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Hey, everyone. Welcome back to The Testing [00:01:00] Psychologist podcast. I am thrilled to have two guests here with me today. I’ve got Dr. Karen Pavlidis and Fran Schopick, who’s an attorney. They are co-founders of the Working Alliance, which is an education resource devoted to helping mental health providers build awareness of risk management and protect their practices.
We’re going to talk all about the Working Alliance and what it entails, but it’s essentially like how we’re always looking for paperwork packets, disclosures, and informed consents, that kind of thing. So it’s all of that with the added benefit of being co-authored by an actual attorney, that’s Fran.
It’s also a wraparound support system where they offer webinars and add-on modules, office hours consultation to assist practice owners and psychologists in risk management. Fantastic resource and you’ll hear all about it during the [00:02:00] episode.
Fran is an attorney in Washington State with a unique background in psychiatric research and social work. She was a social worker before she became an attorney. She devotes most of her time representing mental health care providers facing Licensing Board complaints. She is a speaker on ethics and risk management, and focuses on strategies for providers to avoid or navigate through Licensing Board investigations.
Karen Pavlidis, PhD, is a psychologist with over 25 years of experience, licensed to practice in Washington State. She is the founder of Child and Teen Solutions in Seattle, a group practice that offers both assessment and evaluations for children and teens. Karen also serves as a Clinical Instructor at the University of Washington’s Department of Psychology.
So like I said, we had a fantastic conversation around risk management and everything that entails. I love getting Fran and Karen’s perspective and seeing how they come at things differently as an attorney and a [00:03:00] psychologist. As always, I think there’s a lot to take away from this episode.
It is that time of year though, folks, if you’re a practice owner or hopeful practice owner, and you’d like to join a coaching group with some accountability and support. My Testing Psychologist mastermind cohorts are starting again in January. So there’s a beginner, an intermediate, and advanced cohort. So wherever you’re at in your practice journey, you can possibly join a group and get some support with that. You can go to thetestingpsychologist.com/consulting and set up a pre-group call if you’re interested.
For now, let’s get to my conversation with Fran Schopick and Dr. Karen Pavlidis.
[00:04:00] Karen and Fran, welcome to the podcast.Dr. Karen: Thanks, Jeremy.
Fran: I’m happy to be here.
Fran: Big fan. I’m excited to be here.
Dr. Sharp: Oh, stop. I am excited to have the two of you. Karen, I’ve known you for years now. My gosh, I think we met in Chicago, maybe at the …
Dr. Karen: 2019.
Dr. Sharp: Yeah. My gosh, it feels like a long time ago. I’m glad we did. We’ve had a lot of cool interactions over the years and now excited to talk with you about this project and of course, have you here as well, Fran. I know y’all have teamed up and created something pretty awesome for psychologists and we’re going to talk all about it.
We can start with some brief introductions. I’d love to give people a chance to get to know you and orient to your voice a little bit. So Fran, do you want to go first?
Fran: Sure. My name is Fran Schopick. I have a background as an MSW. For many years, I worked as [00:05:00] an MSW, social worker, therapist and also a psychiatric researcher. This was on the East Coast at Mount Sinai School of Medicine and Harvard Medical School.
Then I went to law school. And so now what I do is I represent health care providers who have problems with the Department of Health. I also help people with disclosure forms, because I find that it’s a very important part of their practice, to have a good disclosure form. And that’s turned into this project with Karen, where we are presenting to you today with the Working Alliance.
Dr. Sharp: Nice. How about you, Karen?
Dr. Karen: I’m Karen Pavlidis. I’m a licensed psychologist in Washington State. I was in solo practice for about 20 years and then 4 years ago started a group practice called Child and Teen Solutions in Seattle, and then also have teamed up with [00:06:00] Fran in the last few years to work on this new project.
Dr. Sharp: Nice. Which we will get into all the details. I’ll start though, with this question that I always start with, which is, why is this important? You can answer separately, of course, but why spend your time on this? Why dedicate so much energy to this topic or this project?
Fran: That’s a good question. It’s very interesting, most counselors grapple with the issue of having a disclosure form, what’s also called an informed consent. And for the most part, what they seem to focus on is what’s required. What does the state require that they put in their informed consent?
What I’ve found is that, of course you want to have what is required, but I have found that counselors have certain choices because it’s important to know how they work and what are the [00:07:00] decisions that they make in their practice. If you can put that into your disclosure form, then you’re putting clients on notice about how you work.
You can explore their ambivalence around whatever it is you might do. You can explore your own ambivalence about whether a client seems like a good fit for you. If you put it all in the disclosure form, it’s there to be referenced, to be reminded and to be stated from the very start. It creates a huge advantage in terms of the work that you do and the client services that you can provide.
Dr. Karen: I agree with all of that, what Fran said. And then I would add, I came at this from a different story, and of course I had a disclosure informed consent as a solo practitioner, but it wasn’t until I started the group practice that I had to wake up and discover how important it [00:08:00] is both in terms of having the clinic run smoothly and our clinical work as smoothly as possible.
As I was opening my eyes to that with the group practice, I could look back and see how we all have certain challenges that pop up in our practices. I’m glad we’re talking to probably a lot of your listeners are people who do evaluations, and that’s a big focus of my practice and always has been, and I work with kids and families.
