Author: Dr. Jeremy Sharp

[00:00:00] Hey y’all, welcome back to The Testing Psychologist podcast, episode 28. I’m Dr. Jeremy Sharp.

Hello, and welcome to another episode of The Testing Psychologist podcast. Good to be back, y’all. My gosh, it feels like it’s been a long time since the last episode and I guess it has been the longest gap in episodes since I started. That’s for sure. It’s been at least 4 or 5 weeks, which, as is the case in the summer, it feels like it’s gone by in the blink of an eye for a number of reasons. But I can say that I am really glad to be back talking with y’all. I’ve been thinking about the podcast. I have a lot of good ideas for interviews and topics coming up. So good to be back and [00:01:00] good to get back into it.

I got to say, over the last few weeks, I have certainly been busy. The summer is never as relaxed as I want it to be, but this summer I tried to prioritize some fun and engage in some business development as well and got to make both of those things happen right in a row toward the end of July. I think I mentioned this in the last episode, but I took a little vacation toward the end of July with friends to catch up with college buddies and it was incredible. It’s always really nice to get together with old friends. There’s nothing like it.

I had a good time there. And then almost immediately came back and turned around and traveled to upper Michigan where I got to spend a week with some [00:02:00] incredible people at a retreat or conference, I suppose led by Joe Sanok of Practice of the Practice. It was called Slow Down School. I’ve mentioned it before.

Slow Down School turned out to be an amazing experience. I connected with some awesome people who are doing really cool things here in the field with their practices and with consulting and also got a chance to unplug from everything here at the practice and here with The Testing Psychologist. It gave me, I think a lot of really nice perspective on where to take things going forward, how to rethink a few things here in the business and with consulting. So, totally worth it. I think that Joe plans to do it again next year. I would definitely recommend considering going to that if you are in the market for some [00:03:00] practice development.

Today, I am going to be talking a little about managing difficult behavior during testing.

When I was thinking about what kind of episode to do here this week, it just made sense to talk about difficult behavior during testing because I have had some really challenging kiddos here lately in the practice. Now, part of that, I should back up actually, part of what has happened this summer is we had some staffing changes, I suppose, and some gaps in our testing dates. So I have been doing a lot more testing than I usually do. Typically, I have psychometricians who do a lot of the testing, but I’ve been doing some testing and it’s been really cool in a lot of ways. I’ve likened it to coming out of retirement to play a sport you used to be really good at, but it’s amazing. It’s come back really [00:04:00] quickly. It’s been cool to interact with these kiddos for so long and get to immerse myself in the testing again. So that’s been cool.

The flip side of that, of course, is managing behavior during testing, which is not always great, particularly with the population of kiddos that I tend to work with. So, I thought I would talk a little bit about how I tend to manage difficult behavior and work with kids throughout the testing day.

One thing that I think about from the beginning is how to prepare kids for testing. This starts when I give parents an information sheet about the testing day. So that happens at the intake appointment before I’ve even met the kid.

I give parents an information sheet and it details the testing day, what the schedule will be, how to [00:05:00] prepare the kiddo for testing, and what to tell them, but it also goes into things like making sure that they sleep well the night before- don’t keep them up watching scary movies or anything like that. I make sure to have parents bring a water bottle and snacks for the kiddo.

And also just to make sure that the kiddo does not think that they are coming to an actual doctor’s office because I found that kids, for whatever reason, think that they are going to get shots when they go to the doctor’s office. And so I always tell parents very clearly to make sure their kid knows they’re not going to get any shots. We’re not going to do any needles or blood work or anything like that. So not that kind of doctor. So, a lot of it I think even starts with preparing parents and having them talk with the kid in a certain way about the testing process.

Parents often ask me, “What do I tell my kid about testing?”[00:06:00] I’ve come to recommend using a line like we are going to do some games and activities and some work to try and get a good idea of what your brain is up to so that we can help with blank. They can fill in the blanks with anything that the kid might be bought into in terms of things that they would like to be better.

For older kids, this might help with reading, help with friends, help paying attention in class, or help to make school easier. It could be anything like that. I tend to leave it pretty general and try to use whatever open door the kid may already have provided.

Usually, there is some buy-in from the kid’s side. Even if they’re defiant and they don’t necessarily love the idea of being here, usually, parents can identify [00:07:00] something to latch on to, something that the kid would like to improve or get better in their lives. I really like that line. We’re going to see what your brain is up to so we can help with blank and kids seem to latch on to that.

So, talking with parents is important. Making sure the kids are coming into the testing with hopefully decreased anxiety and knowing a little bit about what to expect. I think that goes a long way toward preventing difficult behavior in general. In some extreme cases like with kids who are super anxious or don’t want to be here for one reason or another, I’ve had parents bring them by two days early just to meet me, meet my assistants, and take a tour of the office so that it’s a little more familiar so that they know what to expect, and everything’s not brand new.

Now, on the day of [00:08:00] testing, I start right away, and this is just my style with kiddos. I greet the kid right away in the waiting room. I do so before I even talk to their parents. I’m pretty silly. If they’re having a snack, I’ll ask for some of their food, ask if they brought me something, or make a comment about their shirts or shoes or whatever. I have kids myself. At least at this point, I’m somewhat knowledgeable of cartoons and pop culture and that sort of thing. So, I can comment semi-intelligently on that sort of thing. So I’ll make a joke about that.

If it’s a teenager and I sense any sort of hesitation or defiance, which is common, to be honest, I will make a joke about it and say, I’m sure this is exactly what you want to be doing today, right? Or [00:09:00] this is going to be the best day of your life or something like that. I’m pretty sarcastic. And if I sense that a teenager might be able to get on board with that, then I’ll go for it.

With some, I might say, I don’t want to be here either. Man, we’re going to have a long day, so going overboard, playing it up, and disarming them a little bit, but yeah, anything you can do to build rapport.  I’ll talk through the schedule again before taking the kiddo back to the testing room, just making sure they know that they can have breaks and drink water and get a lunch break and all that good stuff.

Once we get into the testing room, then I am again, pretty loose. I am very willing to, let’s say, stretch the standardization within reason, of course. I’m not doing [00:10:00] anything outside the bounds of ethics or anything like that, but stretch the standardization where, I’ll talk to the kid a lot before we even get started with testing asking about their lives, like what they did last night or that weekend, what they had for breakfast, what they like to do, just trying to get a sense of how they feel about being there and diving in trying to get a sense of what they expect and what they anticipate being easy or hard, what their parents told them about being there, if they know why they’re there, if it’s just a total mystery. So I’ll talk about all of those things in addition to the standard spiel about, we’re going to do a lot of different things today. Just try your best. Some things will be hard. Some things will be… I do all that of course, but I try to make as much conversation with kiddos as possible.

I show them around the room. They [00:11:00] often, especially if they’re younger, they’ll ask about everything that I have laid out for testing. And so I’ll let them explore. Often part of that is that I have little rewards and treats and a prize box and some balls to throw and little toys and things like that. So I’ll show them that stuff right away and let them know that, Hey, that’s there and we’ll get to take breaks later and we’ll get to play with that stuff. I just want you to do your best and you can get some time with these break materials later on.

Now, I let them know, of course, that they can take breaks whenever they want, they can go to the bathroom, they can get a snack, they can take a drink, they can get up and stretch, any of that kind of thing, just to make sure that they have a good idea of what to expect throughout the testing day.

For younger kids, we used to have a big whiteboard in the testing room that [00:12:00] we would do this on, but now I’ll do it on a sheet of paper, but I’ll draw a Candy Land type of map of the day’s activities, excuse me, a little scratchy voice, and on that map, I will draw out board game spaces with each space representing a subtest or maybe a group of subtests, and then I will put in break spaces every 3 or 4 spaces on the board and I’ll put in lunch and I’ll put in go home.

So this gives a pretty concrete representation again for younger kids of progress throughout the day. Kids always have some concern about when they’re going to be able to go home and that kind of thing. So, this just helps them know what to expect with the whole process. So, we’ll put a sticker over each space as they [00:13:00] progress and that helps show how they’re doing, how far we’re going, and how close we are to being done. And they seem to like that.

Reward-wise, I have no problem giving kids rewards throughout the day. So if they try hard, if they move through their board game spaces and get to their break spaces and they give a good effort, I have a box full of stuff that I bought from the dollar store, so just a ton of little simple toys and they get to pick little prizes for each break space that they get to. And they seem to like that.

Now, I’ll also break it up if I notice that kids are getting a little antsy. We’ll take breaks to throw a ball back and forth. I also like to take breaks to walk around the office. I call it adventure time. So I’ll ask, Hey, after this, do you want to go on a [00:14:00] little adventure around the office? They always say yes. So we go on an “adventure” to check the mail. We might look outside if there’s no, excuse me, squirrel running around or something like that. I also like those activities because tossing the ball or taking a walk around gives me a chance to informally assess gross motor skills, hand to eye coordination. I’ll also set it up where I have the kid lead us back to the office after our adventure. So get a little bit of a sense of how they navigate, a sense of direction, and that sort of thing. So that can be good qualitative info depending on your referral question.

Now, throughout the day, I’ll give them a lot of high fives, fist bumps, any sort of encouragement if they’re doing a good job, [00:15:00] just to try to keep them engaged as well.

Another thing that I like to do as we get moving through the testing and getting into the latter stages, particularly with the academic measures is, I will give them a choice in how they want to proceed.

Some of the testing has to happen somewhat in lockstep depending on what you’re assessing and the order you have to go in, but with academic skills, I tend to ask what they think is going to be the hardest and then make a joke about it throughout the day. Like, we’re going to do some math later and it is going to be super hard. Are you ready for some torture? Are you ready for some punishment? Just trying to build it up again and make a joke of it being super hard in hopes that it won’t be as hard as they think it [00:16:00] will be, but I will give them a choice of what they want to do.

So if we have reading or writing or math or whatever it might be, typically I’ll say, okay, here’s what we got and you get to choose which one you want to pick. Do you want to do the hard thing first and get out of the way, do you want to do something easy and build some confidence, or what? That just gives a little bit of choice again for how they engage in the testing, which I think helps quite a bit.

Now, two instances that have come up over the last few weeks with some of the kiddos, we’ve had some pretty sensitive, self-critical kids that got upset and melted down. They were crying. It was really hard. They were getting down on themselves about the work that they were doing. [00:17:00] So in those cases, I will break immediately after that subtest, and let them walk around, take some breaths, get a drink of water, throw the ball, talk to them about it like, Hey, is this familiar? Does this happen in school? Is this typically hard for you? Oh, I get it. You’re doing great. Just doing everything that we can to build them up. Sometimes we might have to text Mom or Dad just to get a little encouragement. They tend to like that pretty well.

In some cases, I’ve had 2 kids who, well, let me back up actually with the kiddos who had more emotional meltdowns in the room. It’s a good time to try to practice some breathing exercises or like get them doing some physical exercises to relax their muscles a little bit [00:18:00] and try to regulate them a bit. And that’s also, I think, good data to see how they can recover, engage in some self-regulation, and be flexible with their problem-solving. So try to do some of those exercises.

If they are super hyperactive, which happens, take more frequent breaks.  Definitely up the rewards. I will talk with parents sometimes before the testing day, but sometimes this will happen during the testing day as well. I might text parents while the kiddo is doing a test or talk with them at lunch or something, but with the super hyperactive kids who tend to have ADHD, I’ll talk with them about rewards and can they try to play up a reward for after testing? And a lot of kids tend to respond well [00:19:00] to that. So even something like going to get ice cream or going to get lunch at their favorite spot, or sometimes parents will do a small toy. Of course, we can get into the pros and cons of reward-based behavior management, but for the testing day, that is something that we have utilized a lot just to try to keep kids focused and honed in.

In rare cases, I have let parents sit in the room while we at least get oriented to testing. They don’t sit in the room during the testing unless it’s called for in the standardization. But I have had parents, for example, sit within view out in the waiting area. So kids can look out the door if they need to. I’ve had some parents in extreme cases sit outside the door and we can peek our head out and check in with them if we need to, [00:20:00] if the kiddo is having a hard time.

The other day, I had a kiddo who was getting to the point of being somewhat unsafe. This kiddo was, let’s say very curious and very active and was bouncing around the office to the degree that she almost pulled a lamp down on herself. I don’t think it would have been that dangerous, to be honest. Our lamps are not heavy or anything like that. They’re pretty kid-friendly. Either way, she was getting close to damaging something.

And so in that case, rather than stay seated at the desk and try to call her back, I had to get up, walk over, did the hey, look at me, let me have your eyes. Let’s [00:21:00] talk about what’s going on right now. Let me keep you safe. I have to keep you safe. Here’s what that means.

That’s about as far as I would go in terms of I guess you would say behavior management techniques. I’m a big fan of whole brain child, no drama discipline, that kind of thing where you make sure you have the kiddo’s attention and talk them through what might be going on and try to anticipate what they’re needing and give them some space to articulate that.

After that, we ended up taking a walk and we did some cool things to make her chair a little bit more fun. We got a stuffed animal that she could hold in the chair, little things like that to try and help her regulate and stay seated.

Now, I will let kids stand up and move around the room if they need to. There are a few tests where I think this is not a problem at all, like vocabulary [00:22:00] and similarities. If kids can pay attention, they can even do it during digit span or some of the listening comprehension tests. I mean, standing at the table. I’m fine with moving around. I am fine with it as long as it’s not super disruptive. So try to be cognizant of the fact that it’s hard for kiddos to sit still for too long. And so, we’re taking breaks as much as we can and moving around as much as we can.

And then I think ultimately, in my case, the worst-case scenario is to reschedule testing for another day. We tend to knock out testing in one day for the most part, but there are some cases when that is not possible and it’s clear that it’s affecting the testing process and the validity and you’re just not getting good data. So I think that’s a piece that develops just from clinical experience and being able to gauge how kids are [00:23:00] doing and if they’re attentive or not. But if I find that they’re just not into it and they’re totally losing concentration, we will just set up testing for another day.

In some cases, we can break it up a little bit. If I can do a personality measure with the kiddo and let them answer questions on the computer for a little bit to cut down on the brain drain of the cognitive activities, sometimes that can help and we can return and finish. But in some cases, we reschedule testing for a different day and that’s totally okay too.

Those are some of my thoughts about managing difficult behavior during the testing day. Like I said, that’s pretty relevant for me here lately, so I got to thinking about it and also realized, at least for me, we didn’t get a whole lot of training with that in graduate school. We got a ton of training around how to administer the assessments and score and write them up, but [00:24:00] if you’re working with kids, there are a lot of considerations for managing difficult behavior.

I hope you are able to take some things away from this. I would love to hear some ideas, strategies, and things that others of you might use. You can always email me. My email address is jeremy@thetestingpsychologist.com.

This would also be a great discussion for our Facebook group which is The Testing Psychologist Community. You can find that by searching on Facebook for The Testing Psychologist Community. We have a lot of good discussions in there about various testing topics and things that come up during testing, measures, strategies, marketing, and all sorts of things. So, if you have thoughts on this particular topic or anything else testing-related, come check out the Facebook group.

[00:25:00] The website as always is a great resource; thetestingpsychologist.com. You can find past podcast episodes. You can find information about consulting on testing if you are interested in growing testing services in your practice or adding clinicians to your practice who might be able to do testing and add that additional service area. So lots of resources for you.

As always, I appreciate the listening. It’s been cool to see this audience continue to grow and find that this is a valuable service and source of information for folks. It’s awesome. I love talking about this stuff. It’s great to be back.

Like I said, in the beginning, I do have some cool topics coming up and some great ideas for interviews that I hope will come to fruition. So hope to be doing some episodes on report writing, specific [00:26:00] batteries for particular presenting concerns. I would love to talk with someone about assessment with older adults because I tend to focus a lot on kids just because that’s what I do and maybe even talk more about hiring and training psychometricians. Folks seem to be very interested in that process.

I’m also going to be adding some episodes and some resources for master’s level clinicians who may own practices and want to add testing folks to their practice, even though they might not be doing it themselves. So we’ll be focusing more on some of the pure business strategies and hiring testing folks as well going forward. So glad to be back. I will look forward to talking with you next week. Take care in the meantime. Enjoy these last few days of summer. I’ll talk to you later. Bye [00:27:00] bye.

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[00:00:00] Hello, everyone. Welcome to The Testing Psychologist podcast episode #25.

Hey, y’all. Welcome to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. Good to be back with you again.

Today is going to be a little bit of a different episode than expected. I’ll be doing a solo episode today about when and how to expand your testing practice and think about hiring folks to help you out.

I originally thought that I was going to be interviewing Dr. Karen Postal, like I’ve talked about in the past two episodes, but we had to reschedule, which happens. I’ll look for her in two weeks. In the meantime, you’ve got me and [00:01:00] we’ll be talking about when and how to expand your testing practice.

I’ve told this story before about how I transitioned from Solo practice to hiring my first, at that time, independent contractor to help out with testing. This happened, I don’t know, at this point, probably 6 or 7 years ago, but this was after I’d been in practice for a year or two.

What happened was that our local university changed their policy for prescribing ADHD medication such that anyone requesting ADHD medication had to complete a full psychological evaluation before they could get that prescription. Prior to that, I had evaluated two college students over there and sent the reports over like I usually do. And so, when they changed this policy and [00:02:00] needed evaluations for all these students, they ended up sending them my direction, fortunately.

What happened though was that I found myself with probably 15 to 20 evaluation referrals almost overnight. Prior to that, I’d been doing maybe 1 or 2 a month. Maybe a little bit more than that, but certainly nowhere near the 15 to 20.

At that point, I panicked a little bit, of course, and then sat down, got my wits about me, and started to plan. One of the first decisions I made was to figure out how to hire someone and bring someone on to help me with the testing. So, I guess I would say, stumbled into hiring and technically becoming a group practice at that point. Thankfully, it turned out well and I’ve learned a lot along the way. I did what I had to do [00:03:00] back then but I think there are certainly more of a structure to it and things to consider. I’ll be talking about a number of those factors here over the course of the episode today.

When I think about when it is appropriate to bring someone on, like I said, you have situations like mine, which I think are probably unique. Maybe not. Maybe a lot of you are having that kind of situation, but in any case, I think what you’re looking for is when you’ve reached your, what I would call upper limit for testing and are just getting more referrals than you can handle.

There are a number of ways to gauge that. There’s the, I would say informal way, which is if you just feel too busy; if you’re working at night, if you’re working on the weekend or if you feel overwhelmed with the work that you have, that’s maybe a good time to [00:04:00] say, Hey, I need to consider bringing somebody else on and to get some help here.

