops, so to speak, to come at this business in the right way.
Dr. Rachel: Like I said earlier, at a university somewhere still working in a hospital or whatever, I would have that same attitude about anything that popped up. I think there are a number of really terrible online evaluation options available where people are just given a bunch of rating scales, maybe talked to for 20 minutes, and told they’re autistic or they’re not autistic.
They skew badly in both directions. Some of them are just [00:15:00] giving everybody an autism diagnosis across the board. Some of them are going by the old school, you looked me in the eye, there’s no way you’re autistic, and not diagnosing anybody. And so we’ve got a bimodal distribution of evaluations out there.
And that was part of what motivated me to want to come up with something because it’s already happening. We’re not going to roll back technology. We’re not going to roll back people wanting remote evaluations. We’re not going to reduce the need in remote areas. We’re not going to shorten the wait list in the best places. So we’ve got to figure out how are we going to help these people, and how are we going to do it soon?
I thought, well, I’d like to be involved then to make sure valid assessments are happening, that they’re done reliably, that there’s a real quality to it. So that was what motivated me to get in the game.
I think we all already knew that you can do decent remote therapy, but there was that question of, can [00:16:00] these evaluations happen and be good? I wanted to be involved in that and make sure that they were good if they were happening.
Dr. Sharp: It’s a good way to think of it. It’s part of the problem or part of the solution. If it’s going to be happening, people are going to be doing it. I get at least five questions a week about how to do remote evaluation practices in private practice. So people are going to be doing it. You made the choice to “be part of the solution” and actually shape it on a little bigger scale.
Dr. Rachel: I can’t remember what document it was, but APA put out something at some point about using technology in evaluation, and they used the word unavoidable. I think that’s right. It’s unavoidable. It’s 2025. We’re going to use technology, so let’s just make sure we’re doing it in smart ways, in ways that help the client and don’t cause harm.
Dr. Sharp: That makes sense. [00:17:00] Why don’t you tell us a little about Prosper, what y’all do, what the business is, just for folks who may be a little unclear.
Dr. Rachel: Sure. We do autism evaluation and we do therapy. The diagnostic evaluations are really only, yes, no, this is autism. This isn’t autism. It doesn’t go any further.
Of course, nearly everybody coming through has other mental health diagnoses, ADHD, or things happening. We don’t do formal diagnosis of those at this point, but we make recommendations for things to work on in therapy or places to go if additional evaluation is needed.
And then we do therapy. The therapy is primarily CBT with some DBT elements, some act elements, and then a lot that we just learn from what autistic people tell you works. And what we know from even the special education literature, we know [00:18:00] visual supports are going to be useful for a lot of people. We know having a lot of structure and organization to the sessions is going to be helpful for a lot of people. So what can we incorporate that’s just known in general about autism?
Dr. Sharp: Right. You talked about having an affirming approach when we started this conversation with your investment in just neurodivergence and supporting those folks. And so I’m curious how you are threading the needle with therapy for autistic folks and balancing that whole, hey, we’re not trying to change you necessarily, but here are some strategies that might help “assimilate” into the society. I don’t know, that’s maybe not the way you’d phrase it, but I think you see where I’m going with this question. How does that all play out?
Dr. Rachel: For starters, our therapy is never focused on assimilation or trying to mask signs of autism or anything like [00:19:00] that. The focus is, what mental health things are you dealing with?
Sometimes, mental health issues can arise just from being an autistic person in a world that’s not set up for autistic people. How can we help you adapt to this identity, which might be new for you? How can we help you accommodate yourself or ask for the right accommodations, advocate for yourself to get what it is that you need?
But the CBT I talked about, often we’re helping people with the anxiety and the depression that they’re dealing with. So it’s not so much targeting poor signs of autism, but rather helping people with the co-occurring stuff that happens.
And then sometimes it is a little more directly related to autism. For instance, somebody with sensory sensitivities that interfere with things they might want to be doing and goals that they might have for themselves. So how can we help them [00:20:00] problem solve, work through, and meet their own goals?
We’re very clear in training our therapist to always be very client-centered and client-focused in the goals. I think there’s a really bad history of autistic people, people with developmental delays, being beholden to the goals that their parents want for them to have, or a teacher wants them to have, and that’s definitely not what we do. It’s what the client values and what the client wants to work on and focus to growing from there.