So I think when you bring that combination kids, families evaluation, in Washington State, we have this added complication. I would call it a complication for this conversation, that adolescents ages 13 to 17 can consent to their own care. So there’s just a [00:09:00] lot of nuance when we’re doing services and evaluations.
In these initial months, years of the group practice, I realized retrospectively that there were sections that had I included in the disclosure form in my longer career as a solo provider, it would have really helped smooth out some of the bumps that can come up for us in doing evaluations with kids.
Dr. Sharp: It sounds like it was born in part from just personal experience, which I think is true for a lot of things that we work on. This area is pretty fraught. I think a lot of folks struggle with just documentation and what needs to be in the disclosure form, how much to put in there and what the nuances should look like. I [00:10:00] think there’s going to be a lot to take from this conversation, but y’all, it sounds like you turned your personal experience into a little bit of a springboard to help other clinicians.
Dr. Karen: Very much.
Dr. Sharp: Can you tell me a little bit of the origin story? It sounds like, Karen, were going through some things in your practice and maybe learned a lot through that, but I’m curious how the two of you connected and decided to launch this venture.
Dr. Karen: Awesome question. Fran, do you want to start this one?
Fran: First as a social worker, I spent many years doing individual one-on-one practice. My first job was at an agency in Brooklyn, New York that worked with families, but every permutation of the family. I worked with individual clients who were 2 years old or 3 years old and also who were adults and [00:11:00] teens. And then I worked with sibships; with groups of siblings. I worked with groups of unrelated people. I worked with couples, families. It was a great experience.
I found that the grounding to that work was informed consent, was having people understand what the goals were. Who was the client? Was it the child? Was it the whole family? Was it the couple? The work that we got done was enhanced by that.
Then when I started to do psychiatric research, I noticed that the other people in the project at the school of medicine, they said that they took 2 minutes or 5 minutes to do the informed consent just to get the signature. I realized I was spending 15, 20, 25, sometimes longer with clients, just going through the informed consent because I wanted to give them a chance to ask questions.
Often people would say no, I don’t have any questions, let me [00:12:00] just sign. And I would say, no, for me, then I need to know that you’re aware of this and I want to know how you feel about it because it’s important.
Sometimes I would joke and I’d say there’s going to be a pop quiz at the end where I’m going to ask you questions. I found that process was very helpful. Some people felt that the retention rate was higher when we spent more time with the clients.
So then fast forward and now I’m a lawyer and now I’m helping people put together their informed consent, and I’m just realizing how important it is to have a conversation and to be able to refer back because people, when they come to you for an evaluation or for therapy, they’re not really thinking about what you’re telling them; they’re thinking, I’ve got a problem and I can’t solve it myself and I need your help, can we just get to that?
And so on the part of the therapist or evaluator, there’s an art to it on the one hand, addressing their [00:13:00] concerns, but on the other hand, also wanting to weave in their concerns with the ground rules. I came to realize that informed consent was a two-way street. That it was the client understanding what is involved, but it’s also the therapist or the evaluator understanding whether what they have is what the client needs.
If it’s not what the client needs, then they have an ethical duty as well as a self-protective duty or if it’s not a duty, it’s a hope that everybody can come through this in the best way possible. So I just began to put that together.
And then when I met Karen, Karen has this very interesting practice and very interesting background. And so the two of us, I’m thinking about all these things and she’s like, that’s a really good idea. She found that it was helping her clients. It helped her give better client care and better clarity to the [00:14:00] evaluation process.
So we just realized, wow, this is a really interesting combination and it would be great to put together this product so that we could help people have a better experience with the informed consent and disclosure. The two terms, in Washington, they call it a disclosure, meaning it’s what you disclose to the client so that they can make an informed decision about how to work. Some states call it an informed consent, but it’s basically the same process.
Dr. Sharp: Got you. The way you describe it, it’s almost like, I think it may have been Jordan Wright, who said something like consent is a process, not a document. And this reminds me a lot of that statement, it overlaps quite a bit. That’s fantastic.
From the business aspect, I don’t want to spend a ton of time on this, but a lot of people out there probably [00:15:00] think about selling something, paperwork or who knows, a course or something like that. What convinced you that there was a gap in the market here or what did you see that compelled you to really take the leap and create a business out of all of this versus just hey, we’re friends, you’re an attorney. I’m a psychologist. This is cool. Thanks for the documents. I’ll see you later. How did you take it to the next level?
Fran: Do you want to answer that, Karen or should I?
Dr. Karen: Sure, I can get that one to go. We spent a fair amount of time researching what was out there and that was a really interesting project, and there are a lot of good materials out there. What we were finding was that, at least what we saw was out there, the focus was on requirements. Whereas [00:16:00] a big part of the story of the Working Alliance is realizing the importance of going beyond just what’s our state requirements in the disclosure form.
What I can appreciate is that it really is a tool that helps us work clinically. I could go in all different directions here but in the first months of the group practice, things were bumpy. Just going from solo to several employees and just when you increase the numbers, puts a spotlight on where the vulnerabilities are in the onboarding process when taking new clients. And so each hiccup, I learned to use really productively [00:17:00] because 99.9% of these hiccups are systems problems or a gap in our onboarding process.