Now, if you want to do more of a numbers-based metric, then I would think about the number of referrals. As far as I’m concerned, a full-time testing schedule, if you are doing all of the testing, report writing, and everything from start to finish, if you’re doing pretty full evaluations, then you can maybe fit in 2 to 3 cases a week. If you put in, let’s just say 10 hours per evaluation, you can maybe squeeze in three. If you’re more like in our practice, we do more around 12 to 15 hours. So that’s more in the two-cases-a-week range. So that’s another way to think about when would it make sense to start to hire someone if you are getting more referrals than [00:05:00] you can handle.

You can track your referrals. I would certainly say, try to track them for about six months. And if you’re consistently getting more than 10 or 12 evaluation referrals a month or if you’re getting burned out, then, that’s a good time to consider hiring someone. 

I would say, a key thing when you’re gauging your referrals is to make sure that you have an accurate sense of the timeframe and the consistency. I always look at referrals outside the school year. For us, we’ve tested a lot of kids, so things are busier certainly at the beginning of the year and the end of the year. Things slow down a little bit over the summer. So depending on the population you work with, make sure that you’re gauging your referral stream across the year and not just at a particular time of year when things might be a little [00:06:00] more busy.

As I continue to hire folks and look at testing folks, when I look to hire another full testing clinician, that happened when I was consistently booked out for about 10 to 12 weeks for the initial appointment. I think that I should have done that a lot sooner, but I think a lot of it depends on your community as well. Around here we have, I’d say a fair number of agencies that provide testing, and we also have a children’s hospital within an hour and a half of our community. So, you can call around the community and get a sense of what other folks and other clinics’ wait lists look like.

If you’re thinking from a business standpoint, I think it makes a lot of sense to try to have a shorter [00:07:00] waitlist than the shortest one you can find. So it doesn’t have to be a lot, but I think that does make a big difference. When people are calling around looking for an evaluation, if you can get them in six weeks versus having to wait, let’s say, 12 weeks for the local children’s hospital or another agency, then that makes a really big difference.

When I did the math and figured out, hey, I could transfer over two cases a week to another psychologist and we would still be booked out longer than I hoped, which is two months, that’s when I started looking for another full psychologist to bring on in addition to the graduate students. It talks about the when you might think of expanding and hiring other clinicians in your practice.

The other piece of that though is thinking about when you [00:08:00] might bring on additional staff like support staff, like an admin assistant or a billing support, and those kinds of folks.

I would say, looking back, I waited way too long to bring on those services. I think I’ve joked around on here before about being a control freak. And so I, for a long time did everything myself with regard to answering the phone, doing the billing, checking insurance, following up on insurance. Honestly, it was a complete nightmare and probably contributed to being booked so far out because I wasn’t being as efficient in moving folks through the practice as quickly as I could. If I could go back, I would definitely hire a little bit of support way earlier in my practice.

Two things to consider there:

1. If you take insurance, I would hire a billing service or at least an insurance verification service [00:09:00] almost immediately. That’s a service that can call and check your clients’ insurance coverage for testing prior to them coming in. It typically does not cost a lot. It might be $4 to $5 per patient. The reason that I think that’s so important is because once I started doing that, then that allowed me to: One, it freed up a ton of time. It also led to a lot less confusion on the client side with billing throughout the evaluation process.

When you have an estimate of their coverage ahead of time, then you can communicate that to the client before they come in. So it cuts down on no-shows that might happen or cancellations that might happen when they find out that it’s going to be more expensive than they thought.

It also allows you to put a policy in place for collecting. In our clinic, we collect half of the estimated total [00:10:00] at the testing appointment. That helps with cash flow, aging reports, balance, and that kind of thing.

It also increases client relationships because you’re being upfront about the cost. If it’s going to be a little more expensive than maybe they anticipated, you can communicate that immediately. That builds trust and gives you an opportunity to devise a payment plan if you need to, that kind of thing. So, if you take insurance, I would definitely consider that service pretty quickly.

Now, in terms of office support and an admin assistant, again, I wish that I’d done this a lot quicker. I’m a big advocate of hiring an admin assistant at least on a limited basis, almost from the beginning. There are services out there that are… It can basically be answering services and also do scheduling for you if you want to do a virtual service. I use [00:11:00] Conversational right now as a backup service for our in-house person. If he can’t answer the phone for whatever reason, it goes to Conversational. But I would really think about admin support pretty quickly as well.

Here are just a few tasks that an admin person can take off your plate, even part-time. So this could be someone who’s in two hours a day. They can answer the phone, return messages, and explain the testing process.

This is super important for us because, at least for me, when someone was calling for an evaluation, that phone call would take anywhere from 10 to 20, maybe even longer than that, 10 or 20 minutes of phone call. Now, if you are getting, let’s just go back to that number. If you get three of those a week, it may not seem like a lot, but you’re spending an hour on the phone per week.[00:12:00] That’s a lot of time. You can be doing some other things.

One thing that I struggled with with that was this thought that nobody’s going to be able to explain testing like I can. It’s too complex. They can’t answer all the questions and that’s really important. Well, I figured out that that was not true. So what that forced me to do was write up a really nice, thorough script of what our testing process looked like from start to finish. I included a Frequently Asked Question section.

Of course, there was some training that happened at the beginning. There’s pretty extensive training to, be honest, of our admin assistant, but after that, I have never looked back. He’s gotten really good at describing the testing process and it has not made any difference in terms of folks following through or not. I’ve had a lot more conversion, so to speak from phone calls because [00:13:00] someone is answering the phone and returning messages on time as opposed to me putting it off cause I didn’t have the time that I needed to talk with them. So that’s just one thing.

They can answer questions about insurance if that’s part of your practice. They can follow up on billing issues if that’s the way you have the role set up. They can do scheduling activities. Our admin person schedules all the feedback sessions and schedules all my interviews. So that’s a big task off of my plate.

But I think one of the more important things that our admin assistant does is what you might call case management. After every interview that I do, I have a post-interview form that I fill out. It has a few different fields that has a send a thank you fax to the referral source. We send a fax to every referral source that we get [00:14:00] just to maintain that connection. So sending that fax. Let’s see, asking for any records from any previous providers, like any evaluations, any records from schools any medical records that might be relevant.

It also has a box for scheduling collateral interviews. Often, I will interview kids’ teachers, daycare providers, if parents are divorced, making sure to make contact with both parents, with adults that might involve interviewing a spouse or a provider, you get the idea. So I’m scheduling collateral interviews, requesting records from other folks, and scanning the file in. We’ve gone to a paperless record system using Google Drive, so he takes that file, scans everything in right after the interview, and then that file is [00:15:00] ready to go for the electronic records system. So I think the case management piece has probably been one of the biggest pieces because that it makes things go smoother.

In the past, I would find myself playing phone tag with other providers. I couldn’t get interviews scheduled in a timely manner. And so then that would delay the evaluation. If I was missing paperwork or needed to follow up on materials that needed to come back from parents or something like that, I would just put those tasks off and not get them done in a timely manner. And so our admin assistant really helps with those kinds of tasks.

Again, I’m a big advocate for really considering administrative support pretty early on in the process. Even if you’re a solo practitioner, I think it you can benefit greatly from administrative support.

Once you move on to [00:16:00] deciding to hire other practitioners in your practice to help with testing, I think you get to a decision point. So the question becomes, do you want to hire psychometricians who can help you do the testing but not do any interpretation or, I don’t know what the word is… Sorry. Had a little brain malfunction. ..any interpretation or guiding the evaluation or leading the eval. Or do you want to hire another licensed clinician who might be able to do the full evaluation and take on the whole evaluation themselves?

There are different considerations with both. If you’re a solo practitioner and you don’t feel like you have enough referrals to fully support another clinician, I think there’s something to be said for really considering that because you could hire someone part [00:17:00] time even at the rate of one evaluation a week. That’s 10 to 15 billed hours. And that’s a part-time position for a lot of people. So, you could consider that and see if it fits with your practice. But if you’re a solo practitioner and you don’t feel like you can support another clinician, but you would like some extra time, I think the psychometrician route makes a lot of sense.

So then it gets to the question of, where do you find good psychometricians.

Well, thus far in our practice, I have exclusively employed advanced graduate students as psychometricians. These graduate students are advanced doctoral students. They’re all getting their doctoral degrees in either clinical psychology, counseling psychology, or school psychology. At the point that I hire them, those graduate students have had at least a solid year of testing [00:18:00] experience., not just taking appropriate classes, they have practical experience administering and interpreting test results under supervision. So I think that’s pretty important.

If you are going that route, I think the graduate student route is great. If you enjoy training, if you hire grad students, you do have to provide supervision. So if you don’t like that, then I would discourage the graduate student route. In that case, I might consider more of an independent psychometrician. Those folks are certainly out there. And like we talked about a few episodes ago, there is a board of certified psychometrists that’s starting to standardize that training a little bit more. So there are folks out there who are “only psychometricians” and are not necessarily graduate students. So, that option is out there as well.

In my case, I [00:19:00] really do like training. I think having students in the practice certainly brings freshness, and a different perspective, and keeps us all plugged into updated learning and making sure that we’re on top of the research and that kind of thing. So I love training and I’ve really enjoyed having grad students in the practice.

But again, another aspect of the training piece is that you have to put time into standardization. So, writing up a good training manual. The training process is pretty important. I think I talked about that two episodes ago where we have

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[00:00:00] Dr. Sharp: Hey y’all, welcome to The Testing Psychologist podcast episode 16.

Hey, welcome everybody to another episode of The Testing Psychologist podcast. Hope you’re all doing well today. I’m excited to be talking with Kelly Higdon today on the podcast. Kelly is a licensed marriage and family therapist in California, and she’s a co-founder of Zynnme and the Business School Bootcamp for Therapists, something you might have heard of in the mental health consulting world. Her Business School Bootcamp helps therapists start, grow, and expand their private practices.

On the personal side when Kelly isn’t coaching or teaching, you can find her spending time with her family or tearing it up on the roller derby [00:01:00] track, which we might talk more about as we go along because that’s super interesting to me.

Kelly, welcome to the podcast.

Kelly: Thank you for having me.

Dr. Sharp: Absolutely. Thanks for coming on. Kelly and I were introduced by Joe Sanok who I’ve talked about, I’ve done some consulting with Joe in the past. What I’ve found is when you get into the world of mental health private practice consultants, it’s a pretty small world and all the people that I’ve connected with so far are cool. Kelly is one such person.

Kelly: Thanks.

Dr. Sharp: So I am pumped to have our conversation here today.

Kelly: Me too.

Dr. Sharp: Good. Maybe we could just start, Kelly, could you talk to me a little bit about how you got into being a therapist but then I’m interested in how you transitioned to doing coaching and consulting.

Kelly: I would say it’s funny when you asked me [00:02:00] that question because looking back now, everything has not been planned. So becoming a therapist was because I failed a biology class and was pre-med and I was definitely down this track and then I freaked out and had this re-evaluation about what am I doing? And I ended up becoming a therapist.

And then as I was doing my hours, I started working for the government and I was climbing the ladder. And then again, I was pushing paper and supervising and all these kinds of things and running this huge clinic, and then I thought, what am I doing?

I went into private practice and then as I started my private practice, that’s where I met my business partner Miranda Palmer and we started Zynnyme. Because I [00:03:00] grew my practice quickly with her help and I was like, can we automate some of this stuff that you do because this seems tedious to do it over and over with each client on a one-on-one basis? And that’s how we started that.

So it was never my intention:

a) To be a therapist.

b) To go into private practice.

c) Become a consultant, but it naturally flowed by evaluating my life and what I wanted my life to look like, and then how could I still meet needs and be happy.

So that’s how I grew. From starting Zynnyme, we started with very different programs but soon realized that many therapists were winging it in business. They knew how to be clinicians but they were co-mingling their money. They were marketing on the fly and trying [00:04:00] this shotgun approach where they were just seeing what hit and what didn’t.

I thought, if we could help them be a little bit more streamlined, it makes you a better clinician. It can also help improve your clinical outcomes because you have processes that you can track and measure. And so that’s how Business School Bootcamp started as well.

Dr. Sharp: How long have y’all been doing that now?

Kelly: I think we’re in our fourth year.

Dr. Sharp: That’s fantastic.

Kelly: I really should know. We’ve been together for seven years but Bootcamp’s been around for four. We’ve had psychologists, social workers, mental health clinicians, professional counselors, and marriage and family therapists in it.

Dr. Sharp: That’s fantastic. I’ve heard so much from folks across the field and in the Facebook groups that I’m a part of speaking positively about Bootcamp and what it’s done. [00:05:00] It’s a cool resource.

Kelly: Thank you.

Dr. Sharp: Yeah, for sure. It sounds like your path has been different than you expected.

Kelly: Always.

Dr. Sharp: The cool thing about that, though, is it sounds like you went with it and chose the paths that fit for you and for your life and were willing to adapt when you needed to.

Kelly: Yeah. And that’s something I’m passionate about helping people understand whether I’m working with a therapist or I’m doing consulting in other areas your business decisions should not be soul-sucking, they should be life-giving. And so often we end up doing things in our practices because we feel like we have to or it should be done this way, but what if y’all had said that, do you think he’d be the therapist he is and have had the impact or all these kind of therapy [00:06:00] greats and researchers, if they had just said, well, that’s the way it has to be, we wouldn’t have expanded.

And so I’m always trying to see where there is room for growth so that we could have more stability and balance and joy in the way we’re doing things. This should be fun. I believe that.

Dr. Sharp: Absolutely. I think I’m sure you’ve run into this, that through graduate school and training, that doesn’t come out for a lot of mental health practitioners that it’s possible to:

1. Build a practice

2. Make money from it.

3. Enjoy it.

It’s rare that those components get talked about.

Kelly: Right, the system is set up such that it’s a, we have a hierarchy, you don’t know anything until you’ve done your hours. After you’ve done your hours, you have to pass your exams. [00:07:00] After you’ve passed your exams, even though you’re a licensed clinician, and maybe you can do your testing and you can do therapy, you still are not the level where you can supervise. You got to work towards that.

And then what about your specialty certificates? So it’s always more. The truth of the matter is, yes, I hope that I am a better clinician. I better be a better clinician 10 years from now. I will always be growing but that does not mean I am not good now. It doesn’t negate where I’m at currently.

For those of you who are like, yeah, I’ve never had someone tell me that can be done, remember that when someone comes out of school and interviews you or you’re supervising, you have a great influence to change the trajectory of how mental health is treated in your community and [00:08:00] how your clinicians own it and celebrate it. We’re all part of that. We’re all part of the solution just as much as we’ve been part of the problems.

Dr. Sharp: I think that’s really important. Of course, a lot of the folks who listen are testing specialists who do a lot of assessment and with some aspects of that, I’m thinking particularly like with psychologists and neuropsychologists, that is prevalent where the training track is pretty rigid and it can get easy to get locked into expectations and doing what you think you should. It’s even hard to break out and do private practice sometimes from traditional training. That’s extra relevant for folks who are doing testing.

The thing that you said earlier, I want to talk with you a [00:09:00] lot about this lifestyle practice. It’s clear that that’s really important for you. I’d like to get into it from, for folks who are doing testing for sure but before that, can you describe, what your practice looks like right now? How have you done that in your personal life?

Kelly: Yeah. About two years ago, I sold the assets to my private practice. I took my clients virtually. I don’t take any new therapy clients. I work Tuesday through Friday. I drop my kid off at school. I get home about 8:30 AM and I finish at about 12:30. Sometimes I’ll have a therapy session till 1:30 PM or 2:00 PM and then my daughter gets home at 2:45 PM. So I work maybe 20 hours a week, if that, and then the rest of the time is with my family and like you said, on [00:10:00] the roller derby track.

I’m of the mindset that there’s a lot of stuff we do that we don’t need to be doing. Over the years, I’ve been trying to figure out what’s essential and what can be left to the side because, especially when you’re in your business, you want to do the things that generate income, not that generate stress and busy work. Sometimes there’s a crossover, but oftentimes there’s not.

I used to be a workaholic. I pride myself, I used to work 60 to 70 hours. I don’t know, something ridiculous. There just came a point where I was like, this is not good. I was getting migraines and sick and all sorts of things. And so I was like, okay, what am I doing to [00:11:00] myself here?

And so that has started a journey of understanding what kind of life am I creating. The bigger picture is than just the paycheck or helping my clients, it’s the whole shebang. It’s a good practice. It’s a good flow of income but it’s also a happy life and neither should be sacrificed for the other.

Dr. Sharp: That is important. As you talk about all that, I have a lot of questions, some emotional questions, there’s some practical questions. I’ll just go back to the beginning. Can you talk through how you sold your practice? I think that’s a rare thing and if I were listening, I’d be curious about how that happened.

Kelly: I sold the assets. There are two ways to sell your practice, which is if you have a clinic where you have clinicians and everyone’s going to stay there [00:12:00] and keep their clients, then you could sell your practice, versus me, I’m not going to sell the clients I have to whoever’s buying.

I had a website that I had established with really great SEO. I had a good call volume. I had certain things that were in place to get things running. I had the office set up, and all of that was taken care of. So when I say assets, I sold the website, I sold the marketing materials that were created and the furniture and all of it, so that I just walked away.

I had an attorney draw up the contract and then the promissory note and all that kind of stuff. So I relied heavily on an attorney to determine how to do that. And then there are some things like looking at the website and the call volume that [00:13:00] you could do a projection and then turn that into value. So that’s something that the attorney helped me with versus I think there are people that do sell larger practices or clinics.

Let’s say you’ve got some established processes and you have other people working underneath you and stuff like that isn’t going to really change. Someone’s going to come in and manage that all. You could sell that differently than what I did, which was just an asset.

Dr. Sharp: Got you. That’s interesting. I’ve not heard of the second way. I haven’t heard of just an asset sale. So it’s really curious to me. Huh?

Kelly: So then you think about what are your assets in your practice? You’ve got your testing materials, maybe you’ve got some other kind of assessment tools but there’s other things that you could be creating [00:14:00] like your website and your marketing and the other kinds of things. You may even have a process that’s unique in how you do your testing that’s proprietary. So there’s lots of different things to be thinking about.

Dr. Sharp: Interesting. So any of that, what you might call intellectual property would fall on that.

Kelly: It can. Yes.

Dr. Sharp: Okay. I’m thinking about the folks I know in private practice who do testing, a lot of us do have, I’m not sure if proprietary is the word, but we’ve definitely developed systems for doing testing and being efficient in writing reports, and that kind of thing so there may be some transferable assets there. It’s funny to think of it that way.