Dr. Sharp: That makes sense. Are you seeing a variety of goals from autistic folks in terms of coming in with, hey, I do want to work on these ancillary factors, the anxiety, the depression, the identity component, versus, oh no, I would like to practice my social skills, for [00:21:00] example, and things like that. Is it pre-varied, or what do you see?
Dr. Rachel: I would say probably 80% or 90% of the goals we see are the same six or eight things that do have something to do with anxiety, depression, executive function, kinds of daily living things. There are people who will say that they want to practice their social skills, but it’s often more coming back to social anxiety. It still comes back to some basic CBT skills that end up being useful.
I talked about assessment. I talked about therapy, but there’s another huge component that we have, which is a community. We have a Discord community. Everybody can participate online. It’s only for people we’ve diagnosed or people we know well in therapy. So it’s free of trolls. There are no bullies. Everybody’s really nice. It’s the [00:22:00] most lovely, supportive community.
And so we also have that as an option to help when people are working on social things. They have at least a digital place they can go and they can practice. Some of the people who are in there belong to a local group in their state, and they will get together. They will meet up out in the world. So there’s some in vivo social practice happening, too.
But the point of that wasn’t originally therapeutic, it’s just what would you enjoy? What’s fun for you? Because I think so many people who are struggling with depression, struggling with anxiety, don’t have that focus on their own pleasure and enjoyment, and they start to miss out on these social opportunities that the rest of us might take for granted. So nice to have some of that built back in.
And then, as we know from CBT, just having those regular pleasurable moments and social moments is going to naturally help with [00:23:00] their mental health too.
Dr. Sharp: Sure. This is a pretty detailed question, but I’m curious how you handle the confidentiality aspect and inviting people to that Discord. I’m guessing they all maybe know that they’re all Prosper clients. How did y’all work that out?
Dr. Rachel: They’re told in advance, here’s who’s in the discord. Here are the circumstances under which they join. And then most people who join elect to use a name that doesn’t match their name and isn’t very traceable to them. And so that’s discussed with them too, that they have options for maintaining confidentiality if they want that way.
I’d say very few of the clients seem very concerned about it. I think they’re so driven to meet others and engage with other people. Of course, it’s still important for us to have all the cards on the table and make sure they understand the risks and everything, but there’s so much excitement [00:24:00] about that contact and that ability to be around others that we haven’t had any issue with people not joining for privacy concerns.
Dr. Sharp: It strikes me as a relatively perfect use of discord. That’s a fantastic community, and already seems so popular. People know how to use it.
Dr. Rachel: Sadly, a lot of the autistic spaces can get taken over by negative voices or people who maybe aren’t even really part of that community, but they come in to say rude things. So it’s nice to have a positive option to offer people.
Dr. Sharp: I love that. Let’s switch to the evaluation side. I’m so curious about the evaluation process. So maybe we just start there. What does the evaluation process look like here at Prosper?
Dr. Rachel: There’s a lot of parts to it. One thing, and the thing when [00:25:00] I’m interviewing psychologists that they get the most excited about is all the rating forms are obtained upfront. So there’s never chasing down a rating. So we have all that taken care of. We get …
Dr. Sharp: Wait, can I pause you quick? I am excited, like the psychologist you talked about. How does that happen?
Dr. Rachel: We don’t schedule until the initial rating forms are all complete.
Dr. Sharp: I got you. So, someone reaches out, and this is step 1. You’re like, here’s some paperwork and some rating forms. We’ll book you for the evaluation when these are done.
Dr. Rachel: That’s so.
Dr. Sharp: Okay. I’m assuming this is all happening at some kind of administrative level. The clinicians are not involved in this.
Dr. Rachel: The clinicians aren’t involved. Clients can do all this for themselves online. So it’s all automated.
Dr. Sharp: Great.
Dr. Rachel: But we get early history from someone. We like to [00:26:00] have parents or a caregiver who can report about early history. We have standardized ways of getting that. We also have very open-ended, probably some anecdote kinds of ways we can get that information.
I like having both because different people can give you information in different ways. It’s interesting to see there are people who maybe don’t report anything in a rating form, but then they’ll tell you these specific stories that really illustrate scenarios. And so it’s been great at levels we can.