And it wasn’t a gap in that we missed something that was required, it was that, you know what, we need to give our prospective clients the chance to understand what to expect from us clinically and so really learning to use the disclosure form clinically, what are the expectations for parent involvement? What can they expect risks and benefits, we can come back to that one if you want, potential risks and benefits when you do an evaluation with us? What do people really need to know?
And it’s that setting the expectations and being super transparent, it empowers the [00:18:00] prospective clients as consumers to make an informed decision, and it also creates consistency within a clinic. We all have our different styles and ways of working but those fundamental processes that make us who we are in terms of the quality that we deliver has a lot to do with the structure and processes. And so there was just so much that happened in that first year.
And to this day, I’d say every week, I’m tweaking and adding things to our form. So back to the question about the business, as far as we know, this is the first project, our document package that really addresses the more clinical nuance and the ways to customize the documents to fit someone’s own practice.
[00:19:00] And so what we have is this add-on bank that goes beyond the core. Anything, Fran, that you would add?Fran: We’re always saying it’s important to add that this product is educational and informational. When Karen talks about something that’s clinical or referring to her practice, it’s informational about that. We’re not giving clinical advice and I’m not giving legal advice. We’re not creating legal or clinical relationships.
As a social worker, I was aware that the focus of the duty of care is to the client. As a lawyer, my responsibility is to my client, who now would be the counselor because I’m working that way. So in conceiving these products, I’m thinking about protecting the counselor and the counselor’s thinking about protecting the client. And so there’s this kind of [00:20:00] spectrum that we try to cover because I want the counselors to be safe.
And so there was this discovery about what does the counselor need? Or do you need two signatures of parents to go ahead and do an evaluation? Do the clients understand what the confidentiality limits are? Can we really make that clear? It’d be better to make it clear at the beginning rather than say, oh, by the way while you’re $2,000 into the process?
I also realized from my point of view as an attorney helping people with their disclosure forms is that it’s very important for the disclosure form to have the counselor’s voice and that it’s personal to the practice. So people would come to me with their disclosure forms and I would help them with their disclosure forms. It was always from the ground up.
I still enjoy doing that if that’s [00:21:00] what people want, but people would also say, don’t you have some language? Could you just use it? Could we just pop it in? There are pros and cons to that. And then I thought, maybe I could put together some language and have it work but I still want people to speak to a lawyer in their jurisdiction to make sure that they are following the rules of their state.
So it grew into this project where as I became more and more aware, largely through Karen, that this work was helping her give better services and that the work that I was doing, as I was trying to think in terms of the counselors, was actually giving better services down to the clients. So it was a really wonderful progression of awareness.
And then we thought, if we could put together a project, what about the education piece? So then we wrote up this huge piece. [00:22:00] Each section has an explanation as to why this is important and how it can help you protect yourself as well as give better care to your clients so that you don’t make promises that you can’t keep, for instance, or that you don’t overstate confidentiality.
When people say, everything you say here is confidential, that’s not really true. So many exceptions that from the client’s point of view, it does not feel as if it’s as solid as they are under the impression that it is, that everything is confidential because there’s so many exceptions. So it evolved into thinking if we could have a project and a product that was available, and then we can also explain the things, maybe that could help improve the services all around.
Dr. Sharp: I like that frame, looking through [00:23:00] this lens of the consent or disclosure document as a process, as almost like a rapport builder or an alliance builder. It’s all going to flow through to better service and a better experience for everyone.
Fran: And also more people throughout the country as an educational piece, informational, and we’re not practicing, I’m not practicing law, Karen’s not practicing psychology. There are people throughout the entire country who can benefit from this. So we’re hoping that if people find it interesting and useful that they can also access this product.
Dr. Karen: Can I expand on something important that Fran said? Fran, thanks for clarifying that I’m talking about clinical self-referencing how things work at my clinic. [00:24:00] As Fran said, each section, each add-on, each module, each supplemental form has an educational discussion. We went through great pains when we wrote these to make sure that nobody would experience it that we were suggesting that you should handle this this way or that this way. We acknowledge that everybody works different clinically, everybody has different comfort levels with different specialties and subspecialties.
So those discussions about how to apply this clinically are more about, we highlight questions to ask ourselves, to consider this or that, and we give examples and samples, but it’s not meant to be like, oh, you’re supposed to handle it such and such way. It’s just to bring that awareness to that we have [00:25:00] choices and options, and just trying to address some of the blind spots that I think a lot of us clinicians can have.
Dr. Sharp: I think that’s a nice segway, people for better or for worse, love stories of hardship, mistakes and that kind of thing. I know that from what y’all said before we started to record that there are some personal experiences that drove the creation of the Working Alliance.
I wonder if we could spend a little bit of time there maybe framing it. Fran, from your perspective, you could certainly talk about some of the horror stories or things you’ve seen that were not so great and Karen, you can obviously talk about little missteps in your practice or like you said, the bumpy parts that catalyzed some of the work here. So whoever would like to start, like I said, for better or for worse, [00:26:00] people always like to hear how we might be messing up, and of course, we’ll talk about what to do about it.