Kelly: Yeah. This happens with attorneys and things like that. I do think, why don’t we see that as therapists? I think therapists often are in their practices long-term past [00:15:00] retirement. Sometimes they do it into their 80’s, which is great about this work.

We’ve not been the most business savvy, let’s just be honest but if you look at a doctor’s office, medical clinics, attorneys, or other fee for service kind of providers, this is a common thing. And so we need to get our businesses up to the place where we can do those things.

Dr. Sharp: Mm-hmm. And something that I think is important in that process is I’ve heard people say, you have to work on your business and not in your business, and so being able to have a space to step back and re-evaluate how you’re spending your time and having time to look at your processes and not just be flying by the seat of your pants and just working all day.

Kelly: Right. [00:16:00] I think that being a neuropsychologist, a testing psychologist, you have a bit of an advantage in terms of, it’s a little bit more like somebody can come in and be you for the day. Could that happen and would it have a huge impact on the outcome of what you’re doing?

If you’re doing a testing battery, for example, you tell me, if you were sick one day and another psychologist came in and said, I’ve got this session, I’m going to do the testing for you, could it still be great or is what you’re doing so unique that nobody can do what you’re doing? I’m asking, teach me.

Dr. Sharp: Totally. I would like to think, of course, I have enough ego to say, of course, I’m unique and do a unique interpretation of all the test results but no, especially with the test administration, [00:17:00] at least in our practice, we run what I would call a tech model where I employ graduate students to administer the tests.

Kelly: Exactly. So that is a kind of model, though, that’s easily transferred to another psychologist to run. You know what I’m saying? Versus someone who’s butt in the chair doing the therapy, if I called in sick, someone could replace me, but it’s such a unique relationship and the process is so different versus like if you were just supervising all these other people, that’s something that someone can come in and help with. So I think there’s a little bit of an edge in terms of growth and potential of those kinds of things of sale and if you ever wanted to consider that. I could be totally wrong.

Dr. Sharp: No, I think there’s a lot of truth in what you’re saying. It feels relevant for me right now because [00:18:00] I just hired another psychologist to do what I do, which is pediatric assessment, which would give me more time to step away and do more of the administrative pieces. I’m going through this process of how I or how we as a clinic start to bring clients in who not just want to see me but want assessments through our clinic because that has a good reputation too.

Kelly: You bring up a point, maybe that’s more of a distinguishing factor when it’s less about the I and more about the we, then you know you’ve got something that can transfer around and has other growth potential.

Dr. Sharp: Yeah, for sure. I like that we got into this because I think testing is, especially if you’re doing fairly comprehensive lengthy batteries, it does lend itself to bringing on graduate students or [00:19:00] other psychologists to help and so there’s some real practice growth opportunity there.

And so even for folks who might be listening, who are maybe fresh in their career or just trying to add some assessment services, I would say it’s important to be thinking down the road and thinking is that something that you would ever want to consider? It’s a good business model.

We went off there for a little bit but it’s great. I wanted to ask you, though, you said something earlier about you had to figure out what was essential in your life and how that played into the work you’re doing in your practice. Can you speak at all to what kind of process you went through to figure that out for yourself?

Kelly: Yeah. It’s really funny. I made myself an experiment. I follow two things, there’s the Pareto Principle. I don’t [00:20:00] know if you’ve heard of that where…

Dr. Sharp: Is that the 80/20 Rule?

Kelly: Yeah, the 80/20 Rule. So I started stopping and looking at what I was doing and seeing, like, do I know that this contributes to the business? In different aspects of my life, does this better my marriage? Is this a great time with my family? So I just started looking at what I was doing and a lot of the time I didn’t know. So if I didn’t know, and if I didn’t love it, I got rid of it.

Dr. Sharp: Do you have examples of that?

Kelly: Yeah, I’ll talk in business terms since we’re talking about business primarily. So for example, why do when I wake up, I check my email? Why do I check my email multiple times a day? Why?

In boot camp, I encourage my boot campers to do this thing called RescueTime. It’s an app you can put on [00:21:00] your computer and see where your time is going. It’s like, how much of that email contributes to the bottom line? None of it. It’s a lot of back-and-forth stuff. It’s a lot of scheduling. It’s kind of a waste. It’s just like fluff.

And then if you apply that Pareto Principle to Parkinson’s law, which is, that work expands to fill the time available for its completion. If I set aside, okay, after I do my most creative activity in the morning, so this is another thing, I started realizing that the stuff I gave my first-morning attention to was the most mundane noncontributing stuff.

So I started to get rid of the email. I started to get rid of social media and then I started to replace that with time with my family and then after my daughter’s at school and stuff, I read, [00:22:00] I write. So it’s balancing and I would just play with it.

As my daughter has grown, my schedule has changed. It doesn’t look like it did four years ago, of course, when she was a baby. I am starting to a lot of what we do isn’t necessary and it frees up more time to be creative and enjoy what you’re doing. So the email was a big one. Social media is a big one. Those are big tech sucks for me. So I handle my email very differently than a lot of people. I don’t …

Dr. Sharp: Did you outsource it or eliminate it?

Kelly: I have two email accounts. I outsource the big one and my assistant writes a summary for me. So I have one email to look at. I go through and I [00:23:00] type the responses and she sends them off for me.

So I have one email a day from my main inbox to look at, and then my personal inbox, which I check twice a day. And I really don’t need to, but right now I’m in the middle of a launch, and so I just get a little bit anxious. I’m giving myself some compassion, and that’s what I do.

I get it down to just what’s essential. You’ll find you have a lot more time. And then what do you do at that time? You can be creative, you can do other things and expand your business or expand your personal life, that kind of stuff.

Dr. Sharp: Absolutely. Gosh, when you say you have one email to look at a day, I melted inside. That sounds amazing. How could we do that?

Kelly: You get an assistant and you teach them like, okay, these kinds of emails you archive, these kinds of emails, you can handle that. These kinds of emails, I need to see, send me a summary once a day. [00:24:00] And she sends it to me four times a week. So four emails from my huge main inbox summarized into a sheet of paper.

Dr. Sharp: I would just jump in and I haven’t talked about the value of an assistant on the podcast with testing, but that reminds me that having an assistant, whether it’s a virtual assistant or someone who’s in the office, has been one of the best investments I’ve made for our practice and for me personally, ever. It’s been a huge deal.

Kelly: If you’re listening and you’re thinking, I can’t afford an assistant, okay, well, then limit your email to once a day, check it, set a timer, 30 minutes, whatever you get to, you get to. And you start to teach people, I think we live in a society where we text and we expect an immediate response. We email, we expect an immediate response, but people will [00:25:00] learn like, oh, Kelly, she’ll respond tomorrow. She only checks her email once a day, like they start to learn.

So we have to teach people how to treat us, even in our business, not just our personal life. This is a boundary in business too. So if you’re feeling like I don’t have someone that can help me, well, you need to start parenting yourself and kind of limiting the stuff that’s distracting you from doing what only you can do, which is the work. That’s what’s unique and special. Do more of that.

Dr. Sharp: Yeah, for sure. I know I can just hear folks who are listening and one of the big things is they’re probably saying is, in testing, we have to write these reports and everybody I talk to is like, I hate writing reports. That’s my least favorite part of the deal, but it’s necessary. That’s our product. That’s what happens.

So I’m going to totally put you on the spot. I know you don’t do testing, [00:26:00] but you work with folks who do testing and have complained about report writing and how that takes up so much time, how can you streamline that or do time management around that?

Kelly: One of the things is I do teach eat the frog, do the stuff you don’t like to, the more you put it off, the more painful it becomes. I think also there is some mindset workaround that needs to be done. It’s interesting. You pick your niche around something you hate, the major part of it that you hate, like what’s going on there? I’m just curious, why go this route then if this is what you don’t love and figure out how to frame what these reports mean? I think we don’t love stuff when it lacks meaning.

And when you do something like reports over and over [00:27:00] again, it can start to feel monotonous, a little tedious. And so I think getting back and pulling back a little bit, getting up in the air and looking down at it and saying, okay, what is this that I’m creating? What does it mean to this person? How can this impact the person’s life? That can be very motivating.

And then the other side is, are there things you can do to make it fun? I don’t think sitting and writing your report for hours is a good idea. Think about your brain, especially if you’re a neuropsychologist, people, you know that your brain gets tired. You need breaks.

One of the things I teach is like the Pomodoro method where you can set the timer, do two tomatoes worth of, if you don’t know what that is, if you take a break, have a dance party, put on music, what can you do to make it more enjoyable?

Maybe there is something that is [00:28:00] hard about it that you struggle with, but can you make it more fun? Can you make it more peaceful? Do you need to change where you’re writing it? How you’re writing it? Do you need to dictate it? Those kinds of things too.

So there’s the bigger picture of your why that’s always good to go to. And then moving into some of the tools that you use and your environment and seeing how you can shift the process so that it’s not so painful.

Dr. Sharp: Those are fantastic ideas. It’s gotten me thinking, I did an episode on technology and testing, I know for me, I love technology. So I just recently started to dive into this tool called TextExpander, I don’t know if you’ve heard of that or not, it’s a piece of software that lets you [00:29:00] type in lengthy paragraphs, things that you type a lot and then you condense it down into a shortcut. So you just have to type the shortcut and then it auto-populates the whole paragraph.

And so that is interesting. Just being someone who loves technology, has made report writing fun for me again, because now it’s like this challenge where I have to figure out how to program it into text expander and make it …

Kelly: That’s like the ultimate geekery. I love it. People that don’t do testing, their struggle is even notes, they don’t get them done. And so having these processes and templates and tools is awesome. I love that you found that helps you.

Dr. Sharp: Yeah. It’s got me thinking too that, and this is a process I’ve gone through with your question of why are you doing something that you don’t like. And that idea of bringing meaning [00:30:00] to it is really important.

For me, I’m thinking, picturing how important this is for the family to get this assessment and get these results, in the past, I’ve rewritten all of my recommendation templates just to stay fresh and make sure it’s relevant for the families that I’m working with and that can help switch things up.

Kelly: For example, we have informed consent and all these kinds of things. It’s funny when you read them, they’re so dry, like this is the expectation. This is the cancellation policy. One of the things I teach in boot camp is why can’t we make this more relational? Why can’t it be something that’s giving and helpful to the person?

So like even my social media policy is written in my voice and my way [00:31:00] that connects. And so I think reports can be too. I know you guys have limits, you’ve got numbers and stuff you got to put in there. I just read one last week for one of my clients, which was great. It was helpful. It helped me be a better therapist for her, but I think too, even the way you write it, and the words you use, you have a chance to make a big impact beyond just the statistics or the results.

Dr. Sharp: Absolutely. I wonder how much we feel constrained …

Kelly: Right, why are we? Who set that rule up? We need to start asking this stuff a little bit more because otherwise, we’re going to get left behind. I feel like we need to stay relevant then in terms of understanding, why we do this. If you don’t like it, then you start figuring out why or what could be done differently and [00:32:00] still be of service and of benefit to those that you work for.

Dr. Sharp: We’ve talked a fair bit about balance and finding what works for you in your life and integrating that with your business. Are there any tools, Kelly, that you have that can help people sort through that and start to figure that out?

Kelly: I think one of the things that someone could do right now or after they finish listening to this is to go through what I call the Perfect Day exercise. Lots of people do this in other industries, but you guided meditation. There’s one on our website where you close your eyes and you walk through your perfect work day, not like sitting on the beach in Bali not working, unless you are working in Bali, awesome, good for you.

It’s basically from the time you wake up to the time you go [00:33:00] to bed, what does that day look like? I’ll give you an example, when my first one started with, the alarm goes off at, or no, the alarm didn’t even go off. I just woke up naturally at eight o’clock in the morning. That still is never going to happen because I didn’t know my child would wake up at 5:30 AM every morning but anyway, this is my perfect day. So I’m going to admit this is what I want.

My feet touch the wooden floor. I look out the window and I see trees and birds. And then I go through the whole day; what I ate, who I talked to, what am I doing? Who am I seeing? Who am I interacting with? All of it, every detail, and then you get a sense of like, okay, this is what I want.

One of the funniest things was I was not doing a lot of therapy. I was like, oh-oh, [00:34:00] what’s going on? I’m building a private practice and I’m not doing therapy on my perfect day. What the heck?

And so when you give your brain permission to be creative, it starts to think of things outside the box. So then you have an idea, okay, what could you do one step towards that perfect day? You may wake up an hour early. You may sleep in an hour late. You may change what you’re eating. You may just shift the times that you see your clients.

Whenever I help people psychologists go through this process, they oftentimes are like, I’m doing a lot of stuff I don’t want to do. I’m seeing a lot of people because I feel like I have to. And so then they start to shift their business and their marketing around and start playing with the idea of, oh, do I have to work evenings because I see kids? Do I have to work the weekend because I see families and then they [00:35:00] start challenging these stories and start more aligning with that perfect day?

I have a lot of my perfect days so I do this at least on an annual basis and just check in to see what I want to change. It’s not like it’s an endpoint, but it’s more like that process of as you’re growing, so is your vision for your life and being sure that you’re giving that some nurturance and attention.

Dr. Sharp: Yeah. I know that was a brief description, but I feel like that captures so much. Is there a place that folks could find that? You said there was some resource on your website to go through that exercise.

Kelly: We have tons of free training on our site at zynnyme.com/event and it’s in one of the webinars. It’s a private practice vision webinar and we take you through the process.

[00:36:00] Dr. Sharp: Okay. That sounds good. I’ll link to that in the show notes for sure, for folks who want to go check that out. Just that little brief snippet of the perfect day, this has been really good for me. I’m thinking through how that fits and I imagine a lot of other people are too.

From a testing perspective, this has got me thinking too, about maybe talking about that later down the road too, because I imagine, some of us go through that perfect day exercise and find aspects of our practices or maybe write reports that don’t fit, and there are some ways maybe to address that.

Kelly: I think so. I think there are lots of options and we only can discover them if we give it time and some attention.

Dr. Sharp: You’re right. Well, this has been fantastic, Kelly. I appreciate your time and the things that you have talked about [00:37:00] today. I’ve said many times, taking notes and thinking about changing some things here for me.

Kelly: Wonderful.

Dr. Sharp: There’s our two.

Kelly: Thank you for having me.

Dr. Sharp: Oh gosh, of course. This was great. If people want to learn more about you or ZynnyMe or coaching, what’s the best way to get in touch with you?

Kelly: Yeah. You just go to zynnyme.com and you can check us out there. If you want to know about me, I also have kellyhigdon.com, but if you’re a psychologist, you’re probably going to be most helped over at zynnyme.com.

Dr. Sharp: Got you. And just for anybody listening, zynnyme is zynnyme.com, right?

Kelly: Yeah. What a mess.

Dr. Sharp: That’s a whole other conversation, where did that come from?

Kelly: Yes. That was a marketing lesson.

Dr. Sharp: Fair enough. Well, thanks so much, Kelly. It was great to talk with you and take care.

Kelly: You too.

[00:38:00] Dr. Sharp: All right, welcome back, and thanks for listening to that interview with Kelly Higdon. Like I said, during the interview, there were so many times when I was writing things down and thinking about what she was saying.

I spent a lot of time reflecting after our talk on what my own practice looks like and just trying to walk through and think about those things that might not be ideal. I like that Kelly introduced the idea that we don’t have to do things we don’t want to do, which is a novel concept, as we’re building a private practice. It’s easy to slip into this pattern of just doing what we think we have to, and that’s not always the case. So that was valuable for me to be thinking about.

Thanks again, as always, for listening. This is fantastic. I’ve enjoyed talking with so many great folks over the course of these podcasts and continuing to learn about things [00:39:00] that I don’t know about and getting to meet and connect with all these wonderful people, and I hope that y’all have too, I hope you’ve enjoyed these conversations.

If you have, I’ll be very grateful if you do any amount of promoting that feels comfortable for you. So you can rate and review wherever you listen to your podcast. You can share the podcast with your colleagues and peers. You can share it on Facebook, you can share it on your blog, really anywhere that feels okay for you and all of that is very appreciated.

So as I’ve said, I have a lot of cool interviews continuing on the horizon, so stay tuned for those. We’ll catch you next time. Take [00:40:00] care.

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[00:00:00] Dr. Sharp: Hey everyone, it’s Dr. Jeremy Sharp. Welcome to The Testing Psychologist podcast episode 27.

All right everybody, welcome back to another episode of The Testing Psychologist podcast. Good to be with you again as always. I hope that all of you are doing well, enjoying the summer, having some vacations, having some fun, and also maybe taking a little time to reflect, grow your practices, adjust things, and keep moving in the right direction.

Right now, I’m excited. I am standing at my desk, that’s right, standing at my desk. I got a new standing desk, which has been awesome as [00:01:00] far as I’m concerned and it’s made a huge difference in the amount of work that I get done. As a lot of us do, I have had some trouble in the past with sitting and getting reports done, and working for extended stretches, the standing desk has made a huge difference.

I’m using the VariDesk version. I know there are a lot of standing desks out there, but mine is a VariDesk and it’s cool. It sits right on top of your regular desk and then there’s a hinge system that you operate and it lifts itself. It’s easy to put back down and it’s made a big difference.

So it’s just a quick point of excitement for me. I’ve talked in the past about how you got to switch things up a little bit sometimes to keep things fresh with testing or else writing reports just gets so old and tiring. And so this is one of those [00:02:00] things, it’s a small thing but it’s made a big difference so far. So I’m pleased with it.

Aside from my standing desk though, we have some other things to talk about. Today, I’m doing a solo episode all about how to outsource in a testing practice. I think this is a really important topic that is pretty near to my heart because this is an ongoing process, certainly. I would not say that our practice is completely outsourced and optimized at this point, but I have had quite a journey over the years with going from doing everything myself to now having a lot of quality people and services in place to help take some things off my plate.

So when we think about outsourcing, I think that a lot of us start off by ourselves in solo practice and due to money or maybe having the [00:03:00] time to do it or maybe due to not trusting that others can do things as well as we can, it can be a long process to think about outsourcing some tasks in your testing practice.

And this was definitely true for me. I’m almost ashamed to admit that it took me about five years of being in practice before I started to outsource some of the administrative tasks. I’ve talked in the past about how I hired psychometricians pretty early in the practice to help with administering some of the testing. And that was a big deal. That freed up a lot of time for me, certainly.

But as far as the administrative side, that took me much longer to decide to hire someone else or get some help with some of those tasks. Just to set the stage a little bit, I looked back at some emails with my original admin [00:04:00] assistant and it was 2014.