And then there are also rating forms that someone who knows the person well currently. We have the same thing. We have a standardized rating form, and then we have something that’s just anecdotal, and then we get adaptive measure from that same person. Something that gives us a little bit of information about the functional impact that these things might be causing for the [00:27:00] person.
And then the person does a rating form from themselves too, and fills out a full intake thing where they can also provide more anecdotal information and description. So all that happens before the psychologist sees the person.
So going into the session, they already have some data, they have some information, and it can help steer them, but they go into a very structured two-part interview process. Part one screens for co-occurring mental health conditions that might interfere with the assessment. So, making sure someone isn’t actively psychotic, making sure someone isn’t manic or anything that’s not addressed that could flare up and be difficult to differentiate from autism.
It’s rare that that happens. It’s rare that we have to discontinue with somebody, but every once in a while, somebody needs a higher [00:28:00] level of care, we need to get them to the emergency room, something can happen from time to time.
The other thing we do in the first session is screen for intellectual disability. It doesn’t come up very often at all with our clientele. Our clientele tends to be people who have been to college or are working, doing well, and thriving in a lot of educational and financial ways but maybe struggling in other ways. We have a screen for that.
We have a lot of questions in the first session about getting to know them, building some rapport, some emotion questions, and asking how they feel in different contexts. And then there are also a few conversational presses, just ways of getting a little bit of a sample of how is this person in a social situation.
[00:29:00] A lot of our clients can manage that. These are people who have made it through college, who have had anybody talking to them about autism, so to have a little chit-chat about how’s the weather in Chicago, they can do that.But we still do it. And sometimes interesting comes out, sometimes you can see unexpected gestures, or you can see the person’s completely turned away from the interaction, even though you know where their camera is, you know where their screen is. So we can collect a little bit of observational data that way.
At the end of that first interview, there is a mental status form that the clinician goes through and fills out based on all their observations and data collected from that session. And then they can make whatever other notes they want, of course.
And then there’s a second interview. We have them spaced apart in time so that you’re seeing the person across multiple days. I think seeing a person once, even if you’re with [00:30:00] them for 2 hours, you’re still only seeing them once on a certain day. And so at least, we’re trying to get more data. So we require multiple appointments.
In the second appointment, we ask a lot about camouflaging and masking. I am not thrilled with the existing rating scales and tools for this, so I like to do it via an interview. This gives our clinicians a chance to tease apart things that might be social anxiety, things that could otherwise account for some of the behavior a bit more. So that’s why we do that in the interview. And then …
Dr. Sharp: Can I jump in quickly? I think that’s probably important just to spend a little bit of time on. I was going to ask you about this, and you went in the right direction on your own, which is, I also agree. I don’t know that our measures for camouflaging and masking are great. [00:31:00] I would love to hear your perspective on that and what you mean when you say you don’t think a lot of them are right.
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Let’s get back to the podcast.
Dr. Rachel: My perspective [00:33:00] is some degree of camouflaging and masking is pretty damn adaptive and we’re all doing it all the time. I’ve seen some people, especially online, equate any level of masking with
being autistic. And that’s just not how it is.
We’re all doing it to some degree. It’s part of functioning in society. I think what can happen is autistic people with the bimodal distribution could be at either end of. I have a lot of autistic people tell me they absolutely never mask because why would they hide any aspect of themselves and how they feel?
Of course, there are autistic people tying themselves into knots because they’re working so hard to camouflage and mask, and it really becomes an issue. I think we have to be incredibly careful about it and thoughtful about it.
What we’ve learned from all the research on this topic to date [00:34:00] is that it’s incredibly hard to tease apart from social anxiety. And so people who give you answers, and you hear this all the time, even in questions about autism features.
If you’re asking about social emotional reciprocity in that give and take conversation, and you have someone tell you, oh, I never know what to do or say in conversation, you don’t know that that’s coming from an autistic place. It very well could be someone who’s very socially anxious and underestimates their own ability to navigate those situations. So I think we have to be really cautious and understand that we really don’t know a lot about that until we get details and specifics from the client.
So what I always encourage people to do is to get as many examples of things that happen in real scenarios. As many details as you can from the person. I think that’s a [00:35:00] lot more illuminating than just the overall, oh yeah, that’s so hard for me. I can’t do that.