Fran: The first incipient piece of it was when as a social worker, I was working in New York City. I was based in New York City. I was working in the Bronx at the time and I was on jury duty. Jury duties is very mixed bag so everybody hates it, but then sometimes you develop these little clicks as you’re waiting around to see if you’re going to be called.
We went to lunch and then came back. Somebody said that one of our group of this pod of people that we were hanging out with, she had been hit by a bus. She wasn’t killed, thankfully, but she was hit by a bus. I thought to myself, if I were hit by a bus, would my notes stand up to scrutiny?
I was actually thinking about this, if somebody had to take care of my notes, would they be horrified when they looked at it? Was I up to date? Were they written well? [00:27:00] What would be my legacy for my notes?
And so that really stuck with me. I began to think, it really doesn’t take that much time to write a note as long as you know what you want to do, and it’s actually much easier if I write the note within the 10-minute break that I had between ending and starting another session.
I could do this very quickly if I just put my mind to it. And so I developed this efficiency around doing the notes, which was really very self-protective. I really was thinking if I were hit by a bus, what would my notes show.
And so that was the start of it. And then I began to see that if something were included, I’m trying to think if there was anything you could call a disaster, sorry. I began to find as a lawyer that some people were giving me stories [00:28:00] that were better addressed early. Like someone said, psychologically, I’m so upset, I can’t do what you’re asking. They’d have to write a response to the Department of Health and they’re telling me they can’t write it or they can’t talk to me on the phone about it.
And so I put in my disclosure form, I understand that this is upsetting, I understand that it’s traumatic, but you have to be able to talk to me. If you can’t talk to me, then I can’t work with you. And so I just began to put together these things. Karen, why don’t you go and I’ll try to think of something.
Dr. Karen: Okay. I’m going to knock on wood. I am very superstitious. I haven’t had horror stories. I’d say they definitely fall into the category of hiccups, bumps. I’m a ruminator, lost sleep. I like people to be happy but really it’s around communication.
I think any of us who work with [00:29:00] kids and families know that you have to be really aware when we’re working with divorced families. I’d say just the sheer numbers, you start to see patterns and it puts a spotlight on where the vulnerabilities are. I realized we needed to tighten how we onboard families where the household has gone through a divorce and to educate the parents about how we communicate.
Again, this is not to say what anybody should do, but we found it important to educate families that if we were communicating with parents in a divorce household, we wanted both parents on all of the emails. We didn’t want conflictual emails forwarded to us. We weren’t going to have side conversations with one parent behind the other [00:30:00] parent’s back.
We had to get really clear on payment policies and how payments would be processed for sessions. We also learned to ask certain questions in our screening process with new inquiries, like just wanting to know if the family had been through a high conflict divorce, and we would define that for people who, as part of that question, that’s been really important.
And also learning the importance of inquiring has anyone in the household had legal involvement. Another really important question that’s been important is, are both parents on board with the services that they are seeking? That’s been very key.
Also where we got really [00:31:00] clear, when I say clear, what feels like overcommunicating to us is actually just right for a lot of the people we work with because there’s so much information that we put in front of new or prospective clients. In Washington, with this nuance of 13 to 17 being able to consent to their care, going over the importance of like we can’t have side conversations without the 13 to 17-year-old in the loop or being assumed that they’ll be looped in.
I can pause there, but I can also talk a little bit about evaluations and some considerations there. Should I go on?
Dr. Sharp: I can just validate. I feel like this experience of working with separated or divorced parents is a pretty common one. I feel like of all the issues that I’ve [00:32:00] consulted our practice attorney about in the last 5 years, it’s probably 90% something related to separated or divorced parents, medical decision making, who has access to records and who can do this or that.
We also have that situation where in Colorado, I think it’s 12 where kids can consent to their own services and what circumstances, is that appropriate or not, when can parents be, just to validate all of that.
Fran: And also putting the providers in the middle, putting them in the position of accusing the provider of having violated the parenting plan because they’re not in a position to interpret somebody else’s parenting plan and yet they’re placed in that position or characterized that way by the families. It’s very upsetting. You are triangulated in this power.
[00:33:00] Dr. Sharp: For the payment issue, that would come up a lot in years past. We fixed that by now but it took a few go rounds where we had to be like, look, we are not mediating your payment dispute. One person is going to pay for this and y’all go figure it out. Otherwise, we’re not going to be taking multiple payments from people and deciding who pays what.Dr. Karen: It takes going through it to realize, oh, we need to be clear.
Dr. Sharp: Absolutely.
Dr. Karen: There were also things that weren’t new to group practice, but more in retrospect, realizing, oh, this would have been really helpful over my career if I had included this and emphasized this for my evaluations.
Often, in my clinical practice, hiccups come up with evaluations, particularly around autism, [00:34:00] whether the diagnosis is given or it’s expected but not given, or test scores maybe being not what was expected. I have found it really important, it’s probably one of my favorite sections of my disclosure form is the potential risks and benefits of evaluation.
So every intake, I start with that. I go over, in quite a bit of detail, what the potential benefits are in validating what the family is looking for. I’m working with mostly kids here that I’m evaluating, and then also just walking through the risk that a diagnosis might be given that’s not wanted, or a diagnosis may not be given that is wanted, or that [00:35:00] there might be some scores.