I had been doing everything myself up to that point. So answering the phones, doing the billing, doing the scheduling, doing all the clinical work with writing reports and testing and interviews and things like that. Doing my accounting, my website, and marketing. So there had been a lot on my plate for five years.

I finally got to the point where I was, I think the breaking point was spending so much time on the phone with insurance companies because we were getting a lot busier. I’d hired a postdoc at that point. So we had officially become a group practice. There were multiple clinicians to be working with. And the administrative tasks, particularly the insurance piece just got out of control.

So I finally took the leap and put out an ad to find someone to help me tackle some of [00:05:00] these office tasks. At that point, I don’t think I had a great idea of what I was looking for aside from I knew that I needed someone to help me return my phone calls and check insurance benefits. Those were the two main tasks that I was like, I have to get rid of these. This is taking too much time.

So I put the ad out there. I put it on Indeed. I got a few applicants right off the bat. I was so excited. So I interviewed, I selected someone. My first applicant, she was so kind. She was a kind graduate student. She came to work the first day. I sat her down at the computer and told her what I thought was an accurate description of what the day’s tasks would look like.

Looking back, [00:06:00] that was not the case at all. It was terrible and it was vague. She, I’m sure, had no idea what to do. I basically told her, okay, so here’s some clients, here’s their insurance information, I need you to call and verify these benefits. And if the phone rings, just answer the phone. Here’s how you’d answer it and give me the messages. I don’t know if it was exactly that bad, but it was pretty close.

So she worked one day and then quit. I was disappointed, to say the least. I liked her and thought that she had a lot of potential, but it caused me to think about what I may have done in that process to contribute to her taking off so early.

And so I’m sure you’re guessing from the description that I could have been a lot clearer with job tasks, expectations, [00:07:00] training, any number of things could have been so much better. Luckily, I had a second applicant. This person was pretty amazing. Her name was Michelle.

I remember Michelle very fondly. When she ended up leaving after about a year or so, we had this big dinner and sent her on her way off to her next adventure. She was a graduate student in counseling. I said, Michelle, thank you so much for showing me that I could trust someone with my practice. It was a nice moment.

Michelle was incredible. Like I said, she was a counselor in training. She was kind. She got along with everyone. She had that gift of being able to talk on the phone without being awkward, which is a mystery to me, to be honest. She was super patient. She was able to roll with it when things were [00:08:00] not as well defined as maybe they could be from my side.

So that was my first foray into bringing on an admin assistant. I learned a lot along the way. So I wanted to talk with y’all about a few different aspects of outsourcing in a testing practice and how we might go about those things and some key tasks to outsource and how to do that.

When you’re thinking about outsourcing in general, the reason to do that boils down to having more time, so freeing up more time to do whatever you want to do. So that might be more clinical work, it might be being off with your family, it might be reading, studying, getting better at what you do, but either way, I think outsourcing is a great way to free up more time in your schedule.

The further I go in my practice and in my [00:09:00] career, the more I am settled on this idea that I wish that I had outsourced much sooner rather than let the administrative tasks fill up any extra time I had in my practice at that time. I wish I had just done it right from the very beginning and save myself all that time.

And so at this point, I’m a big proponent. I talk with my consulting clients a lot about outsourcing as early as possible and different ways to outsource. So that’s just my bias, and particularly with testing, I think that’s important because it can get so wrapped up in the time it takes to do evaluations and it goes by quickly. And the time gets eaten up quickly. And so being deliberate as early as you can about outsourcing and ways that you can do that.

So in those tasks that you might think about outsourcing, I [00:10:00] named a lot of them earlier, but it might be things like answering the phone, billing, scheduling, writing your reports, doing your accounting, doing your website, doing your marketing, the testing itself, you have to look at what things you are doing because you like to do them versus what things you’re doing because maybe you’re afraid someone else won’t do it well or you think it costs too much money to outsource it or one of those other reasons. And so that might give you a good idea of where to start with outsourcing.

So when you think about getting started with outsourcing, maybe you’ve identified some areas that you don’t want to do anymore. It doesn’t bring you joy. You are willing to take the leap and let someone else try it. I would advise taking at least two weeks before you put out an ad, before you [00:11:00] interview, before you bring someone on, take two weeks and start to write down everything that you do in your day. It’s important to be very literal with this log that you’re going to keep.

So everything that you do. You don’t have to talk when you check Facebook or whatever you might do like that but work tasks. Write down how long you spend on your notes. How long are you spending on testing? How much time are you spending on the phone? What do you say when you’re answering the phone?

What do you subconsciously or consciously have as your expectations when you are interacting with your clients? How much time are you spending on scheduling? Do you do your own billing? All of those pieces. So you get the idea to start with writing down just about everything that you do and trying to track not only [00:12:00] the time that you spend on those tasks, I think that’s important, but also tracking almost literally exactly what you say.

And the reason that I highlight that is because for me, developing scripts has been a huge part of outsourcing. I’ve joked around before in a not-so-joking way that I’m a bit of a control freak and so for me, it was scary to think about outsourcing answering the phone. I was thinking there’s no way that a non-psychologist could explain the testing process and sell that process to potential clients. There’s no way somebody could do that. I am the only one that can do that effectively.

Of course, that’s ridiculous. I’ve learned that since then, but one of the big things that helped alleviate my worries [00:13:00] about that early on was to write scripts. I sat down, and you could do this any number of ways; you could record yourself when you’re on an actual phone call and then transcribe it.

Speaking of outsourcing, you can go to a site like Upwork to transcribe audio recordings. You wouldn’t even have to do that yourself, but you can transcribe a phone call. You can simply sit down and imagine a phone call in your head and type out what you would say. Be as thorough as possible pretending that you’re having that conversation right there live and document everything that you would say in that phone call.

What I found after I did that was that naturally led to a bit of an FAQ section in terms of what clients typically ask, questions they had, issues that came up during those initial [00:14:00] phone calls. And then that led me to write out even scripts for some of these FAQs.

So that was one of the things that was really helpful for me when I thought about how to outsource answering the phone. So I wrote out a ton of scripts. I did walk through it with Michelle when she first came on and with my admin assistant after that.

The way that I did it, two times, I let her sit in and listen to me answer the phone and go through it while she was looking at the script so she could compare and contrast what I was saying with what was on the page and start to adapt it to her own words. After that, I let her take two phone calls while I was listening. We had a setup there where she could look at me and I could tell if she needed to know an answer. We had the [00:15:00] phone close enough where I could hear what the clients were saying.

So she took two calls and then I had confederates; relatives and family members call in and pretend to be a parent asking about testing for their child. And then they gave me feedback on how they thought she did. So as far as outsourcing answering the phone, that is how I went about it. Like I said, the script was super important.

Let me back up, before I totally leave answering the phone, I think that this is one of the easiest areas to outsource both in terms of logistics, so it’s very easy to write out a script but also in terms of cost. So there are any number of virtual assistant services that you could contract with.

There are a lot of folks at least here in our area [00:16:00] that would serve as a virtual assistant but local. So these are individuals who would like a stay-at-home job but they just have your practice phone or you set it up where the phone number rings to their phone. It’s easy to find folks to do that and it’s pretty cost effective.

I use Conversational, which has come up on some other podcasts for mental health folks and they do a great job. Right now, they handle our backup, and our overflow phone calls and they do a great job and it’s very cost-effective. And so you can potentially check that out.

I’ll just say that if you outsource anything, I would think about outsourcing your answering the phone pretty early on. I also think it lends quite a bit of professionalism to your practice. A lot of us who do testing, there’s a bit of a medical overlay to it where it’s a little more formal and there’s a level of professionalism that [00:17:00] we might want to represent and having an answering service helps with that. It’s like a real “doctor’s office”.

The next thing that dovetails well with that is, I’m going to skip billing for a second, but go to scheduling. I think scheduling is pretty easy to tie in with answering the phone. Those naturally go hand in hand.

If you have someone who can answer the phone, assuming you don’t want them to just take a message and pass that along to you, but if you want to go that next step, which I totally recommend, you can have them do the scheduling as well.

At least in our EHR system, which is TherapyNotes, it allows you to have an administrative account for free. So individuals can access the schedule and the billing. So that’s great. That’s a cool feature. You can give someone access to your EHR, I would imagine others have that feature as well. [00:18:00] They can set your schedule.

I am someone who has had any number of different schedules over the years and so my admin assistants have had to be pretty flexible in terms of keeping up with my schedule and my expectations for the schedule. This is a place where scripts and guidelines come into play. This is a place where it’s important to communicate your expectations.

In my case, it was things like, I only want to do three intakes in one day, no more, or I cannot go more than four hours without a break. I have to have at least 30 30-minute break somewhere in there, or I don’t like to see clients the last hour of the day so that I can return phone calls and do notes. So setting guidelines like that and setting the expectations [00:19:00] is super important. If you can do that, if you can nail that down, then be as explicit as possible, then that’s a great place to turn things over to people.

The one place that I still retain a little bit of control over is the scheduling of testing appointments only because it depends on the client and how much time they’re going to take. I suppose there are certainly a way that I could turn that over to our admin assistant, but I like having that interaction with parents at this point, just to describe what the testing day will look like and answer any questions and then it flows naturally to scheduling the testing day, but you could totally do that.

I think another big area that a lot of you might be wrestling with is billing. I have certainly wrestled with outsourcing the billing for a long time. [00:20:00] To be honest, I’ve taken baby steps over the years with outsourcing the billing. I’m still not totally there.

The solution that we have in place now is that we have, and this depends on if you take insurance or not, but we do take insurance, a lot of it. One of the big steps that I took was to have someone come onboard to verify clients’ benefits and coverage before they come in. I cannot say enough for how much this has made a huge difference in our practice mainly in terms of collections and getting paid for the work that we do.

With testing as you know, some of those outstanding bills can be pretty big. Testing is expensive even with insurance sometimes. What I was running into is that I would tell people on the phone that they were responsible for checking their benefits. They would say they did [00:21:00] or forget. I wouldn’t always ask about it. And then we ended up with many cases where clients owed more than they thought they would or maybe they never even had an idea of what they would owe which was my fault for not communicating it.

Anyway, you see where this is going. So we ended up with a lot of outstanding bills and I had to go through all sorts of acrobatics to figure that out. So getting a company to verify insurance benefits before clients come in has been so huge.

We work with a local company, they operate nationally and they happen to be local, but they are so good with calling, verifying coverage and benefits, and knowing if we need pre-authorization for testing or don’t need pre-authorization. They can sometimes get a handle on how many hours of testing are approved and it’s very cost effective. It’s something like $4 or $5 per patient and they turn it [00:22:00] around in 24, maybe 48 hours at most.

I’ve used that effectively to guide a conversation with clients in the initial intake about here’s how much testing is going to cost, here’s what you can expect, will that work for you? Here’s our payment schedule, things like that. Oh, it helps so much with collections and making sure that we’re getting paid for the work that we do.

I’m in the process now of transitioning over to a full billing service. When I say full billing service, I mean, totally handing over verification of benefits, submitting insurance claims, sending out bills, collecting bills, sending multiple statements, and eventually taking people to collections if need be for unpaid bills.

Up to this point, we’ve done it in-house. Our office manager has handled that task and has done so very [00:23:00] well but as we continue to grow, I found that the office manager is a lot better suited to other tasks around the office. And so I’m looking into a full-service billing company.

Billing companies will generally take between 6% and 9% of the total collected. It should be a pretty seamless process when you’re looking around for a billing company. Many of them have software or ways to integrate with your EHR. Many EHRs have ways to print off reports and client information so that you can easily transfer that information to the billing company to submit claims and keep track of balances and things like that.

I think this was huge, obviously. I can’t remember if I’ve talked before about some of our troubles with collections in the past, but there have been times when I’ve looked at our [00:24:00] 60-day overdue aging statement and it has been in the tens of thousands of dollars and have a bit of a freak-out moment. And that has led to a number of changes over the years.

I think billing is super important to help you run your business and make sure that you don’t feel like you have to work all the time because it’s a vicious cycle; if you’re not collecting the money, then you both spend time trying to collect the money. And if you’re like me, it felt like you had to work more to make up for the money that you weren’t collecting. So it was like burning the candle at both ends. Billing service, even though it seems like a lot of money, I resisted for a long time thinking that they would take 8% or 9% of our total collections, but when you do the math, it totally makes sense.

Those are the two main areas when I think about outsourcing. We could talk a lot about accounting [00:25:00] and website and marketing. We could go into each of those in a lot of detail. I will cover them a little bit more quickly here simply because I haven’t dove into those as thoroughly as the first two topics.

With accounting, I think that’s really easy. Of course, you have an accountant or you should have an accountant. Most of them will give you the opportunity to share your books with them. So QuickBooks Online, it’s about $20 a month. It on the one hand makes accounting so much easier so that when you get to the end of tax season, you have all your numbers right there in front of you. You don’t have to go combing back through credit card statements and receipts and all that kind of stuff.

I consider outsourcing because it is offloading a task that you would otherwise have to do to an external source. [00:26:00] I use QuickBooks Online. I do share it with my accountant. Many accountants will “do your books” for you each month where they reconcile payments and deductions and credits and all of that kind of thing.

I would totally recommend it again. The time that you would spend on it is not worth the time or the money that you would otherwise make. So that’s one option for accounting.

Website-wise, I know that websites have been covered ad nauseum on other podcasts or in different Facebook groups, but there are a ton of really easy, do-it-yourself options for websites. If you want to totally do it yourself, Squarespace and WordPress are great options, but we’re talking about outsourcing. So unless you’re really good at websites or you like doing it and [00:27:00] you’re willing to say, I’m going to trade clinical hours to do my website, then you maybe should look at other options.

One of the big ones here in the mental health world is Brighter Vision. Kat Love also does websites specifically for therapists. These folks, like I said, they’re very specific to the mental health world and they provide a great service. SlapShot Studio is another one. I use Legendary Lion.

There are a lot of options out there for folks who can do websites for therapists and can do a really good job.

And again, the likelihood that you would pay someone as much as you would make is very unlikely. People balk at the cost of a website, but there’s so many options out there to just do it.

I think you need a website of some sort. We’ve talked about that before in other episodes, but [00:28:00] finding some way to outsource that website creation is super important. So a lot of services, Brighter Vision, I know does a monthly fee of $59. For a lot of folks, it feels a lot more doable than a one-time fee of say $1,500 to $2,000. Either way, weigh it out, figure out what works best for you, and go that route.

Same thing with marketing. When I say marketing, I mean online marketing or print marketing, I’m not talking about the kind of marketing like networking. I don’t think you can outsource that. I haven’t found a way to do that, nor do I want to, I like meeting with people.

In terms of online and print marketing, this is an area I learned the hard way that it’s really easy to lose a lot of money very quickly if you don’t know what you’re doing. I can’t remember if I’ve told the story, but there was one point [00:29:00] I was trying to get some clients for a men’s group that I was doing and I put up a Facebook ad. I was really proud. I got so many clicks on this Facebook ad. Of course, clicks on a Facebook ad mean paying money for those clicks and I paid a lot of money really quickly and didn’t get a single client from that Facebook ad.

So if you think about online marketing or print marketing, it is definitely worth outsourcing the setup to someone who actually knows what they’re doing. Alternatively, you can spend the time to learn how to do it, but just know, you have to spend the time to know how to do it because it’s a science in and of itself and you can do a bad job easily.

Lots of resources, there’s a Facebook group for online marketing for therapists. Michael for Micah does a lot of this. I think John Clark at Private [00:30:00] Practice Workshop has an SEO and online marketing team. Two great resources to outsource marketing.

Aside from that, we’ve talked in other podcasts about how to outsource the testing itself as far as report writing, therefore a long time, I had graduate students or undergraduate students writing the clinical histories. They would take my clinical notes from the intake and write up the histories from those, type them up or transcribe them. That worked really well.

Over time, I’ve circled back around where I’m writing my own histories because I’ve gotten efficient at it and that time versus money trade-off doesn’t make quite as much sense anymore. So I do write my own histories now, but if you don’t have a [00:31:00] graduate student doing it, and that would be a great place where scripts and expectations are very important. I use templates. I used to do as many dropdown options as possible so as to keep things standardized.

If you don’t want to go that route, I would consider dictation software, a version of outsourcing. It does make things a lot quicker. Of course, a lot of you have run across dictation software and Dragon is a big one.

So testing itself, I’ve covered that in other podcasts, but certainly worth considering psychometrician work if that fits with your philosophy and with your practice model. And just to put in a plug that if you do go the psychometrician route, that I think almost more than anything else is a place where the scripts and the expectations and the standardization process is so important.

I talked in a previous [00:32:00] episode about how we hire and train our psychometricians. You can refer back to that episode if you want more information with that, but I’ll just leave it today by saying that that’s one of the places where standardization is obviously important.

I hope that you have enjoyed and learned a little bit from this episode around how to outsource in your testing practice. Many of these things are common to a number of practices, but I think in my experience that when you do a lot of testing, there’s something about the process, the describing it to people, the billing for it, the scheduling, there are a lot of nuances that go beyond maybe a typical therapy based practice and so just a few extra things to consider as you’re [00:33:00] thinking about outsourcing.

Like I said at the beginning, my feeling at this point and my bias is that outsourcing is important. I wish I’d done it a lot earlier. I would definitely recommend that each of you consider outsourcing as early as you can in your practice. Don’t shut that door just because it seems expensive or because someone might not be able to do it as well as you can. There are a lot of great options out there.

As always, thank you for listening so much. I’m going to be out of town the next two weeks, so there is a chance I may not be talking with you for two weeks. One of those trips, like I’ve talked about before, I’m really excited about. I’m going to upper Michigan to Traverse City to hang out with Joe Sanok, Kelly Higdon, and a bunch of other cool people for Slow Down School. We’re going to do some business coaching and practice [00:34:00] development work. I’m really excited for that.

So I may not be able to record a podcast for the next two weeks, but either way, I will look forward to talking with you the next time that I do. In the meantime, if you would like to connect with others doing testing, please come check out our Facebook group. It’s been amazing. This group just continues to grow. We’re up to 140 members or so. We keep gaining steam.

You can find The Testing Psychologist Community on Facebook just by searching The Testing Psychologist Community. If you’re interested in doing any consulting or even trying to figure out if consulting is the right option for you, you can shoot me an email at jeremy@thetestingpsychologist.com or go to the website, thetestingpsychologist.com.

Thanks as always, y’all. Take care. Talk to you next [00:35:00] time.

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[00:00:00] Dr. Sharp: Hey, y’all. This is Dr. Jeremy Sharp. Welcome to The Testing Psychologist podcast, episode number 26.