Dr. Sharp: Oh, sure. I like the way you frame all of this. I would love to see better measures for these behaviors. I think we’re in the beginning of figuring out what these constructs are and how to measure them. So it seems like we’re aligned on that, but this is also a fraught topic. I think we all want to do the best work we can and not minimize anyone’s experience, and at the same time, we don’t have great standardized tools for this right now.
Dr. Rachel: That’s exactly right. And then, as with so many things, the more academic debate on this can go very polar. I think that’s not super helpful, either. I think there’ve been academics who just shut down any talk [00:36:00] of masking and camouflaging, and I think that negates the experience, especially of a lot of girls and women, which isn’t helpful, but at the same time, we just don’t know enough to be overconfident in what these tools are telling us.
Dr. Sharp: That’s so interesting. Are you referring to the discussion around, can someone mask to the point that they could hide a theoretically socially driven diagnosis? Can you mask so well that you can hide symptoms that are primarily social in nature? Is that what you’re talking about when you say the debate?
Dr. Rachel: Yeah. That’s the core of the debate. I think in contrived testing situations, it’s a lot easier than it is in natural in vivo things that happen in the real world. But unfortunately, we’re not getting to see clients out in the real world. We’re only [00:37:00] seeing them in these contrived, unnatural situations where it’s a lot clearer what’s expected. It’s a lot clearer how to fake it.
Dr. Sharp: That’s true. Full disclosure, I wrestle with this a lot. I have a hard time with this. It is tough. I do see both sides and I honestly want someone to tell me what the right way to think of it is.
Dr. Rachel: We’re not there yet.
Dr. Sharp: Okay.
Dr. Rachel: I usually, in fact, be suspicious of anybody who’s overconfident about the right way to think of it at this point.
Dr. Sharp: That’s fair. There’s nuance to everything. I’m, like I said, still thinking through my own process with how can someone mask well enough if they truly have these social concerns. It’s hard to reconcile sometimes, but like you said, it is nuanced.
So I’d [00:38:00] interrupted. You said the academic debate gets polarized.
Dr. Rachel: It definitely does. To jump back into what happens in the second day of the interview, after we do a masking and camouflaging interview, and one other thing about that, part of the reason for including it, besides, I think it’s important just to find out more, and hear what they say about things. It also gives you a little bit of information into the person’s social insight and how they think of all this.
It also helps build rapport because it shows people that you’re listening to this, you want to hear. A lot of the people who come for autism evaluation have been told many times, they’ve been dismissed, and they haven’t felt validated when they’ve brought up mental health concerns.
And so going through that process is also therapeutic. It gives us good clinical data that we need for evaluation, [00:39:00] but I also think it’s inclusion that’s pretty therapeutic for a lot of clients.
I have it structured so that that conversation happens before going into a detailed interview about autism traits as defined in the DSM. And this is the bulk of the interview, but we do a very deep dive into every symptom category with a lot of questions and pulling for specifics.
And that’s the meat of the evaluation. It’s where I put the most importance. Of all the data we collect, we look at all the data, I’ve come up with frameworks for how we think about and take all the information in, and weigh it with each other, but I encourage people to think most about what the client’s actually telling you. What are the details? What are the [00:40:00] specifics? How does it really play out in their day-to-day life? Because that is the key. That’s the gist.
And then there’s the oral feedback. That’s all scripted and structured so that we’re giving people a lot of psychoeducation and walking them through and helping them not just know I have a diagnosis or I don’t, but what does it mean for me? How does this show up for me? What do the features mean?
There’s that overused phrase of if you’ve met one person with autism, usually it’s in person first language, so if you’ve met one person with autism, you have met […] A person’s a person, whether they’re autistic or not, and we need those specifics to help us understand those descriptions to help the people understand what does this mean for me? And then what do I do with it? Where do I get support? Where do I get whatever the recommendations are that might be the things I need?
[00:41:00] The cool thing about working with a startup is we’ve been able to come up with some very neat tech that helps take the notes that we’ve taken during the interviews, helps take rating form data and everything, and populate it into a report. We’ve got recommendation banks that are really easy to pull from.There’s a lot of cool things on the tech side that I wish I had 20 years ago, I would’ve been so amazing. All the waste of time on reports, but I think it just gives us higher quality reports. It’s even in the last year improved exponentially over where we were about a year ago, just because we’re able to build and things keep growing and evolving with the tech. That’s the whole evaluation process.