And also talking about as part of that, not just, okay, here’s the risks, here we go, but also talking about the steps that I take to mitigate those risks and create transparency in the evaluation process. I’d say more recently, seeing that families really need to benefit from education about the reports that we write are, a part of the health care record. And so it’s not a collaborative document where we can just drop diagnoses or drop scores or drop descriptions of scores.
That awareness too, for us as providers, makes us really mindful of what we write and thinking about the importance of sensitivity and who our audience is, which is the client, their parents [00:36:00] and schools often. And then we also talk a lot about gifted testing too, because we see a lot of that in Seattle.
Dr. Sharp: Oh, absolutely. I can imagine. Could we take a little detour here? I would love to hear a piece of how you are tackling this diagnosis expected but not given situation because I think that comes up a lot and that is a frequent topic of conversation in the Facebook community and consultation groups. This is pretty common these days, and then we can pivot. I definitely want to get into the details of the Working Alliance.
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Dr. Karen: So you’re talking specifically about wanted often like autism, is that what we’re talking about?
Dr. Sharp: Yeah, ADHD comes up frequently, but autism is a big one.
Dr. Karen: Sure. That seems to be a more [00:39:00] current, this wasn’t something that I was grappling with 5 or 10 years ago, this has been in the last two years more and more. What I’m finding is that it’s that open discussion in the intake. I haven’t had a situation like this recently, but I think if I were to realize that someone was coming into this invested, I probably would really talk a lot in the intake about how do they feel about if the diagnosis is not given, and do they still want to go forward?
It’s a big investment of time, emotions, often money, knowing that that might not be the outcome and maybe give them a chance and also us as providers, a chance to decide [00:40:00] whether or not it makes sense to even move forward with the evaluation if it seems there’s discomfort with that risk. I don’t have an easy answer to that. I think it’s new. We’re figuring this out. It’s a good question.
Dr. Sharp: It sounds like just talking about it explicitly and introducing the idea that the outcome may not match the expectations.
Fran: That’s why it’s important to make the distinction between reading the words on the page and having a discussion because the words on the page, they’re a great start. That’s a good start but in terms of getting a sense of what the concerns might be or what the fears of the person or anticipation might be on that person’s part, you have to have a conversation. That’s the way that those issues [00:41:00] can surface so that you can handle them or you can address them.
It’s really important to address them. Sometimes the laws in the state are not clear or there might not be any particular laws about that. It’s really up to you to engage a person in that discussion to find out if you feel that this is a safe place to have this testing done.
I think often people are just focused on getting that signature and move on to the real stuff. My feeling is that that is the real stuff. I’m often saying that having a well-administered disclosure form is the single important risk management tool you have at your disposal.
Well-administered meaning you have these discussions; you allow for questions. If people don’t ask questions, you provide the questions like if I were in your position, here’s what I might be asking or a lot of people ask me this [00:42:00] question and it might be good to go over it.
People might not want to talk about what their anticipated diagnosis would be for their child. And sometimes you even think that the parent will be happy that they might not have the diagnosis, but they’re not happy about it because they really want it in terms of maybe entitlements that they can get from their community or services at a school that they were hoping to get. And so it’s important to explore that early on rather than later.
Dr. Karen: And this idea of conversation is worth lingering over because when I was talking about going over that section of the disclosure of the evaluation intakes, it really is a dialogue and that is where it is an invitation for parents or caregivers to share their thoughts and perspectives on diagnosis. [00:43:00] They bring up some sensitive areas that I don’t think would have been brought up if I hadn’t started that conversation. So sometimes that can take 20, 30 minutes and it’s well worth it.
Dr. Sharp: It makes me think too, about the work that Stephanie Nelson does. I don’t know how much you have seen her stuff but she talks about this idea of secret questions and I see this whole thing as, there’s a lot of overlap there where maybe we start in this place of a sterile disclosure conversation or informed consent, but that pretty quickly moves into getting at people’s motivations for seeking the evaluation and what are their fears around the outcome or their hopes around the outcome and deeper concerns that may not otherwise come up. It’s just another entry point, I suppose.
Dr. Karen: Yeah. I think a common referral is, [00:44:00] hey, can you test my kid for ADHD? And it’s like, just give my kid that test. It’s our job to educate and onboard families about, this is a very complex process where we have to look at the whole picture and it’s not just a matter of giving a test. We have a responsibility, I feel like, to really inform families about that.
Dr. Sharp: I agree. I’m guilty of not doing that. It’s being crunched for time and especially, taking insurance, there’s a lot of, hey, we just need to be as efficient as possible and move to the, like you said, the good stuff, but there’s a lot to be done.
Fran: That’s where that balance comes in. It’s an art to be able to do it in a way that you can tolerate and that you can still get what you need to get done.
Dr. Sharp: I wonder, [00:45:00] I know I keep putting this off. We will talk about the actual product that y’all put together, but this is a rich discussion. I am curious if y’all have strategies; when you say it’s an art, are there ways that you found, either of you, to be helpful in navigating these conversations beyond just hey, do you have any questions about our paperwork? Or, hey, do you have any questions about our policies? How’s this actually getting woven into the appointment?
Fran: One of the disasters that can happen, to give you an example, is where you start to talk to somebody and then they tell you something that requires mandatory reporting. They’ll say something about let’s just say abuse of a child, but you haven’t yet had a chance to get into the disclosure form, so you haven’t formally told them that there’s mandatory reporting.