Hey, everybody, welcome back to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp, hope you’re all doing well this morning or this afternoon, whenever you might be listening.

Today’s episode is one that I’ve been looking forward to for a long time. As I mentioned in past episodes, I have been going back and forth with Dr. Karen Postal to schedule an interview with her. And today is that day. I am very excited to have her on the podcast. We’re going to talk about a lot of different things related primarily to feedback. Karen has written an amazing book called Feedback that Sticks. We’re going to talk about some of those pieces, as well as some other things that she’s got going on.

Karen, just briefly, welcome to the podcast.

Dr. Karen: I’m very happy to be here. Thanks.

Dr. Sharp: I’m very happy to have you. Let me do a more lengthy introduction and then we can jump into it.

Dr. Karen: Great.

Dr. Sharp: Dr. Karen Postal is board-certified in neuropsychology and pediatric neuropsychology. She’s a clinical instructor at Harvard Medical School where she teaches postdoctoral fellows in neuropsychology. She is the president of the American Academy of Clinical Neuropsychology.

Dr. Postal has a lifespan private practice dedicated to helping people think better in school, at work, and throughout later life. She frequently works with students from elementary school through college to overcome barriers to academic success. She also has expertise in working with traumatic brain injury.

Dr. Postal is the author of the Oxford University Press book Feedback that Sticks: The Art of Effectively Communicating Neuropsychological Assessment Results.

Karen, once again, welcome. I’m so glad to have you this morning.

Dr. Karen: Yes. I’m really excited to talk to you.

Dr. Sharp: Good. I know that we’ve had some rescheduling bumps over the past few weeks. That’s the thing that happens over the summer. So I’m really glad that we’re able to connect and have some time this morning to talk through your book and maybe some other things as well.

Dr. Karen: Sure.

Dr. Sharp: Maybe we could start off if you could talk just a little bit about what your practice looks like right now. I know you’re doing a little bit of research as well. Could you just give me an overview of what your professional life looks like these days?

Dr. Karen: Sure. Most of my time is spent in my private practice. I see kids starting at age 6 and I go all the way up to geriatric folks, 99, 100. It’s a really varied patient population, which I like a lot. And then I teach once a week.

The research that I’m involved in, most of it has to do with how we communicate better with our patients, with colleagues, and most recently, in the court system. I do qualitative research. The book that you mentioned, Feedback that Sticks was the result of a three-year qualitative research project. My co-investigator for that one was Kira Armstrong. And then more recently I’ve been involved in a qualitative research project looking at how we communicate better in the court system. How do we share our results with jurors, judges, and triers of fact?

I also do some research on report writing. We’re in revisions with a paper, a group of assets at Harvard Medical School. We call it The Stakeholder’s Project. We’re looking at what are stakeholders in the neuropsychology report writing process. Think of what we’re doing. So we asked neuropsychologists and we also asked our referral sources, physicians, and other referrals to comment on the reports and that’s been super interesting.

Dr. Sharp: Sure. Is that the thing that you are hoping to turn into another book or what are you looking at as far as […]?

Dr. Karen: The Stakeholder’s Project, we are in a revision process with the clinical neuropsychologist. So it’s a journal article at this point. Most likely we’ll go on to survey other stakeholders including patients, patients’ families, probably school districts as well, and the attorneys: what they need, what they think of what’s valuable to them in our reports.

Dr. Sharp: Well, I can just say that I think all of that information is so relevant and very practically applicable. As you’re describing that, I’m like, please, I needed that yesterday.

Dr. Karen: I always tell people that I feel very selfish in my research because as I’m talking with colleagues about best practices for communicating with patients and writing reports, I’m really busy integrating that stuff immediately into my practice. So it makes me a better practitioner.

Dr. Sharp: Sure. Well, I guess you can make the argument, that’s the best use of research. You can turn it around right away.

I know we have some other things to discuss, but I am curious how you run a research program primarily as a practitioner. I think a lot of folks may be interested in how that works.

Dr. Karen: The genius thing about having one’s own private practice is that you can make an executive decision that it’s worth your time to engage in research. For me, I follow my passion in terms of what I’m truly interested in. And so, for me, communication has been my main clinical and research interest. As a private practitioner, I can just say, you know what, I’m going to devote so many hours of my time and essentially pay myself for that time and then engage in the research. It’s not grant-funded, I suppose I could go out and look for grants, but essentially by the time I did that, the hours and hours and hours of grant writing, I could just do the research itself.

I fund my research with my income from my clinical practice and then in turn that research gives me a platform to talk about my work and leads to more referrals. In other words, it helps people know that I am a skilled clinician. I’m just realizing the phone is ringing in the background. I’ll turn that off.

Dr. Sharp: Sure.

Dr. Karen: Oh, sorry. The research and the writing that I do help people understand that I’m a skilled clinician and it leads to more referrals. Therefore, I think it’s a wise business practice. There’s a lot of psychologists who do that. Robert Heilbroner is a great example of a clinician who’s done a ton of really wonderful work. Manfred Greiffenstein who we just lost, was a wonderful clinician and researcher. Basically, he had the same model. They were people who did a lot of very helpful work but self-funded.

Dr. Sharp: Yeah, sure. I think about it from the business side. We talk about that a lot on the podcast. I would imagine that’s certainly not the only reason you wrote the book, but it certainly doesn’t hurt either. I would imagine people read the book and probably seek you out and that’s it.

Dr. Karen: Yeah. I think it’s a smart business decision, but in a way, I get to fund my research habit with my clinical practice.

Dr. Sharp: Yeah. Well, that’s great. I admire how you and others have integrated research into your practice. I think that’s something that can get lost pretty easily once we move into clinical work. 

I am really curious, just to transition a little bit, how you came to the idea of writing a book about feedback specifically.

Dr. Karen: Well, I read a book called Made to Stick. I don’t know if you’ve come across this book. It was a best-seller in the business trade book market for two years in a row. It was wildly popular. It was written by Chip Heath and Dan Heath. One is a folklorist and one is a professor of organizational behavior at Stanford Business School. It was this genius book where they were looking at the question, how do we take boring information that is outside the framework of listeners’ understanding and make it compelling and interesting.

They gave this great example, there’s a nonprofit organization called Center for Communicating Science to the Public. I have something like that. This nonprofit is a national organization that they’re tasked with explaining nutrition information and other health facts to the American public. The authors of this book said it’s just intrinsically boring information that most people ignore, right? I mean, we all know that we should be counting calories and looking at cholesterol, et cetera, but very few of us actually pay attention to that.

This group had this breakthrough where they were supposed to explain the amount of saturated fat in the movie theater popcorn to the American public. And instead of having a press conference with some charts and graphs, they did this amazing thing. They took this banquet table and they put an entire day’s worth of disgusting high-fat food; eggs, and bacon for breakfast, a big Mac and fries for lunch, a steak dinner with all the trimmings for dinner. They put that huge banquet out and then they also put a single small movie theater tub of popcorn and they had their press conference. And they said, you could eat all of this high-fat food, or you could have the same amount of fat in this small popcorn.

I don’t know if you remember this, but I remember this. It was all over the Today Show. It’s about 15 years ago. The Heaths point out that within two weeks, the Ever Single Major Movie Theater chain switched the oil that they use to pop their popcorn too low saturated fat. It was so wildly successful. What they point out in their book and their research is that we can take even intrinsically dry boring information and make it compelling and engaging if we work at it.

I read this book and I was like, oh my God, that’s exactly what we need to do in this field, right? Here we’re sitting in feedback talking to people about standard scores and statistics and T scores and Z scores. It’s not accessible. It’s boring. It doesn’t necessarily connect with people’s lives. And if we’re going to do all this work to do an assessment, we really need to figure out how to make this information accessible, understandable, and memorable for people. And so that was the aha for me, was reading that book.

Dr. Sharp: What a story. I like that last thing that you said about making it accessible and meaningful. It is easy I think to get bogged down in a lot of the dry information and to just know what’s important to different people.

Dr. Karen: I think so. Another point that the Heaths made, and I think it’s so critical is that, as professionals, it doesn’t matter what your profession is. You could be an accountant or an attorney or a physician or a psychologist, we’re so used to speaking in our jargon and thinking with our basic assumptions that we learned in psychology 101 all those years ago, that those assumptions and jargon, it become invisible to us.

So we literally can’t see that other people have never heard our jargon or they don’t know our basic assumptions. And so our message is inaccessible to them. It’s like, if you or I sat down with our tax attorney and they started talking about what they talk about, we can’t access it. It doesn’t make sense to us. We can’t remember it. Not because we’re not smart, we’re smart, but it’s just we haven’t heard those assumptions. We don’t know that jargon. And so part of what my research has been about is how do we consciously and intentionally create access? Be aware of what words really are jargon that people don’t really know about and be aware of our basic assumptions and needing to explain those in an engaging way.

Dr. Sharp: Sure. I think that makes a lot of sense. As we’re talking about it, it occurs to me it’s almost like we have this feedback session time to teach someone an entire or a family, an entirely new topic in an hour or an hour and a half, and somehow make it relevant to their lives, but we’re starting from zero and there’s a lot of information.

Dr. Karen: I truly believe that it’s the most difficult thing that we do as professionals, being able to take all of this rich data from the history, from the medical records, from our testing, our knowledge of statistics, developmental history, brain function, and communicate it in a way that’s accessible as you said, in an hour without losing people. It’s very difficult.

Dr. Sharp: Well, I think that’s a nice segue to talk through some of the things that you found that you ended up turning into this book. I just want to point out before we totally dive into it, that something you said earlier sticks which is that this is research-driven. You were pretty methodical in putting this information together, interviewing folks around the field, getting it on the ground perspective for what really works in feedback sessions. I think that’s really valuable. It’s not just theoretical.

Dr. Karen: Right. My goal and the goal of Kira Armstrong, who was a co-investigator, we really wanted to interview seasoned neuropsychologists who had methods that they felt were really effective in communicating specific issues. So we ended up interviewing 85 seasoned neuropsychologists from across the lifespan in different practice settings. And we said to them, look, all of us have had the experience of talking to patients and their families and you’re explaining stuff and you can see their eyes are gazing over, you’re losing them. And other times, you can really see by what you’re saying, that they’re nodding and they’re smiling and they’re with you and they’re engaged in a back and forth.

And most of us, when we hit upon a way of explaining something where we really see that our patients are understanding it, we’ll use it again. Those stories, those analogies, those concise explanations. Over time, we’ve hit upon those. And we use those pearls on a regular basis. Or maybe a supervisor or close colleagues shared those with us. And so we said to people, look, that’s what we want to hear about. Don’t tell us theoretically what you might say, but what do you actually say. We ended up collecting thousands of those pearls from our interviewees. And that’s what we put together in a book.

Dr. Sharp: I would love to hear some of that. I think there’s a lot that goes into a feedback session. So maybe from a big picture perspective, can you speak a little bit to what y’all found makes up, let’s just say, a generally positive or successful feedback session to create a good experience for the family?

Dr. Karen: Sure. The first thing that we found, and it was very clear to us early on in the research was that there’s no one single way to provide outstanding feedback. It really was multiple effective strategies that really depend on the practice setting, the disease entity, the culture, the language background, the family systems background, and then the test scores themselves. So, pretty early on in the research, we realized that what we were going to find was multiple effective pathways.

As we personally heard these pearls and methods, some of them would fit with our personality. And they were like, wow, I definitely can see myself using that. Others might’ve been a great thing to say or a great way to approach it, but may not have felt quite as comfortable.

So the research, and looking through the research, the book format was the way we decided to publish it because it was just so much. It couldn’t have possibly gone into a journal article. But as you access all of that rich data, what we found most people do is they’ll end up gravitating to certain pearls and methods and other methods they won’t gravitate to so much. So that was the first thing that we found.

Another thing we found is that even though there were multiple effective ways of approaching feedback, there were some common denominators. One of the things we heard very frequently from seasoned clinicians is that it is well worth our time to engage in feedback sessions. I say this because the process of doing a feedback session at all is really something that’s evolved in our field.

When we interviewed senior neuropsychologists, meaning, folks who were around from the beginnings of our field of neuropsychology, what they told us is that back in the day, they were discouraged from giving feedback sessions. Most people learned in their graduate and in post-doc experiences that what you did is you did the test and you wrote a report, you sent the report to the referral source, and that person gave the feedback.

As we’ve gone through a process, I think where patients are much more empowered, they really want to know about their healthcare. They don’t want Marcus Welby to make decisions for them. They want to be equal participants in making decisions. The focus has shifted to direct feedback. In fact, in a research project where we asked referral sources about our stakeholder’s project and report writing, we asked referral sources, Hey, do you like to give feedback about the neuropsychology assessment or do you like the neuropsychologist to give the feedback? And overwhelming, referral sources said, oh no, we want you guys to get the feedback.

Dr. Sharp: Sure. That makes sense.

Dr. Karen: Yeah. We had interviewed Muriel Lezak about, well for the book, and she had said to us, she thinks it’s immoral to spend all this time with the patient doing testing and to give them either a super brief feedback session or no feedback session at all. She called it a hit-and-run assessment, which I thought was always. Mark Brisa, who’s a wonderful neuropsychologist in Texas, he calls it diagnose and adios. If you just say to a person, look, here’s the diagnosis and you spend 10 or 15 minutes with them, ask the existential question, was it worth all this time?

The other thing that we found which was a real common denominator is, people really believe in the process of feedback and think it’s a worthy thing to do. Most clinicians felt that there was something psychotherapeutic about feedback. In other words, that real seasoned clinicians saw feedback sessions as an opportunity to do their clinical work with folks. And that plays out in a lot of different ways.

Many clinicians told us that this might be the only stop along the way in medical care where after a traumatic brain injury or with a developmental disability or something like Alzheimer’s disease, that a clinician really gives a person and their family an opportunity to grieve. Many clinicians spontaneously brought that up with us. They said this is really a place where at some point we need to just stop talking.

Most had some language that they would use to invite families into that grieving process. Some it might’ve been as simple as, this is really hard, or this is really sad. Sometimes it was a little bit more specific. Mike Westerfield had said something that was so striking. He says to families when a child has had a traumatic brain injury, he will say, your child was injured but really you all were injured as well. It night might not be a physical injury but it’s been an emotional one.

And so many clinicians rely on their primary psychotherapy training to not only share information in the feedback session that really open up a space to process that information.

Dr. Sharp: I think that’s so important. I’m just thinking back to many feedback sessions of different types. You can see the tears welling up in a parent’s eyes, and like he said, just to stop and say, I know this is really hard to hear.

Dr. Karen: That is right. This is really tough to hear.

Another common denominator with feedback is that many clinicians felt like one of the goals is to help empower people. Mark said to us, and I think this really summed up what a lot of clinicians felt like that if you just gave the diagnosis information but didn’t help the patient or family understand how they might make changes in their life, then you really haven’t done your job.

So empowering could look like helping families understand how to navigate an IEP meeting or helping people connect with resources in their community or helping people understand how they might get accommodations at work. Sometimes the empowering us about how to help people reframe the use of compensatory strategies. For example, one of my favorite Pearls in this area is, I don’t know if you work with elderly folks or not but I see a lot of people where we’ve identified either an early Alzheimer’s disease or mild cognitive impairment where there are some memory issues and I’m introducing the concept of using some compensatory strategies.

I think it’s very similar to hearing aids. A lot of people know they need hearing aids, but they’re embarrassed to use them. And for a lot of folks in the 65 and over the crowd, they feel very embarrassed about using memory compensatory strategies. It will Telegraph to people that there’s something less than about them.

What I’ll say to people is like, Mr. Smith, what you need is a presidential assistant. You got president Obama or you had to suss out if they’re Republican or Democrat, you can fill in your president, President Obama when he goes to a major state dinner there are like 300 people in the room, he doesn’t remember the names of everybody. He probably doesn’t even remember that he’s met most of the people on the ground.

 He has a presidential assistant that stands by his side and says, sir, this next person in line is the ambassador to France. You met him last year with his daughter who’s a soccer player. And then President Obama will say, oh, Mr. Ambassador it’s nice to see you, how’s your daughter doing with her soccer game? And the president will look like a hero and the ambassador will feel great. 

Mr. Smith, that’s exactly what you need when you go to the Seniors Center. You need a presidential assistant to stand next to you and say, Hey, that’s the Jones’ and we just played bridge with them last week. They’re going to go to Hawaii on vacation. Why don’t you get your wife to act as your presidential assistant?

Dr. Sharp: I like that.

Dr. Karen: And so you’ve reframed that idea to a status symbol as opposed to a symbol of weakness. And that’s one method that you can use to empower people.

Dr. Sharp: Yeah. That’s great. There we are. There’s something right away to take away. Empowering folks. Making it a therapeutic process.

Dr. Karen: Yeah. The other thing that came out which really fascinates me, I always loved sociology when I was an undergraduate, but we heard a lot about the use of social pragmatics in a therapy session. One is the tone of voice, one is facial expressions, the extent to which you might share personal information, how rapidly you’re speaking, the use of jargon, body language, all of that. It’s the language behind the words. It’s not necessarily what you’re saying, but it’s how you’re saying it.

The classic example of that is the phrase, let’s go outside. If you’re sitting with someone in a bar and you say that to them, depending on your social pragmatics, you might mean, Hey, let’s go fight or, Hey, let’s go outside and smoke a cigarette or whatever together. So that social pragmatic, that language behind the words is really important in communication.

What seasoned folks were telling us is that they specifically manipulate those factors to reach clinical gangs. In our personal worlds, we all have one set of social pragmatics, and we might have different sets of social pragmatics that we use with different sets of people.

I recently interviewed Desiree Byrd who’s a wonderful neuropsychologist and researcher. She was telling me that there’s a sociological term called code-switching which many African-Americans will describe as a way of saying, we have one set of social pragmatics, tone of voice, even accent for one group of people that we specifically switch in different situations. So what we discovered in our research is that many clinicians in the feedback session will take what they would normally use in terms of tone of voice and body language and alter it for clinical aim.

I’ll give you a great example. Gordon Clooney had said to us that for most of his patients, he has really folksy social pragmatic. He’ll lean forward in his chair. He has a slow tone of voice. He doesn’t use any jargon. He’ll say stuff like, Hey, does that make sense to you? But he says, when he has a patient that’s super high status, like an attorney or a physician or a CEO that he’s tested, he will specifically change those social pragmatics. So he’ll lean back in his chair and he’ll purposely use jargon and he’ll speak more rapidly and he’ll make more direct eye contact because he wants to alter his authority level through those social pragmatics so that the person will listen, respect what he is saying. It’s really fascinating.