Dr. Sharp: Thanks for diving into that. I’m curious, personally, I’m guessing, given your [00:42:00] history, that you probably came up in training environments and work environments where you were doing a bunch of in-person autism testing. I’m guessing you’ve given a bunch of ADOSes and any number of other things as part of the batteries.
Dr. Rachel: Yeah. From graduate school on, it’s been the standard research battery of a cognitive, an ADOS, adaptive, and an ADI-R and then whatever neuropsych you do on top of that. But that would’ve been my core battery my entire career, even for adults.
Dr. Sharp: Right. That’s where my question lies, was there any personal hurdle to jump over to get to this place where it’s primarily interview and rating-scale-driven without those more classic [00:43:00] measures and a classic process? I’m curious what that was like for you.
Rachel: It was complicated for me, for sure. There was a period of testing it out. So taking people who I had done full evaluations on, or who I already had seen for years in therapy and knew really well, and having them go through this shorter evaluation process, and seeing what happens with that. So seeing that we were getting really good data and really helpful data, that was useful.
And then I think also all these years I’ve been seeing adults, I have been frustrated with the standard process. When I evaluate a university professor, and I’m trying to do an ADOS Module 4, it feels pretty stupid, hard, and awkward.
Obviously, the questions are still valid and useful, and there’s a lot that comes out of it that’s good, but it’s a much stronger and more [00:44:00] comfortable tool when you’re giving a Module 2, when you’re giving a Module 3 than it when trying interact with adults who have intact intellectual ability, who have strong verbal skills.
When I was training years ago and working with Ami Klin, who was my mentor at Yale, we would do the standard research battery, but he would also come in and do this interview magic of being there clinically with the person in the room and having that interaction.
I think even though I’ve always been in the research world and doing these tighter evaluations, I also saw how powerful and useful a purely clinical experience with a person could be. I think there still is structure to that. There still can be rigor with that. There still could be a systematic approach, [00:45:00] but being able to be the other person and use yourself in that way as a tool can be really valuable.
I think what happens though is when people get incredibly clinical, they tend to let the rigor fall away. They tend to stop being systematic. I think when we do that, things get really sloppy and messy.
And so that’s been part of my concern in this autism world is we’ve got people who are incredibly affirming, warm and lovely people, but some of them, not all of them obviously, but some of them have lost the rigor and have lost that approach to having a system for going into evaluation and a system for making sure we’re ticking the boxes and doing the steps.
And I wanted to make sure we didn’t do that. I wanted to make sure that we were as affirming as we can and celebrating the people we’re [00:46:00] evaluating and all the strengths that they bring to the table, but also going in with rigor and structure so that what we’re doing meant something, it would hold up for them over time. It wasn’t just a one-time feel-good experience but was a tool to help them in their progress as they’re trying to work on their mental health or understand more about themselves or whatever.
Dr. Sharp: I think that’s super important. I was wrestling with how to frame these thoughts or feelings, but a lot of us, I’ll speak for myself, I don’t want to project onto anyone, but I think part of the deal with doing autism assessment is that it is inherently looser than a lot of other testing that we do because there’s a subjectivity even with the ADOS or the way that we’re interpreting ADI-R answers, or how we see the examples people give us and whatnot.
It’s already inherently a little [00:47:00] looser. And to get away from what appear to be standardized instruments, I don’t want to take away from that with the ADOS or some of the other tools; that feels scary.
I like what you’re saying about the process where it feels like you’ve instituted a fair amount of rigor and structure to these interviews, to the rating scales and whatnot that you’re administering. I would guess that does feel a little more comforting and gives you more to fall back on.
Dr. Rachel: Yeah, that’s right.
Dr. Sharp: I want to ask this question around. These are messy questions, but there’s always stuff around bias in situations like this, where you are a self-proclaimed autism testing business. And so I’m curious how you work through or [00:48:00] deal with that knowing, hey, people are seeking us out for an autism diagnosis. How do you talk with your clinicians? As the CCO, how do you work through that to combat what must be pretty inherent confirmation bias and any number of other biases?