[00:46:00] What can be helpful is to have in all your materials, like on your emails or on your website, on your call waiting, if there’s a recording as a person waits to get through on the phone to say something about that there’s mandatory reporting, that if there’s information about abuse of a child or abuse of a vulnerable disabled or dependent person, that that you’d have to report so that, at least, that’s out there.You want to go over it again with the disclosure form, but it’s out there so that if you’re hit with that information before you have a chance, you can at least feel that they’ve been informed. That’s one thing.
So then a person comes to your office and they want what they want, let’s say testing or if it’s therapy, and you’ve got this thing to handle, which is that they need some services from you. By definition, they’ve come to you because they have a problem that they’re not able to solve on their own. They come to you [00:47:00] because you’re a person who’s informed and maybe even an expert in the problem. And so they want your help.
As you’re talking to them, you have no idea of what they’re actually hearing because on some level, they’re probably focused on whatever it is that they’ve come to you for. So if you start in on a consent form, they’re not going to listen to you because they’re like, why can’t we talk about why I’m here?
So in general, it can be helpful to talk to the person about what brings them there. How can I help? What is it that you need? But at some point before you end that session, you’re going to need to go over the disclosure form.
Some people would say that they should sign it before they even walk into your office. The problem with that is that they won’t have had a chance to ask questions, and they won’t have had a chance to be able to say that they have no questions, or that they’re satisfied, that they understand what the whole process is, because you can’t be sure of that.
So it’s a choice that you make. And in general, one way to do it can be to talk to them about why they’ve come to see you and spend time on that. [00:48:00] And you know what the disclosure form says, so you can begin to weave in some of those concepts as they’re telling you about their problem.
So they get the satisfaction of telling you about their problem, you’re listening and hearing why they’ve come to you, but you’re also planting the seeds of the disclosure. And then at some point, you’re going to say, the intake process might take more than one session, but I need to look at this disclosure form with you and I need to be sure that you understand what’s in it.
Hopefully, they will have read it so that they have some chance to ask questions. They’re usually likely to say, oh, no, I have no questions. Let me just sign it. Let’s just get onto the real work. And then that’s the moment where you can say, for my benefit, I want to be sure that you understand certain things. I need to know that I’ve communicated certain things to you clearly.
And you can also say, as I said before, you can say that these are some questions that a lot of people ask, or if I were in your position, here’s what I’d want to know. And so you’re constantly [00:49:00] balancing their needs with yours or characterizing the needs to go through the disclosure form as a need of theirs because it is a need of theirs.
They do need to be put on notice of these things. They do need to understand certain things. It’s just that that’s not the need that they want to address first. So you’re always engaging in this balance of administering the disclosure form, but at the same time addressing why they’re there and how you can help.
Do you see what I mean? It’s an art, I don’t mean artful in the sense of manipulative or complicated or wrongly based, the art in the idea that it’s that art is taking the human need and being aware of how it fits into the whole picture but it’s a very complicated balance when you think about it.
And then also the fact [00:50:00] that you are engaging a person and depending if it’s therapy or evaluation, how you see your role, if it’s a compassionate role or if it’s a client-based role or humanistic role or whatever that might be, but also you’re in authority. Even if it’s something you work with client determination, that doesn’t mean that you give over the authority. You’re always balancing your own role so that you can provide the best services possible. It’s very complicated.
Dr. Sharp: It is complicated.
Dr. Karen: I have some other angles too, today. One of the harder things of what we’re talking about as far as communicating the information and the disclosure is that it’s so much language and it’s so much reading and I think it’s a lot to put on our clientele.
I haven’t found a [00:51:00] solution for this but one of the things we do, we find that at first inquiry, there are scripts or email scripts for responding to initial inquiries have critical information about how we work, specifically around the role of parents and a little bit about how we work with families where there’s been divorce.
And so at that first inquiry, we’re giving people a chance to self-select already a little bit. So then the people who want to go on to the next phase then, again, with each journey, I recently was realizing I mapped out the client journey before they even see a clinician.
There’s six phases for the client journey and in most of those phases, we’re [00:52:00] doing some of that onboarding and educating about how we work. So it’s some content that’s in the disclosure form or in these email communications.
There was a time I experimented with, I didn’t continue this, but I literally had a PowerPoint video for families as a way to lessen the reading load, to go over some of the really key areas for people to understand. I had a lot of positive feedback about that. What was hard was that it’s hard to keep up to date but I might go back to that.
Another thing that we’ve done is for teens. We have a teen handbook. It’s an online document, but now that we’re doing a lot more in person, they get this physical handbook that talks [00:53:00] about cancellation policy, but also how we handle confidentiality, how we handle disclosures about self-harm or suicidality. It’s got these lovely graphics, and it’s engaging, and so it’s also a way for the clinician that supplements the onboarding.
And then we also, within the first month or so, this is something that I’ve more recently discovered is really helpful, is having a formal treatment planning meeting with the families and seeing are we all on board with why we’re here? Not only like why we’re here, but how we’re going to get from here to there and what kind of alignment do we have? And that has been really powerful as well.