Another thing about the authority that I think was really interesting, most of us if we have a psychotherapy background, we’re trained in one of the many schools of psychotherapy where we’re taught to either have an equal sense of authority, status level or one down, right? The classic style munching family therapy is that one down stance or super neutral, like, the Carl Rogers, super neutral or the Floridian, not even saying anything at all, right?

A feedback session we heard from many people is a really unique time for a psychologist or a neuropsychologist when sometimes we have to take a voice of authority. Aaron Nelson, he’s a wonderful neuropsychologist in the Boston area, he said, it’s your job sometimes to be the authority figure. And you’ve got to be willing to step up and be that for people.

Oftentimes, people need to have some direction that directly relates to safety issues like driving or medication management or whether it makes sense to go back to work a certain amount of time, whether it’s safe to do so and having a one-down position or neutral position really isn’t necessarily the clinically best thing to do.

Dr. Sharp: Yeah, I think that’s really important. I’d imagine some folks may be listening saying, well, I’m not sure how to do that or that’s hard for me.

Dr. Karen: I’ll tell you a funny story. I had given a talk about this research to a group of developmental pediatricians at Tufts Medical School. There were, I don’t know how many, there’s like 20 or 30 of them in a room. They’re all MDs and they’re listening to this. Part of my goal was to share this research with them and then get their feedback on how this might differ from the way that they engage in feedback with patients. When I came to this voice of authority portion of it, they all said, oh no, we have no problem with that.

As physicians are taught from day one, you got to take the authority. But just as you point out psychologists, we are just not used to doing this. I’ll give you a great example. If for those people who work with dementia, probably the number one difficult thing to do is to successfully have a conversation about driving.

If you have a geriatric practice, you will have experienced the following a lot. One common thing is you’ll say, well, how is mom driving? Or how is dad in the car? And the adult children will look at you and they’ll say, well, I don’t know. I won’t drive with them. Or you’ll say, well, this person is pretty severely demented and I’m concerned about their driving. They have maybe a mini-mental of 16, or they have a full-scale IQ now of 60, that they’ve failed all the attention tests. I’m really concerned. And you’ll get the adult children in the room saying something like, well, he only drives to the post office and back.

What’s really happening is, patients with dementia have true anosognosia. They have a true neurologically-based unawareness of their deficits, but the part of their brain that could tell them that they’re not safe to drive, that part doesn’t work anymore. So they can’t know, but family members often have a psychologically-based denial. They understand that driving in this country has a lot of very rich, deep, important meanings for adulthood, independence, agency, dignity, and taking away a driver’s license is taking away something much more from their parent, right? They know it’s going to hurt them. And in a way, it’s kind of the death now for that person still being their parent in the way that they relied on through their whole life.

When you have a parent who’s who has Alzheimer’s disease, you’re losing that parent. And when you come to the realization that you have to take their driver’s license away, there’s no denying that you’ve lost them. It’s a horrible moment for everybody. But if as a clinician, you can’t make it happen, then you think about, well, I’m going to drive with my children in the car tomorrow and that exact same person could kill all of us. There’s public safety and there’s a personal safety issue. That’s so compelling, but are literally fighting against the patients neurologically based unawareness and the family members’ really compelling psychological defenses. So how do you do that?

That was one of the main things that we asked people who were seasoned, and I’ve got to say, one of the absolute best methods. A few different folks told us about this. People tend to use this one. Originally, I think I first heard it from Mark Burris, again, but what you say to folks and again, you have the patient in the room, the adult children in the room, and you say to folks, no one ever reads the fine print of their auto insurance policy. But let me tell you something. Every auto insurance policy written in this country has this little paragraph that says that if you have a medical condition that makes it impossible for you to drive safely, they don’t have to cover you.

So if dad gets into an accident, and the insurance company gets a hold of his medical records, they don’t have to cover this accident. He could lose everything he’s ever worked for. Similarly, I usually use both. I say also, everybody sues everybody in this country. And [00:43:00] so if dad gets into an accident, even if it’s not his fault on the way to the post office, then the person at the scene might get the idea that he has a memory problem because he’s asking questions over and over again. That person could Sue him even if it was her fault. They would get his medical records showing that he has Alzheimer’s disease and never got a driving test to prove he safe. Your parents could lose everything they’ve ever worked for. I am telling you, the first question out of the adult children’s mouths after you give them that Pearl is, where do we get the driving test?

Dr. Sharp: I can see that.

Dr. Karen: Because now you’re looking at a financial issue. If they lose everything they’ve worked for, how are we going to support them? Or are we now going to lose our inheritance? It is dramatically effective. For the person who has early dementia or late-stage dementia, even if they’re anosognosic, even if they don’t truly believe that there’s a problem with their driving, then they’ll still agree because they understand if I have this medical condition and I haven’t taken a driving test to prove I’m okay, then I could lose everything I’ve ever worked for. So that’s a very effective strategy.

Dr. Sharp: Yeah, absolutely. So let me ask you since we’re on this topic, just giving difficult feedback in general, I do wonder, and I selfishly I’m asking for myself, I work with a lot of kids, and so I think about how do you talk with parents about an intellectual disability diagnosis or even autism spectrum. That can be pretty heavy. Do you have thoughts on that or things that you’ve learned from others?

Dr. Karen: Yeah, absolutely. It’s such a great question. Just to expand it a little bit, even news that we don’t necessarily consider bad news could be taken as bad news by folks. I’ll give you an example. I had a physician couple that came in to get their child tested. They had their child in a very academically advanced private school. She wasn’t doing very well and they thought she might have learning disabilities. It turns out she didn’t have learning disabilities. She had what I would consider a wonderful IQ. She had a high average IQ, I think let’s say like around 115 or so. The mother was crying in the office because of that 115 IQ and literally said to me, I can’t believe that this is her IQ level. I’m going to have to rethink her entire childhood now that I know this information. That IQ number was a narcissistic injury to this particular parent.

Here’s another example. The somaticizing patient where you’ve got great news; you don’t have early Alzheimer’s, or there is no lasting effect from that concussion, or your scores are absolutely normal. That news could be taken as proof that yet one more doctor doesn’t understand them. So there is enormous potential for whether it’s truly bad news or whether the person thinks that it’s bad news to have people injured or experience what you’re saying to them as extremely difficult to hear.

Dr. Sharp: That’s such a great point. It makes me think about the flip side too. I’ve had a lot of parents and families be relieved almost to have a diagnosis that others might think is not a good thing. It’s pretty devastating.

Dr. Karen: Yes, it’s all about the frame. One of the best ways to have a successful feedback session is to go into it knowing what those frames are. And that means that you actually start your feedback session during your initial clinical interview. Karen Willis, a wonderful pediatric clinician, had said to us, and it just really stuck with me, that if you do the initial interview correctly, you’re going to know the fears of the person or the family. You’re going to know the different perspectives of major players in the family.

Maybe grandma doesn’t believe in ADHD or maybe dad had it as a kid and the medicine, he felt like it made him a zombie. You’re going to know the theories that people have. Maybe mom feels like the child is really lazy or maybe mom feels like their nonverbal child really has amazing cognitive skills that are hidden. I mean, if you do that interview correctly, you will know where all the minefields are. And so that way you can tailor the feedback so that you’re going to go softly, or you’re going to Telegraph, or you’re going to inoculate against some of those problems in the feedback session.

I’m forgetting who it was, but one clinician actually included in her intake form for families, please tell me the estimated IQ of mom, dad, and of the patient. She said she did this because that would Telegraph to her if they already knew that there was a discrepancy.

Dr. Sharp: Yeah. Oh, that’s really interesting.

Dr. Karen: Just to have that information before you went in. I think Joe Morgan had said, early in his career, he had a patient who he didn’t know until the feedback session when she started crying hysterically, that her goal was to go to an Ivy […] College. In the feedback, he was giving her the great news about a high average IQ and he just threw out, maybe this isn’t a Harvard, but this is something, right? It was devastating to her. And he said, from then on, he really made sure in the initial interview that he was getting that information about people’s dreams. So that’s one piece of advice about giving tough news.

Another wonderful way to think about it, and this was something that Kira had brought to our research and I think it was her supervisor who originally told her that this idea of leaving the door of hope open. This is particularly relevant when you’re doing assessments early on with someone who has a severe developmental issue or early assessments with someone who’s had say a severe traumatic brain injury or a really catastrophic tumor and oncology at treatment.

It’s to say, look, I’m going to tell you the worst-case scenario and the best-case scenario. My job is to tell you both. And what I hope for you is that you’re going to come back here in a year or five years and say to me, you know what, you were wrong. The outcome was the best outcome and all of your dire predictions didn’t come true. I hope that that’s what you’re able to say to me, but what my job is to do is to give you the worst case and the best-case scenario.

Once you’ve said that, you’ve left that door of hope open and the person can listen less defensively to both sides. You’re giving them space where you can tell them what you think will probably happen but you also don’t give them that space where they have to be in a situation or just denying it. Like that’s not true.

Dr. Sharp: That’s great. I like that a lot. That’s another thing I could easily see using very quickly.

I think we’ve talked a lot about successful feedback and elements that can help it go well. I wonder if we might talk a little bit about things that people would say are mistakes in feedback session or things that I think when I was, either the book or maybe some material online about the book that you said it’s not about the data, it’s not about the scores, something like that. I wonder, are there any common mistakes or paths that people go down that may not be so helpful in feedback sessions?

Dr. Karen: Yeah. I think that two things that emerged. What clinicians told us, almost all of them said is that the rookie error people make when they’re just starting, is they’re so attached to the test scores. They feel like  their job is to sit down with people and explain all the test scores. And if you’re on the other side of that, it’s number one, mind-numbingly boring. It doesn’t have any relevance to their lives. They don’t understand the basic assumptions of standard scores anyways, right? And it’s not because they’re dumb. It’s just because, it’s like us listening to an hour of tax laws. It’s just boring and inaccessible.

So most clinicians will say that sharing actual scores is way down on their list of goals for the assessment. A lot of them don’t share scores at all. They interpret the scores.

Dr. Sharp: I’ve hard that. Yeah.

Dr. Karen: Now, there are exceptions to rules like this. For me, there are times when I will start with a score. For example, if I’m assessing an adult for dyslexia and this person is coming in maybe in his 40s because he finally wants to find out, I know that there’s a huge likelihood that all of his life he’s thought he was dumb. And man, if I get an IQ of 100 or better, the very first thing I’m starting with is that IQ score. I’m starting with, I just have to tell you, we gave you an IQ test and you aced it. Lots of people who have reading problems conclude that that’s because they’re dumb, but I want to tell you first piece of knowledge I can give you is that you are not dumb. You are a smart person. So I’ll start with that if it’s clinically relevant, right?

Or someone who’s worried well, and they come in with a concern that they have Alzheimer’s disease and they got a really good score on a memory test, I’ll start with that. And I’ll say something to let you know, Mrs. Smith, I got to tell you, you aced that test. If I took 100 people and I put them in a room, you would do better than 89 of those 100 people on this test. You make it accessible. So there are times when a standout score is great, but most of the time scores are not going to help move the narrative along.

The other thing that is a rookie error that people tend to make is they bury the lead. For some crazy reason, we have this warmth in our field of saving our conclusions in our report to the very bitter end, right?

Dr. Sharp: Yeah. Right.

Dr. Karen: We start with all the minutiae of the history and then all the minutia of the test data. And it’s not until the very last page that you say what you thought, right?

Actually, we had a writing coach from NASA whose job was to help the scientists communicate better with each other; faster communication with each other. We got him to help us with the question of how do you write better reports on the Inter Organizational Practice web toolkit, its the IOPC toolkit. What he was telling us is what they did at NASA was they taught people to use an inverted pyramid method for their reports, where they would start with the bottom line and then they would go into details as you need it, just like a newspaper article is written.

The idea is that we can do that with our feedback sessions as well. Why bury the lead? Why use this strategy of first talking with people about how we got to our conclusions and then finally at the last minute sharing our conclusions? Why not instead start with the conclusion.

Now, this really depends on the clinical situation. So many clinicians will say that depending on the type of results they give, they might start with the conclusion or in a different situation, they may do it a different way, but here’s two examples of where you might want to start with the conclusion.

Let’s say you’ve got a family that’s brought their kid and they think he might have ADD. The kid is not in the room. It’s just family feedback. And here you are as a clinician talking, talking, talking, talking with them about all of the different things that you measured. You’re building up to your big conclusion which is in the last 10 minutes of the feedback session. Most of the time in the thought bubbles of those parents, it’s just static and anxiety the entire time. Like, is Dr. Postal going to tell me, it’s ADD, maybe it’s not ADD. He watches videos. And he seems to be able to pay attention to that. Man, if it is ADD and we’ve got to medicate him, my mom’s going to blow it. She has to blah, blah, blah. Right? That’s what they’re thinking when you are coming to explain stuff to them. And so they’re not really accessing your message because there’s so nervous about it.

And so what you can do is that you can start with, you know what, I got to tell you straight upfront that you all brought John to me because you were concerned that he had attention deficit. And I’m going to tell you, my bottom line is I think your instincts were really right on. My conclusion is that he does have ADD. I want to spend the next hour really unpacking that. We’ll talk about how I came to those conclusions and then we’ll map out a roadmap for what we can do about it. But I just wanted to let you know right off the bat that’s what we have.

Same thing if you have a worried, well the person who thinks that they might have Alzheimer’s disease and your conclusion is they don’t, you better tell them right up front. Why make them sit on pins and needles for the entire session? So I think that’s another area that people don’t really acknowledge the degree to which their feedback is what’s behind curtain number one, and you don’t want to keep people on pins and needles the entire time.

Dr. Sharp: Yeah. That makes sense.

Dr. Karen: Another error that people make, and this is one that’s specific to folks who do pediatric work. We also asked people about how we give feedback to other professions. So there’s a chapter in the book about giving feedback to other professionals- how do we talk to the pediatrician on the phone or how do we talk to the IEP team? I don’t know as a pediatric person if you’ve ever gone to IEP team meetings.

Dr. Sharp: Oh, sure.                                                                                      

Dr. Karen: So most people have had this experience of like this dreaded war of standard scores. That they’ll say, so Dr. Postal, we notice that when you tested Sally, you got a processing speed score of 89, and yet, we got one of 91, and you are like, oh, it’s going to be a long meeting.

So when I go to IEP team meetings, I resist this whole idea that I should present my report. They’ll say to me, “All right, well, Dr. Postal, you’re up. Can you please present your report?” I don’t touch my report. I literally do not take my report out. Instead, I bring a three-dimensional plastic brain model in a little bag and I pull that out. And so I’m using a prop. I pull up my brain and I say, so this is the part of the brain here- I’ll point to the frontal area. This is the part of the brain that brings us all the things that we value in a successful student: focusing, organizing, planning, and memorizing information, and also this part of the brain also helps us respond well to stress and handle frustration.

Now when Sally had a severe traumatic brain injury two months ago, this was the part of the brain that was injured for her. And the team, you guys probably noticed that as much harder for her to focus, harder for her to concentrate, but I know you guys have noticed that it’s really hard for her to handle frustration, right? When she can’t do something she expects to be able to do, she just flies off the handle, right? And that’s this part of the brain. So let’s talk for a while about what strategies we can use to help her accommodate these changes. I haven’t talked about a single test score. Instead, what I’ve done is I’ve used a prop to drag the conversation away from standard scores to this child’s brain and what she needs at the moment to help her. That’s really effective.

Dr. Sharp: Sure. So you sidestep that whole conversation and maybe argument about what diagnosis or cutoffs or whatever, and just say, okay, we know that this is what’s going on, and here’s what can help.

Dr. Karen: Yeah. Let’s talk about the brain, not scores.

Dr. Sharp: Yeah. I like that. I would imagine too, especially in a school setting, that’s nice to have a visual prop instead of just the other focus.

Dr. Karen: Yes. We ask people about props and people use props and all sorts of great ways. Monica Rivera offers people camomile tea. It’s really interesting. What she told us is that in the Latino and Latino communities, camomile tea has healing properties, and by offering people tea, you’re doing two different things, you’re creating a really warm and relaxed environment. You’re telling them that you respect their cultural background and that this is going to be a place of healing. She does that very specifically. She’s offering something very specific.

Michael Santa Maria gave us this genius one. He has a prop, he hands out full-color copies of a newspaper article showing a grisly car crash that an elderly person got into -a really gristly photo. He just hands it out to every member of the family sitting in the room and then he brings up the conversation about driving.

Dr. Sharp: Oh, gosh. Okay. That’ll do it.

Dr. Karen: If you’re at a tertiary care medical center, you might have a dedicated monitor in your office for brain imaging, and that can be a wonderful prop. Some people have a bell curve that they’ll have on a board and they’ll use that as a prop, but props can be helpful.

Dr. Sharp: Yeah. Absolutely. I’ve seen a lot of folks who will have that second monitor or an iPad where they can walk through and do some visual prompts.

Dr. Karen: I’ve used an iPad. I don’t know if you’ve seen them in 3D brain atlases you can get on the iPads.

Dr. Sharp: Oh yeah, those are great.

Dr. Karen: Those are awesome. To me, with the adolescent and young adult crowd, it raises your stock, right? Instead of just showing a brain model, to be able to rotate the same on the iPad I think it’s really helpful. You get their attention.

Dr. Sharp: Absolutely. Oh, this was great. I’m just looking and an hour has gone by so quickly. We have talked about so much.

Dr. Karen: Oh boy, that is fast.

Dr. Sharp: I’m wondering Karen if I might just ask you a few nitty-gritty questions about how you do feedback, and then maybe we could transition to any other resources or things that might be helpful but I’m just curious in terms of how you set it up, like how long are your feedback sessions? Do you have the kid present if you’re doing pediatric and like a rough estimate of how you divide up the time between scores versus diagnosis versus recommendations? Any of that detailed info.

Dr. Karen: For me, I have an hour-long feedback session that I always give. From my perspective, the more the merrier. So the more people who are present in that [01:08:00] feedback session, I think the more likely that some good is going to come out of it.

For my adult and geriatric patients, I’m super happy if I have an entire extended family in the office. Brothers, sisters, adult children. I think it’s just really helpful.

For my pediatric patients, with teenagers, I tend to have them present during the feedback session unless it’s an issue where there’s a big fight with the score and a substantial amount of what we’re going to talk about is a pitched battle with the IEP team. In that situation, I don’t think it’s clinically helpful for a child to hear about adults fighting. So I’ll have a separate one.