Dr. Rachel: I think one of the most powerful things we can do is check reliability. Everybody knows that there are clear cutoffs for things, and everybody knows that there are going to be reliability checks and that we need to make sure that everything’s in line, but we keep a pretty careful eye on diagnosis rates too.
It’s going to be higher anywhere I’ve ever worked because I’ve always worked in autism places. It’s going to be well above 50%, but I think we have to keep a careful eye on that and watch on that because I think that there’s drift over time. [00:49:00] So we have reliability projects, we have times where everybody needs to come and coat things, and I’ll make sure that we rotate in cases where there isn’t autism. So that we’re seeing the non-examples.
I think we need to over time, we haven’t gotten here yet because we’re still pretty new, but over time, we also need to have video examples of interviews with people who aren’t autistic, but are saying some things that might be in line. I’m constantly giving examples of ADHD type fidgeting that doesn’t count as a repetitive behavior in autism, for example.
I’ve sat here nonstop moving and fidgeting, and if you ask somebody, do you have any repetitive behaviors, I might say, yeah, I move my chair back and forth all day. We’re really careful to train people then what are the follow up questions? [00:50:00] How do you differentiate that from a repetitive behavior that’s autistic?
Of course, there’s going to be limits to that, but we’re very careful about the non-examples, not just the examples, and really careful about the reliability. We are working and establishing relationships with external reliability partners too.
I think that’s a big fear of mine is that maybe with blinders on, it would be really easy to drive right off a cliff thinking I’m going the right direction and doing the right thing. And so putting a lot of time and effort into building those external relationships and having some external checks and balances too is crucial.
Dr. Sharp: Agreed. Even the practice of monitoring your diagnosis rate is pretty powerful. Data can tell a lot of stories and give you some great information.
Dr. Rachel: One of the most [00:51:00] interesting things I didn’t expect to have come out of that, when people want to schedule with a clinician, they can go look at their bio and see their picture first and then schedule. I do think certain clinicians are pulling for different kinds of client populations.
And that wasn’t something I had anticipated, but we had one clinician with a higher than average diagnosis rate and one with a lower than average diagnosis rate. We took a check at both of their recent cases, and they were accurately diagnosing people, but they had very different caseloads.
It’s interesting, I think there be something there we can maybe figure out over time is what’s drawing clients to specific clinicians? There’s some really interesting stuff to learn about that.
Dr. Sharp: Oh, 100%. This is the big data I can get behind. I love those kinds of statistics and those relationships. Are y’all [00:52:00] doing anything with the data that you’re collecting? You mentioned some research, but I don’t know what that actually looks like.
Dr. Rachel: We get a standard release when people come in for evaluation or therapy that things might be used in the future for research. So we didn’t have anything planned when we started and we’ve started getting that release, but I am now doing a perspective or an analysis of data we already have for an upcoming conference in May.
We are going to look at two things: One is, on the therapy side, we collect quality of life data. And so we’re going to look at how does quality of life change over time for therapy clients? And is having the addition of some kind of community activity, like the Discord or some community groups we have, does that have an additive [00:53:00] benefit?
I think that will be really interesting. I like using quality of life measures as opposed to insurance companies want us to be using the PHQ-9 or the GAD-7 or whatever rating. I like knowing that this person is feeling like they’re seeing a significant change in an actual aspect of their everyday life as opposed to here’s a little movement on a symptom. So that I’m excited about.
And then we also are looking at evaluation data for the same autism conference. We’re going to do factor analysis to see all out of all these different data points we collect, what’s most predictive of diagnosis. I have ideas of what that’s going to be but I’m curious to see what the data tell us.
Dr. Sharp: That sounds great. This is the part that I miss, research is hard to do in private practice. We’re [00:54:00] doing a little bit with some of our evaluation data, but the stuff is fascinating. The fact that you’re gathering so much data from so many people is powerful as long as you are using your powers for good.
So tell me a little bit more. How do clients find you at this point? What is the main funnel here? Are they getting referrals from their physician? Are they doing online searches? How do clients come to you?