And so even though that doesn’t look like the [00:54:00] disclosure, it is related to that process because it’s orienting people and giving another chance to have this discussion maybe several weeks into starting.
Fran: And also always being clear about who’s the client and who’s a collateral because parents might approach you for services for their child, but if the child is the client, that’s where the focus is and the duty of care.
Especially when you have a 13-year-old, or as you say, in Colorado, a 12-year-old in charge of the process, there’s a real departure from the normal or the usual power balance within the family. Usually it’s the parents who tell the kid what to do, but in this case, for the parents to even talk to you, they might need a signed release of information from the child. So that’s a big adjustment and it’s important for the evaluator to be clear, and you’d be surprised how many times people are not clear about who’s the [00:55:00] client.
So it sounds like a simple question, but it’s not a simple question, and that’s a really important piece of the care, is making that clear, because you might be clear about it but the clients, whatever that means, whoever those people are, the people in the room might have a different understanding of it.
That’s why Karen was talking about overcommunicating. One example of it is that you think it’s clear because you said it once, but it’s not necessarily clear. It’s important to reiterate it every time so that it’s reinforced and everybody’s in agreement about it.
Dr. Sharp: That’s such a good point. In a profession that’s based so much on trust, this is a huge part of the process in doing our best to ensure that we’re transparent and communicating everything as clearly as we can. It’s easy to miss things.
[00:56:00] Let’s talk about what y’all have going on. This has been a long buildup, but give me just big picture, what is the Working Alliance?Fran: Karen.
Dr. Karen: Okay. We were excited when we came up with the name, the Working Alliance. A bit of a play on words. What Fran and I have discovered is that together we have a synergy in ideas, and we write really well together, and so we’ve created this working alliance to help providers with the alliances that they have in their work.
In the last 2 years, we’ve done a [00:57:00] number of continuing education talks more locally, like to the Washington State Psychological Association, UWO, Seattle Children’s and then some other early career psychologists in Washington State and some other areas of our mental health community.
Fran, for years, has been presenting nationally for continuing education on law and ethics. I think where our synergy, where we focused a lot in Washington is working with the nuances of working with children and families as well as considerations for reducing risk of board complaints.
Our primary emphasis when we formed the Working Alliance was on these educational webinars. And then as we moved forward with the project, we got more fine-grained in the products, and so we have [00:58:00] a core form that aims to cover core requirements, at least, in Washington state.
And then also we have a bank of add-ons. And like we were talking about before, each add-on has an educational discussion. So it’s not just a template. And then we also have supplemental forms. The nice thing is that we’re always building our bank and so this is a plug, but anybody who purchases the document package will have access to a dashboard, so any sort of revisions or add-ons to the bank of document modules, they would have access to that as well.
We were also going to talk about the M&M Review, but I’ll pause there.
Dr. Sharp: I think that’s a good start. I [00:59:00] just want to make it really clear for folks what they might see when they go to the website and what the product is here, so to speak. It’s pretty full-featured. Y’all have put together a lot of pretty amazing materials, and I want to make sure folks know what all is out there.
Dr. Karen: Yes, we have a solo document package, and then we have group practice. We have two different price points, depending on the size of the group practice. And then we also have, for larger group practices, the option to have us customized because we figured the larger the practice, the more need there’s going to be for customization, but the solo and group are basically the same, it’s just different wording, instead of my policies, it’s our policies.
And then we also have, for the group [01:00:00] practices, a provider addendum so that each provider has a document with their own education history. Examples of some of the add-ons we have are modules that we would consider of general interest like adolescence and confidentiality, LGBTQ+ affirmative mental health care.
We have sections on role clarity, multiple roles, a lot about communication, so how providers might think about electronic communications, questions to consider about a “No Secrets” policy. We also include discussions about respectful communication and how that’s a value in the workplace. Again, for providers who are interested in this, who want to also communicate to [01:01:00] clientele that there’s parameters around respectful communication.
And also we thought it was really important to include a section that addresses domestic violence. For testing and evaluations, we talk about that all important topic of risks and benefits of evaluations, working with psychometrists, issues that come up with gifted testing.
We also have templates for release of information, collateral consents, provider addendum for group practices. And then we have a child assent not as a form, but as a guide, just questions for providers to consider when having discussions around child assent.
We have a long list of ideas, we just realized we wanted to launch with at least a subset of our ideas but [01:02:00] our intention is to keep adding to that bank. And also we want to hear from people, what they think is missing and what they would like to see, because we will write those add-ons as well. So that’s the document. And then let us know when you want to talk about the M&M review.
Dr. Sharp: We can transition to that, but I want to highlight on y’all’s behalf that yes, you have this really comprehensive document package that you can tailor for different types of practitioners or groups. And like you said earlier, it goes beyond the documents. It’s these modules, these webinars, you mentioned office hours, it’s a, I don’t know if wraparound support is the right term, but it’s a pretty comprehensive, almost like risk management option for folks if they want to take advantage of some of those resources that y’all have built into the site, [01:03:00] which is super cool and distinct from some of the other similar offerings out there.
Dr. Karen: Thanks, Jeremy. We wanted to provide people with a dialogue with us, and so we’ve already held some office hours, some webinars and plan to schedule more in the new year. And then we do have this, I guess I would call it a specialty service that is also on the site that we call the M&M Review.