For younger adolescents and kids, I’ve gotten to the point where I always have two feedback sessions. I have a feedback session for just adults where we can speak entirely, frankly. And then I have a second shorter feedback session where I have the parents and the child in the same room together and I give a very positive kid-friendly version of the feedback. I do it that way because I think that almost all kids who are in your office for testing suspect that they’re dumb. And whatever it is, that’s the problem. They think it’s because they’re not a smart person. And I think it’s so critically important from an emotional perspective for them to hear straight from my mouth what their strengths are.

Dr. Sharp: I’m with you.

Dr. Karen: And then the other thing is that almost always, I find in pediatric practice, no matter what the diagnosis is, there are effective strategies that I want this kid to engage in and their parents to help them engage in; whether it’s more effective study strategies or 40 minutes of aerobic exercise every day or changing their sleep patterns. This, I think, requires direct buy-in from the kid. From a family systems perspective, I think that them hearing the information in the presence of their parents, not just them and me, but them hearing it then being asked to buy in in the presence of the family system is a more effective way of coming and getting a good outcome.

So, that’s typically how I do it. Usually, it’s an hour for the adult feedback and a half an hour for the kid feedback. Any time that there is a psychotherapist in the picture, I love to invite them. I think if I can get members of the IEP team on either in-person or on speakerphone, that’s also oftentimes really helpful. So again, not just the family members but important stakeholders are present. For adult populations, it’s oftentimes, like a worker’s comp case manager, it could be like a disability specialist. Those are important people to have for the feedback.

Sometimes, I will do some extra work after a feedback session which to me feels like an extended feedback session as opposed to psychotherapy. So if someone isn’t using their C-PAP machine which is one of the most common ways that you get to thank you have early Alzheimer’s disease when you don’t, tons of people hate C-PAP because they’re anxious about using them, I might have them bring in their C-PAP machine and we do a little bit of work to make friends with it, right?

If it’s an adolescent who’s going to bed at 3:00 in the morning and gets up at 7:00 am for the school bus, I might do a couple of extended feedback sessions about sleep hygiene, just low-hanging fruit. And if they still need some CPT after that, I’ll refer them.

So to me, I might do a couple of feedbacks initially about some study strategies. I do this, particularly with college kids. I’ll say, look, what I want you to do is come back and see me in three months after you’ve started the fall semester, and let’s do a course correction. We’ve mapped out a game plan, and let’s figure out what works and what doesn’t work and make sure that we get you totally on course so that you’re successful next semester. So, sometimes the feedback sessions might be in the distant future but I consider all the feedback sessions.

Dr. Sharp: Okay. I like that framework. It often feels like, admittedly I don’t do that very much, and so I like that extended feedback framework. So it’s not like you just deliver all this important information and then send folks on their way.

Dr. Karen: Yeah. From a business of psychology or neuropsychology perspective, I think we shortchange ourselves in terms of our clinical skills. A lot of us say, well, we’re either assessors or therapists and we don’t realize that there’s a fairly large gray area. If you think about the model of an ear nose and throat doctor or cardiologist, when the family physician refers to the ear nose and throat doctor because of a sore throat or because of adenoids, the ENT doesn’t say, oh, I’m here for the diagnosis and spit them back to the family practice doctor. They say, here’s the diagnosis. We’re going to do a little work to fix it, then we’ll send it back.

Dr. Sharp: It’s a great point.

Dr. Karen: So in terms of the business of neuropsychology, there’s no reason in the world that we can’t say, look, we’re going to do this consultation for your school district or pediatrician, whoever, we’re going to do a little bit of work, get the person back on track and then we’ll send them back.

Dr. Sharp: That makes sense. I like how you frame it that way. When you illuminate it, it makes sense and just a different way of thinking.

As you talk or as we’ve been talking, one of the themes that has jumped out at me is the overlay of therapy and assessment, but also maybe the need for flexibility. I think we get locked into data and the science of testing and that’s what draws a lot of us to do an assessment but then there is so much art and flexibility to it and reading people and knowing the family system and knowing people’s expectations, like all of that is just so important.

Dr. Karen: I think you are right on. I mean, a feedback session is just one of the most complicated things we do. We’re bringing psychotherapy skills, family systems skills, social power, developmental theory, brain theory, and standardized testing there. It’s all there all at once.

Going back to errors we might make when you’re just starting in practice, you might try to map out what you’re going to say during the whole feedback session. In reality, it’s like a battle. You can create these detailed battle plans all you want but as soon as the first shot is fired, it’s all chaos. You’ve got to be ready to be very nimble and attentive to what’s going on in the moment in the room.

There’s something that the US military uses. This was from the Heaths’ Made to Stick book that I love; it’s called Commander’s Intent, which is, that military leaders understand that detailed battle plans never work because everything is just very chaotic. And so instead of a detailed battle plan, what they’ll do is they’ll give their subordinates something called commander’s intent. By the end of the day, I want you to take that hill, how do you do it, who knows? But that’s the intent. And so you can go into a feedback session saying, all right, here’s the commander’s intent. By the time I leave here, this is what I help my students with. By the time you leave, you want to get A, B, and C on the table. That’s the goal. How you do it, you’ve got to be nimble in the process.

Dr. Sharp: That makes a lot of sense, know your path and know your outcome but be willing to adjust to get there. Well, this has been an incredible conversation, Karen. I really appreciate it. So just in terms of resources, I know we’ve barely scratched the surface of what’s in your book. So have to put in another plug for that. I think everybody should read it. It has so much good information. I’ll have that in our show notes, of course. But are there any other resources that you know of that might help folks learn more about feedback sessions?

Dr. Karen: Yes. And this is going to sound really crazy but my number one recommendation recently to people is to take improv classes, you get what I mean? Alan Alda for years had this PBS program, it’s like Nova, and he interviewed scientists. I don’t know if you’ve ever seen it. He was so struck by the fact that some scientists were great at explaining their science, but most of them were really bad. 

He felt like if we don’t train scientists to communicate better with the public, science funding will dry up, right? And so he created this center at Stony Brook University and it’s all about training scientists to communicate better. It’s just a genius idea. They give these workshops all around the country. So you can take a one-day or two-day workshop. They come to major cities, a lot of universities. But once a year, they do a Bootcamp that’s for one week and they have scientists from all over the country come to this Bootcamp.

I signed up and I was accepted to the Bootcamp last winter. Half of the day, they spend teaching you about communication styles, but the other half of the day it’s improv training. And the reason for that is that they pointed out on anybody who’s been through graduate school knows this, like the process of scientific graduate school, getting your Ph.D. or PsyD, it literally beats the good communication out of you. We become terrified of making mistakes. We are over-rehearsing language and using jargon to the point where it makes sense to get up in front of a convention and literally read a scientific paper to the audience. We’re so jargon-laden, and we’re so afraid of actually using our bodies and moving them, or express an emotion to go with what we’re saying, or using analogies and stories. You can take a person who had perfectly good communication skills and then put them through a Ph.D. program and just beat it all out of them. So that you’ve got these scientists who just don’t remember how to communicate.

What improv training does is it really rapidly forces us back into good communication strategies. So with the improv training, what they would do is they would have these exercises where they would force us to make mistakes. So they would give us these like motions we had to do with a partner and they made us go so quickly. You literally, couldn’t make a mistake. And then when we made the mistake, we were instead of shriveling up a little ball of humiliation, we were to throw our hands up in the air and shout tada.

Dr. Sharp: I love it.

Dr. Karen: So here we were like 50 physicists from MIT and all sorts of fancy people all of us making the day mistakes and shouting tada. Other exercises force you to be in the moment, like really truly focusing on what’s happening in the room. The common denominator of so many of the exercises is this concept of yes and right. So you’re not allowed to say no in improv. You have to say yes. So someone hands you something, a patient says to you, is it this? And our typical way and feedback is to say, NO, it’s this, but you don’t know I know, but with the improv, teacher’s shooter is to take what they’re giving you and say, ah, yes, and right. You take their metaphor, their analogy, their story, and you extend it.

As you go through these improv techniques, what happens is you start to focus on what are the needs of your listener? What did they need at the moment from you to get access to what’s in your head? And it’s not about what am I saying, or what am I thinking about, and do I sound right? It’s about what they need and literally, the anxiety disappears.

So for trainees, I think improv training is just a genius way of getting people to the point where they can be nimble and in the moment and attentive to their patients and their patients’ worried families in the moment, not just trainees, I’m actually recommending that mid-career folk consider this as well because I have to say from my experience after a week of improv, it really was mind-blowing in terms of the difference in my not just feedback, but also public speaking skills.

Dr. Sharp: I got you. I think that’s such a good point. It’s interesting. That’s the second time in a week that I’ve heard improv classes mentioned as a, let’s say valuable addition to someone in life.

Dr. Karen: Really? That’s awesome. That’s so great.

Dr. Sharp: Yeah, who was the other, I think it was James Altucher’s show, which is a podcast about business and peak performance and things like that. He was interviewing a guy who was speaking about the book Play. I don’t know if you’ve heard of that. They were talking about the value of improv as a means of opening yourself up and saying yes, like that whole concept of just saying yes to things versus shutting down and it was effective.

Dr. Karen: If people want, I’m aware that Alan Alda Science or Center for Communicating Science. They have a schedule of where they’re giving the shorter workshops all year long, and then anybody can apply to do this week-long boot camp. And man, it is really worth the time. People want to invest in that.

Dr. Sharp: Oh, that’s fantastic.

Dr. Karen: The other resource that I would say it’s just a lovely resource the book, Therapeutic Assessment.

Dr. Sharp: Oh, sure.

Dr. Karen: It’s different but the Therapeutic Assessment Movement is really talking about actually conducting an assessment in a different way. The research we did was more traditional assessments. How do you explain the results. But I think many of the concepts from this therapeutic assessment model are so lovely and helpful in this framework.

Dr. Sharp: Yeah, that’s great. It’s nice to reinforce that. I did a podcast, I think episode 10 with Megan Warner,  who’s actually in the Northeast as well. She talked all about therapeutic assessment, the value of that approach. So I’ll put that link in the show notes. I think a lot of people appreciate that approach.

Well, Karen, this has been fantastic. I really appreciate your time. I feel like there are just so many… It’s really important. You’re really doing what you are passionate about and what you love. It’s great to talk with folks who are doing that. I know that we did not talk about your new book, but I’m just going to take that as a motivation, I suppose to maybe have you on again, when everything it’s gets finalized with that.

Dr. Karen: That sounds great. Okay.

Dr. Sharp: That’s great. Well, thank you, Karen. Take care.

Dr. Karen: You too.

Dr. Sharp: All right y’all, thanks for listening in this time. I hope you enjoyed that interview with Dr. Karen Postal. I have to say that as you could tell while we were doing the interview, there were many times when I was picking out nuggets and valuable information that she was sharing. Even as somebody who’s read the book and looked at many parts of the book several different times, I was still picking up things, just hearing it directly from Karen. And I hope that y’all took away some nice gems from that as well that you can start to integrate into your feedback sessions.

Like I said, if you have not read her book yet, it’s definitely worth checking out. I’ll have the link to that in the show notes along with many other things that she mentioned during our interview.

Hope y’all are doing well. Summertime continues to roll along. I am really excited about an upcoming trip of mine here in two weeks. I’ve mentioned, I think in the past podcast episodes that I did some consulting with Joe Sanok at the Practice of the Practice about a year ago, and I am really excited to be going to his summer conference called Slowdown School. We’re going to take two days to totally unplug then really hit the ground running with some pretty intense business coaching and thinking through how to take practices to the next level and take our businesses to the next level. So if there’s anybody out there who is interested in doing something like that, you might check out to see if there are any tickets left, but that’s where I’m going to be headed in two weeks. I’m really excited to connect with folks up there.

In the meantime, I’m continuing to be so impressed with our Facebook group. We added about 40 members within the last 2 or 3 weeks, which for our little group, is quite impressive. It’s really cool to see that group continue to grow. If you’re interested in joining that group, it’s The Testing Psychologist Community on Facebook. We have some great discussions there about different measures, business practices for testing, insurance billing, things like that. So, I would love to have you join that discussion if that’s interesting to you.

As always, if you’re thinking about growing or starting testing services in your practice, that is what I am here for. So if you have questions, if you are thinking about consulting, if you may be just want to brainstorm a little bit, feel free to give me a call, shoot me an email; it’s jeremy@thetestingpsychologist.com, and we can just have a little conversation about whether consulting might be appropriate for you. If not, I will point you in the right direction and just help you get moving however that might look for you. So take care and I look forward to talking with you next week. Bye. Bye.

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[00:00:00] Dr. Sharp: Hey y’all, this is Dr. Jeremy Sharp. This is The Testing Psychologist podcast, episode 17.

Welcome everybody to another episode of The Testing Psychologist podcast. Today, I am talking with Dr. Erika Martinez, who’s a licensed psychologist in Florida. Erika and I initially got introduced by Kelly Higdon who I have talked about and who was just on our podcast not too long ago. So Kelly, in addition to being a private practice consultant is also a great networker. She has introduced me to a bunch of great folks and Erika is one of those people.

When I first talked to Erika, I was really struck by how she has a lot of training in neuropsychological assessment, which we’ll [00:01:00] talk about, but she has also taken that and shaped it to fit her practice in a different way than most classically trained neuropsych folks have, so I’m excited about our conversation today.

I will introduce Erika here and then we will dive into our talk about neuropsychological testing and how that can take a little bit of a different approach. Dr. Erika Martinez is a Florida licensed psychologist and certified educator. She specializes in the assessment and treatment of a variety of mental health conditions in young adults. Using her expertise in neuropsychological testing, she helps others explore life’s challenges and brainstorm solutions using their personal strengths. With greater self-awareness and confidence, they are able to move forward and lead personally and professionally rewarding lives.

Dr. Martinez provides psychotherapy to high-achieving teenagers and professional millennials facing quarter-life crises, relationship meltdowns [00:02:00], and existential dilemmas that can present as a myriad of symptoms like anxiety, destructive behaviors, self-sabotage, depression, burnout, poor self-esteem, and poor social skills.

She previously worked in graphic design, human resources, and community mental health. Prior to entering private practice, she worked in secondary and university public education settings for about 10 years helping parents and educators better understand and serve students with ADHD, Giftedness, and learning disorders.

So Erika, welcome to the podcast.

Dr. Erika: Thanks for having me on, Jeremy. I appreciate it.

Dr. Sharp: Yeah, of course. That is quite a biography, goodness. As I was reading through all of that, I recognize you have done a lot of stuff over the years, so that’s pretty incredible.

Dr. Erika: Yeah, I got started early.

Dr. Sharp: I guess so. I know that people take different paths to getting their doctorate and getting into private practice, did you go [00:03:00] straight from undergraduate to graduate school and then straight out?

Dr. Erika: Yeah, I did. I did undergraduate here in Miami and I was one of those high achievers myself. I was about 19, maybe just about to turn 20 when I graduated with my undergraduate thanks to some accelerated courses in high school. And so I was one of, if not the youngest graduate student in my program at Carlos Albizu where I graduated eventually from with my doctorate. So I have done a lot but it’s also because I got started pretty early.

Dr. Sharp: It sounds like it, goodness, so you were ready to go?

Dr. Erika: Yeah.

Dr. Sharp: Ready to get out there and do it

Dr. Erika: Yes.

Dr. Sharp: When we talked before we were recording, you mentioned that psychological testing and neuropsychological testing has been [00:04:00] in your blood, so to speak. Could you talk about that just a little bit?

Dr. Erika: Yeah, absolutely. My dad is a psychologist as well. He’s also a trained neuropsychologist, but he’s also a physician. When he was in his 30s, he had a heart attack and decided to stop practicing medicine because of the stress and those sorts of things. And so he got into psychology and as he was going to school, I was a little girl. I must have been about eight or nine years old.

One afternoon, he had an old DSM. I think it was an old DSM-IV. It wasn’t even the DSM-IV-TR at that point. And he had it lying in the backseat and I was in the backseat and we were stuck in Miami traffic, which is pretty hard. [00:05:00] And curious bookworm that I always was, I opened up the DSM thinking it was a novel, and it wasn’t.

I had opened up to histrionic personality disorder and read through the snippet with all the box with all the criteria. Here’s me, eight or nine years old, from the backseat, telling dad, hey dad, I think so and such has this histrionic thing and I’m sounding it out as little kid would.

I must’ve really scared my dad because he pulled over as soon as he could and leans back and turns around into the backseat and says real slow, okay, yes, you’re right but we can’t say that to people. [00:06:00] And then he launches into this whole explanation about the book you’re holding is very important, and he’s trying to break it down for me that it’s not a kosher to run around diagnosing people.

But it certainly intrigued me enough that there is this labeling and categorization system out there that we can use to better understand people. And I think that’s what fed my desire to know more about testing and quizzes and that sort of thing. So I was definitely a quiz junkie growing up. And that got me started.

Dr. Sharp: Well, yeah, that’s super early. So diagnosing family members with personality disorders is not something that we all do.

Dr. Erika: No. I think we all know it in the back of our mind, but it’s precocious for an eight or [00:07:00] nine-year-old to chime in from the backseat and say, I think so and such has this.

Dr. Sharp: Right. I’m sure your dad was just like, oh my goodness, we got to take care of this.

Dr. Erika: Yes, pretty much.

Dr. Sharp: File under stories of psychologists’ kids.

Dr. Erika: Yes, definitely.

Dr. Sharp: That’s funny. Literally and figuratively, it sounds like you got an early start with diagnostic work. How did you take that then? So moving through undergraduate and then going to graduate school, did that stick with you? How did you pick to go the neuropsychology route once you got into formal training?

Dr. Erika: I had no intention of doing neuropsychology. I think once I got older and I was a teenager and I saw what dad was doing, it’s totally the opposite, I don’t want to be a neuropsychologist. Are you crazy? [00:08:00] That’s what dad does. That’s so boring.

So it was totally on the other end of the spectrum. I had said, well, when I go to graduate school, I’m going to focus on forensics. I want to go into profiling and chasing criminals. Back at the time, there was a popular show called Profiler on TV. I loved that show. And of course, Silence of the Lambs, one of my favorite movies. So I was totally into that. That’s what I was going to go to school for. That’s what I was going to do.

And then when I was in school, picked up my non-terminal master’s and that’s about the time when the recession was about to hit back in 2007, 2008. I was working at a local program for kids that had emotional disturbances within the school system. And when [00:09:00] that economic downturn hit, they had to do something with us but they were defunding that program. And so the school system said, well, these people have educational degrees. We have a teacher shortage. We’ll put them in the classroom.