Dr. Rachel: We definitely get referrals from physicians, psychiatrists, therapists, other friends who have recently been evaluated, but primarily it’s an online search. We do have Google ads that run. There are ads in Meta that run, but not a ton. I think that’s something that probably will grow and change over time, but right now it’s primarily through Google.
Dr. Sharp: Sure. [00:55:00] And what’s the financial situation? Is all this out-of-pocket? Do you process insurance? How does that work?
Dr. Rachel: Oh yeah. We work with insurance. We have people who are credentialed with most of the panels out there. There are two weird exceptions where it’s been hard to get a contract or whatever, but we work with insurance.
We have a private pay option, too. I don’t remember offhand what it is, but it’s significantly less expensive than traditional in-person testing. We are in 12 states currently, but then also the PSYPACT states.
Dr. Sharp: Great. Maybe we start to close just talking about the clinician experience. I’m curious about what it looks like for your psychologists who are doing these evaluations.
Dr. Rachel: I think it’s different for different psychologists. So we have some people who do nothing but [00:56:00] this, and they might do six evaluations a week. And so it’s a very full-time thing. And then we have other people who have a private practice but wanted to learn more about autism, wanted to do a little bit of evaluation, and so might give us two or three evaluations a week. So I think it’s very different for different people.
One thing I’ve tried to put a lot of effort into is making sure that there’s a community for psychologists. One of my biggest worries is about people in isolation getting their own ideas and drifting away from what’s best practice. What do we think is the right approach?
And so, almost every day there’s some kind of opportunity to drop in and meet with other psychologists and talk about cases. On a monthly basis, there is an ECHO Case Conference that uses the ECHO model. It does a deep [00:57:00] dive into one particular case. And that’s really helpful.
And for those, I always record a didactic that goes along with that so that they’re also learning about something and then can get a little bit of continuing education for it.
Dr. Sharp: Can I jump in? What’s the ECHO format? That’s maybe a naive question, but I’ve never heard that before.
Dr. Rachel: No, I should have explained it. It’s a model that comes from Medicine. It’s a model of expanding and educating the group of people who can provide a given service. So it’s common, for example, if you’re trying to treat HIV in rural Africa and you want to reach all of these physicians in different places, you have a regular case conference where you do a deep dive on a case, and then there is a short presentation.
There’s a hub team that is a panel of specialists who can chime in. And so when we do [00:58:00] ours, for the hub team we have somebody from psychiatry, somebody from occupational therapy. We have a trans-autistic person to talk about their lived experience. We have a few different people who can give different takes on the same case.
It has been a great educational thing, but ECHO autism by itself is a big and active thing. And if anybody who’s listening wants to check them out online and they put ECHO autism, they’ll find a lot of different things that are offered through ECHO autism. We’re separate from that, but it’s a connection that we have, and we use that model.
Dr. Sharp: Fantastic. Very cool. Community is super important. I hear that just in my consulting, psychologists doing testing tend to feel pretty isolated. It is tough wrestling with so much complex data and making decisions about folks’ [00:59:00] lives, futures, and interventions. It’s a lot to carry, and community goes a long way.
Dr. Rachel: It is. And then the experience of psychologists in different states right now is so different because different things are happening in different states. And so we do also have opportunities like our Texas group has one chat and our Florida group has another chat so that they can also talk about those things, especially if they’re trying to advocate for legislation or different things happening in their areas.
Dr. Sharp: Absolutely. I’m curious where things are headed from here. Are there any future projects or exciting developments that you can talk about?
Dr. Rachel: Yeah. I think we’ll just keep growing. Right now, I said we’re in 11 or 12 states, and the plan is to be completely national and also to expand what we offer. So we only do individual [01:00:00] therapy at the moment, but there are other options there where we might expand.
I’d also like to evaluate things that commonly co-occur with autism. I think it’d be fairly straightforward to add mood and anxiety to what we’re doing. I think there are some other places to do ADHD, but I’d like to dive more into that and see if there’s anything that we could improve upon or expand upon with that. There’s a lot of directions we can go in the future.
Dr. Sharp: It’s exciting. I appreciate you being here and talking through all of this, bearing with all my questions, wrestling with some philosophical dilemmas, and all of this. Thank you so much for being here, Rachel.
Rachel: Yeah. Jeremy, thank you for having me. I’ve enjoyed 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 [01:01:00] 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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