This is for anybody who wants to have a consult, their own hour devoted to a conversation with Fran and I either about something difficult that happened that they want to debrief on and we’re very clear that it’s not legal [01:04:00] advice, it’s not clinical advice that we’re there.
We would never want to have these conversations about an adverse event when someone’s in the midst of an adverse event. We always think people need to hire an in-state attorney and consult with their risk management services through their insurance if they have that available, but it could be really helpful after the fact to debrief and do a review of the practice and risk management just in general to see where maybe some systems can be strengthened.
The idea of M&M Review truly came out of just a casual almost joking frame that I came up with early on in that first year at CATS, my group practice clinic, where, as I mentioned earlier, every bump, every hiccup, we [01:05:00] analyzed in a way that was incredibly productive.
And so the term M&M stands for morbidity and mortality, as some listeners may know. I heard about that on Grey’s Anatomy. I would serve M&M’s and it was just a way to warm up difficult topics. We still have M&M Review and it’s always followed by happy hours. That’s very key part.
Dr. Sharp: That always happens.
Dr. Karen: It’s Friday.
Fran: You can […] it with happy hour, and then people will talk more freely.
Dr. Karen: There’s an happy hour after we’re through the hard stuff but when I looked up, where did this idea, I know it didn’t start in Grey’S Anatomy, where did it come from? So reading a little bit about it, I learned, okay, this has been around for at least 100 years.
The [01:06:00] idea has always been to take mishaps that happen in a medical practice and look at how those can be prevented moving forward. The intention is always for it to be psychologically safe, non-blaming. That is not what I saw in Grey’s Anatomy, but it is how we practice the M&M Review is that that sense of psychological safety is so crucial and that most of these things that happen are not a people issue, they truly are a systems issue.
And that has been the number one most, I’d say, powerful source of how we’ve improved our systems and our communications with our clientele, and I love it. So we thought, oh, this would be really cool to offer [01:07:00] people as well.
Dr. Sharp: I love that, like a debrief, a post-mortem.
Dr. Karen: Exactly.
Fran: Which I heard you once say, Karen, that a crisis is a terrible thing to waste.
Dr. Karen: Yeah.
Fran: And I thought that was a great way to put it, that it’s really a learning opportunity when you’re both intellectually and emotionally invested in wanting to make it better the next time.
Dr. Karen: Absolutely. I think that’s a Winston Churchill. Every crisis, it’s like, ooh, we lost sleep. It was stressful, but let’s sink our teeth into this and make great use of it and it can be incredibly productive.
Fran: I agree with Karen’s point about how there can be these systems issues, but I’ve also seen that when I asked people, did you see this coming or just to ask, did you have a sense of this [01:08:00] family or this person or this situation being fraught? Usually, they do because counselors and evaluators, one of their strengths is that they see these things coming. They understand when people are upset before the person knows that they’re upset or that the people are angry before they know they’re angry.
So they do see these things coming, but the other side of the work is that you don’t want to be judgmental. There’s this feeling that you should be neutral, that you should give the person the benefit of the doubt. So what can end up happening is that you give the other person the benefit of the doubt to your own detriment.
And this is another way in which we’re trying to help people do these debriefs, the M&M debrief or just in general to call a situation for what it is when you’re trying to decide if you’re the right person, if what you have to offer is what these people need or bringing together those matches.
It’s an encompassing a 360 approach to this work and [01:09:00] using the disclosure form in order to help you do that, and then process. That’s the overall of what we’re trying to offer here so that people can protect themselves before they enter into these situations, but also in the situations, how you can make the best of it and afterward, how you can debrief.
Dr. Sharp: That’s the thing that I love about this approach is that it’s a 360-degree perspective where you’re trying to support clinicians at every step of the process. I love the idea of the debrief because that’s, I feel like we never get that. Maybe we do it with our friends or colleagues or spouses or whatever, but to actually sit down and have a little bit more formal informed debrief and think, what do we learn here? What would we do different? And have some real input from professionals is [01:10:00] super helpful.
Fran: Right. A lot of these forms that we’ve seen are, this combination of my being a lawyer with being with the social work background and Karen’s being a psychologist, we bring a lot of experience to it and a lot of thought over the years, I think that they’re unique in that way too.
Dr. Sharp: Sure. I appreciate y’all coming on. I know we’re pushing time a little bit and just talking through all of this with me, the more you share about it, it just seems clear that you’ve put together a pretty stellar thing here for folks to check out. And Lord knows, risk management is something that we have to deal with on a pretty regular basis. So I hope that folks will go check out the website and see what’s out there, and reach out.
Fran: Yeah. Thank you for having us. This has been great.
[01:11:00] Karen: Yeah.Dr. Sharp: Good. I’m happy to have you. Thanks for coming on. I’m very grateful.
Fran: Okay, thank you.
Dr. Karen: Jeremy, we are going to give a code to your listeners for 10% off the documents. We will share that with you, but this has been really fun. Thank you, Jeremy.
Dr. Sharp: Of course. I’ll put all that information in the show notes for anybody listening to make sure you go grab that code and check out the Working Alliance. Thanks y’all.
Fran: Thank you.
Dr. Karen: Thank you.
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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