And so that’s what they did with me. They put me in the classroom. And in working with those kids with these special needs, I realized that there is such a huge need for better-understanding autism and learning disorders and all these that are now in the DSM called neurodevelopmental disorders, and that’s what shifted my focus more towards the neuro track and I’ve never looked back at forensics since.

Dr. Sharp: It sounds like a defining moment for you and push you in a different direction then. So then did you go that formal neuropsychological route through graduate school and [00:10:00] internship and postdoc and everything?

Dr. Erika: Yeah, I did, gosh, I’m trying to recall. You’re making me go back ways. I went through the neuropsychology concentration in my program and then when it came time to do an internship, I got accepted to interview at some pretty Snazzy internship sites but unfortunately, personal life circumstances kept me from being able to accept those internship positions. So I realized that I had to take a generic, I guess, for lack of a better term, community mental health setting internship.

I just reconciled myself to the fact that I would be doing an extended postdoctoral stint for neuropsychology. And so that’s what I wound up doing. I did my internship and then [00:11:00] my postdoc, I was very picky about which one I took. I found a great local neuropsychology practice that I stayed with after my graduation and I did all my postdoc work with them and I’m actually still been with them. This month is my last month with them because …

I’ve stayed with them for quite a while doing work with, there’s a lot of, geriatric population that we work with there and I’ve enjoyed that work as well but I’ve stayed with them for quite some time and learned a lot along the way.

Dr. Sharp: Yeah, absolutely. I know that you’re in private practice, so have you been building your practice on the side over the years or how does that work?

Dr. Erika: I did my postdoc with them, once I was a full licensed clinician, I knew that [00:12:00] I wanted to do private practice and that’s why I chose that particular postdoc because it was a private practice and I could learn both sides of it. I could get my neuropsychological training but I could also get an insider’s look at private practice and how it’s run and that sort of thing. Once I got licensed, I started very slowly building my private practice, which has resulted in a very different-looking private practice but nonetheless, the experience that I got there has been invaluable.

Dr. Sharp: Let’s jump into that. That’s one of the really interesting things for me. Like I mentioned at the beginning of the show is that you have taken this neuropsychology training but now you’re doing a little bit of a different path. Can you talk about that?

Dr. Erika: Sure. I think what happens when you come to a profession so young is that you’re also not fully [00:13:00] formed and you don’t know what you don’t know, so to speak. As I’ve grown as a person and as I’ve grown as a professional, I’ve realized there’s this whole other world of psychology that because I was so immersed in neuropsychological training that I didn’t get to explore as a professional.

And so I think that has been the path of my private practice to explore those things and to come to an understanding of that side of the work. I love my testing but I realized that I don’t necessarily love report writing.

Dr. Sharp: I’ve heard that before.

Dr. Erika: It’s tedious, it’s time-consuming and while I love testing, I don’t necessarily love the report writing that [00:14:00] comes along with it. So what I’ve done is that I’ve racked my brain and found a way that allows me to still do the testing that I love, understand, and conceptualize cases in a way that fits for me, but that doesn’t necessarily require psychological testing. And that’s what we were talking about earlier before we started the recording.

Now I have a name for it. I didn’t know there was a name for it. Thank you, Jeremy. Now I know it’s called therapeutic assessment. I was doing it and I just didn’t know that there was a nomenclature for it.

So what I do is when I onboard new therapy clients, I have certain tests that I administer, things like the Beck scales but depending on what they’re presenting with, I might administer Kristin Neff’s self-compassion scales, [00:15:00] I might administer an MMPI. It just depends on what the presentation is. I’ll administer those tests and I’ll use that to help conceptualize the trajectory of the therapy that I’m doing with that person.

It’s very much collaborative. I’m the stage on the stage kind of thing. I’m the one, here’s all this information, and here’s where we’re going with your therapy. I do take probably two or three sessions to work with that client, help them understand what the testing says, and where I think there’s room for us to explore, where there’s room for growth. And then really engage and have that conversation with the client about what their goals are for therapy and how this impacts their goals for therapy.

So that’s what I’ve been doing and it seems to [00:16:00] work really well. It definitely accelerates therapy because we don’t go into therapy blind to see just what comes up in conversation. It does give us a clear goal as we’re working together and it brings awareness to the concerns that perhaps might show up as obstacles. So it definitely accelerates therapy, which is good for the client.

I know I’ve gotten a lot of resistance and a lot of pushback from other clinicians as I’ve shared this model with them because their concerns are more financial in nature. They’re concerned that if the client goes through therapy so quickly and it’s so effective, what do you do from a business perspective when you’re doing that? [00:17:00] I’ve personally haven’t found that to be an issue.

Dr. Sharp: Okay. Let’s dig into that a little bit. I’m really curious about some of the details about how you do this. Actually, before I jump into all those questions, I’m just curious, I think for me, it would be hard to leave behind all of this formal training. It’s even hard for me sometimes to think about cutting tests out of my current battery which is already pretty comprehensive. So I’m like, oh my gosh, how do you let go of all that data and all that training and experience? Was that hard for you at all or was it natural?

Dr. Erika: Well, no, I wouldn’t say it’s natural at all.

Dr. Sharp: Okay.

Dr. Erika: What I realized, and I think this is more of an exercise in personal growth is I liked the testing because of the [00:18:00] certainty. The numbers were the numbers, the data was the data, and all I was was a steward and an interpreter of the data. As I’ve grown as a person, as I’ve grown as a clinician, I realized that certainty is an illusion, control is an illusion, and it’s all kind of BS.

I’ve also realized that testing is just a glimpse. It’s a snapshot of a moment in time for a person. It’s a tool for information but it’s not an ultimate or a defining tool. So I use them in that way. I don’t use them as this definitive here’s a picture of this person, here’s what’s going on with this person and this is how we define this person [00:19:00] which I think in a lot of cases people who specialize in testing do. They have that clear picture and then they just pigeonhole the individuals that get tested based on the parameters of a test.

Again, as I’ve grown as a person, I’ve realized that one test does not define me and I’ve had all those tests done on me because dad used me as a guinea pig going through graduate school. As I look back at those tests and the results of those tests because he was generous enough or insane enough to let me look at them in hindsight, I realized that who I was then is not who I am now day and night. So [00:20:00] I like to afford people the same courtesy.

Dr. Sharp: I like that. I feel like we could certainly go down that path for a long way. I’m always struck by how I’ll test folks even like five years, maybe 10 years after their initial evaluation and things can be pretty different. So I think that’s a good point. It sounds like making peace with that for you was a big part of the process and being able to let go of some of the more formal testing and move to doing more in the moment or brief evaluation. Is that fair?

Dr. Erika: Yeah, definitely fair. I still do neuro testing. I still do comprehensive evaluations. It’s just that is not my every day. I [00:21:00] equate it to fishing, Jeremy. To me, those kinds of testing cases, it’s like fishing for marlin as opposed to fishing for yellow snapper. To me, therapy is more like your snappers. Snappers come in all the time but every once in a while, I’ll catch a marlin, a marlin will be on the hook and that’s how I run the practice.

Dr. Sharp: Got you. Spoken like a true Floridian. I like this. That’s a good way to think of it.

Dr. Erika: Yeah.

Dr. Sharp: Okay. So that’s good to know. You still have some comprehensive evaluations in there but it sounds like you’ve moved to this more therapeutic assessment model for the main part of your practice. So let me ask about that. I’m curious, just detail [00:22:00] oriented, how do you present that to clients, and how does that factor into the cost of therapy? Let’s just start there and see where we go.

Dr. Erika: Sure. When I was kicking this idea around about a year and change ago, in fact, I was kicking it around with Kelly. I sat down with her and she helped me figure out how much time this would entail, how to structure it, and how to charge accordingly for it. What I came up with is that I just needed to increase my rates slightly ever so to justify the amount of time that it would take me to do the additional interpretation.

A lot of the tests that I use [00:23:00] like an MMPI or an MCMI is a lot of it is automated. A lot of it is done for us and you know that. We put in the information into the computer, the computer spits out a report to us, and that’s what I sit and I work with clients using.

So because I was cutting out the report writing and the clients understand that I’m not doing a report, it’s not a formal report sort of thing, I wasn’t able to increase my rates, not in a very drastic way so that it wouldn’t, make me cost prohibitive to clients, especially the clients that I serve. That’s also really important to me.

When you’re working with millennials and millennial professionals, these are people that are pretty early days into their careers. They’re not senior-level executives or anything like that. They’re not making a [00:24:00] lot of money and so I wanted to always remain cognizant of that and provide a really unique service for a really reasonable value. I think I’ve figured that out.

Dr. Sharp: It sounds like you don’t necessarily bill for a “separate assessment”, the assessment process and is just billed into your therapy session rate. Is that right?

Dr. Erika: That’s right.

Dr. Sharp: Got you. Okay. Fair enough. So when you say, and you don’t have to talk details necessarily, but kind of relative to the market cost of therapy there in Miami, where do you think your rate falls then to incorporate these assessment pieces?

Dr. Erika: I think it puts me right at the average level, actually. I think I’m right on par with the going rate [00:25:00] in the community where I’m at, which is in central Miami, it’s somewhere between 150 to 170. So I’m right there. I’m right in that range. It’s not like clients are paying more than they would normally pay in terms of a going rate, but they get this added benefit to the kind of therapy that they’re doing and it’s much more targeted and in alignment with where they want to go in terms of their self-exploration.

Dr. Sharp: When do you incorporate the assessment, is that during the intake session or do you do it over the first two or three sessions or how does that work?

Dr. Erika: So there’s a few assessments that I always give initially. So the Becks, those kind of screeners are always, [00:26:00] I always tell clients to come in a little bit early just so that I can fill out those. Besides that, the other stuff gets tailored in as needed within the first four weeks, usually of therapy.

So usually they’ll come in once a week. And for the first four weeks, as I’m getting to know them, really understanding the clinical picture, by the fourth week, I’ll have administered most of the assessments that I’ll usually need to really make an informed case conceptualization and approach the client with a plan or a strategy for their therapy.

Dr. Sharp: And do you do this with every client?

Dr. Erika: I do this with most of my clients at this point. I have very few clients that I see right now that I haven’t implemented this model with, these are the clients that were with me before I started [00:27:00] using this model and they come in for maintenance, I call them tune up sessions. They come in as needed basis. So those are the only clients that I haven’t done this with at this point.

Dr. Sharp: How do you incorporate the results from these assessments into the session? Is it a formal feedback process or do you just throw it in there when it feels appropriate as you’re doing typical therapy or how does that look?

Dr. Erika: Initially it looks more like a feedback session, I would say, depending on when I’ve administered these and it really just depends. So in some cases, I’ll know just from the initial free phone consult that I need to administer an MMPI. I’ll know it just from that conversation. So I’ll tell the client, listen, you need to [00:28:00] come in either an hour before or plan to stay an hour later to do this particular test. It takes about an hour to do. And then we’ll discuss the results. It’ll help us.

I know you explain why, that’s really big with millennials. You really have to explain why we’re doing this. So I’d like to be really clear with them. Usually, yes, it’ll look like a feedback session initially but then as we’re in therapy and we’re going through the different sessions of therapy, we’re always referring back to the testing and is this possibly what the results were indicating? We’re always having a conversation about that, so it’s a bit of a dual process, if you will, going on.

Dr. Sharp: Sure. Going back just a little bit, could you give me your script for how you explain why this is necessary? Whether you say that out [00:29:00] loud or it’s on your website, how do you explain that this is just part of your process?

Dr. Erika: It is on the website. So most people aren’t too shocked when I have that conversation with them initially. I always frame it as sometimes there’s things that we’re not aware of that even with our best efforts and with somebody who’s very insightful and self-aware may not be aware of some underlying processes. Lucky for us, we have these tests that are able to access certain underlying processes that we may not even be aware of or be able to verbalize.

So when I explain that to clients, they get it. Usually, they say, okay, yeah, let’s do this. I [00:30:00] want to grow. I want to obliterate the psychological obstacles that I have in my way. If this is the way to do it, then I trust you. Let’s do it.

Dr. Sharp: That’s great. I like that way that you phrase that we can uncover processes that we might not be aware of and we have these instruments that allow us to do that pretty quickly.

Let me switch gears just a little bit. I know we’re getting a little bit close timewise, but how do you market these services? And then does that look different than marketing just a typical therapy practice?

Dr. Erika: Most of the clients find me organically. They find me when they’re doing a Google search. They find me on Psychology Today, by word of mouth. I would say those are the majority of my [00:31:00] referral sources. These sources have served me well for the last few years since I’ve been in private practice.

Could I do more marketing? Yeah, I could. I could definitely start talking to all sorts of other ancillary professionals that might come into contact with my ideal clients. Absolutely. I don’t know that I’m there yet and I don’t want to grow the practice so fast that it would become overwhelming for me to be able to manage that many cases.

I like to see about 15 clients a week and that’s my sweet spot as far as therapy clients. I don’t like to do more than that simply because there is the testing that I do for vocational rehab that I do love [00:32:00] and it’s really rewarding for me. So between those evaluations and the 15 therapy clients, I pretty much have a full plate and so I haven’t ventured off into marketing more for that very reason.

There is coming a day very soon where I will probably start marketing more and I will probably start taking on independent contractors to handle the overflow of clients.

Dr. Sharp: That’s great. Congratulations. It sounds like you’re in a good spot. If you’re seeing 15ish therapy clients, if you tack on an evaluation there, that’s gets you right up to full time pretty quickly. I totally understand that. Well, before I let, oh yeah, go ahead.

Dr. Erika: I was going to say about 15 therapy clients and maybe one to two evaluations [00:33:00] and that’s a full plate for me.

Dr. Sharp: No, that sounds about right. I’m a little bit jealous. I have more than I need. So being down at that level sounds pretty good right now.

Before I let you go, I wanted to ask you, any resources for the assessment process that you use, any books, any websites, and also any books or resources that are helpful, particularly with millennials that you could recommend.

Dr. Erika: The majority of my work in therapy revolves around perfectionism, codependency, shame, vulnerability, so I think that the work of Brene Brown, and the books by Brene Brown are really instrumental and key for that. I’ll refer a lot of my clients to her books and also now to her new website, courageworks [00:34:00] where she’s got some online courses for people to take to help them in the therapeutic process.

I find that when clients do those courses, some of them are free, some of them are paid, but they’re really reasonable, it really helps springboard the work that we do in therapy. It’s like homework, so to speak, so it just reinforces what we’re doing in therapy. So that’s really helpful.

I really love the work by Tara Brach on self-compassion, Kristin Neff’s work on self-compassion. She’s got some great resources on her website for meditations and exercises and journaling that people can do when they’re struggling with self-worth and self-compassion, which a lot of these millennials are struggling with.

It’s really surprising this generation, [00:35:00] how much they struggle with that and how that shows up in their relationships, especially their romantic relationships, because that’s really important. They’re in that Ericksonian stage of intimacy versus isolation and to watch them go through that and how they struggle and how self-worth interferes with their ability to form healthy, long-lasting relationships.

Dr. Sharp: So important.

Dr. Erika: So a lot of that work by those ladies are key.

Dr. Sharp: Absolutely. I remember, gosh, I think I was on my internship at UT Austin and my then girlfriend, now wife passed along Tara Brach’s Radical Acceptance and I remember that was a game changer in my life and so nice to start to get into that world, and since then the self-compassion [00:36:00] realm has really blown up in our field. And so totally on board with all of that. I think those are great resources.

Dr. Erika: Yeah. I know that’s more on the therapy side but as far as the testing side, I think that’s more along the lines of some of the listeners, I love the resources from the Wiley books, I call them the red, white and blue books. I always refer back to those books for different testing measures and especially refreshing my knowledge when I haven’t used a test in a while or a new test has come out, I always turned to that series of books for that.

Pearson’s got some great webinars by some of the test developers themselves [00:37:00] that come to mind. So if people haven’t signed up for those webinars or for those notices and emails, I’ve found those to be really helpful too.

Dr. Sharp: Okay. That’s good to hear. I get those emails for those webinars often, but to be honest, I’ve never jumped on and taken one. So that’s good to hear a little endorsement for the Pearson resources as well.

Dr. Erika: Yeah, I did one on the MCMI when the new version of it came out, especially the behavioral medicine one, that was helpful as well as the MMPI-2-RF. That was another one that I did and I found those helpful, especially just as primers for these new tests that were coming out just to better understand what the changes were, how the focus shifted within the measure themselves.

Dr. Sharp: Yeah, absolutely. That’s great. Well, thanks. And thanks for the [00:38:00] time. This has been a great conversation. I really appreciate you being willing to sit with me for a little bit and talk through this cool approach to using neuropsychological training in a different way in your practice.

If folks want to get in touch with you or learn more about your practice or about you, what are the best ways to do that?

Dr. Erika: The best ways to probably do that is online at my website, which is www.envisionwellness.co. You can always find me on Instagram, which is the millennials go to social media profile and you can find me @envisionwellnessco and that’s the same on Pinterest and I think that’s about it. If you go to the website, you’ll see all the social media links. So you can always find me through the website. It’s probably the easiest.

[00:39:00] Dr. Sharp: Erika, thanks so much for coming on the podcast. This has been a great conversation and I really hope that our paths cross again in the future sometime soon.

Dr. Erika: Yeah, absolutely. My pleasure. And thank you so much for having me on. This has been really fun.

Dr. Sharp: Yeah, same here. Take care.

Dr. Erika: Thanks. You too.

Dr. Sharp: All right. Thanks again so much for listening to that interview with Dr. Erika Martinez down there in Miami. I think it’s really cool how Erika has really built her practice to use assessment in a way that feels good for her and that follows her passion. I’m in a little bit of admiration that she was able to just turn her back on all that neuropsychology training, not entirely but for the most part, and has chosen to go a way that fits more with what she likes to do. That’s fantastic. So I hope you learned something there.

Thanks again for tuning in as always, is really exciting to see things continue to grow; podcast downloads, people joining the Facebook community. [00:40:00] It’s been great to reach out and connect with so many folks around testing. It seems like this is something that we need to be talking about.

So if you do want more information or want to join our community, you can go to the website, which is thetestingpsychologist.com, and there you can check out past podcast episodes, blog articles. You can find our Facebook community, which is The Testing Psychologist community on Facebook. That is a little different than the business page. So if you’re looking for it, just make sure you add that community to it if you’re searching.

I hope to continue to reach out and talk with you all week to week. Next week, I’ve got an interview with Allison Puryear coming up. She’s one of the best private practice consultants and she’s going to talk with us about networking even for introverts how that might work and how you can do that to build your testing practice. After that, I have a great interview scheduled with Aimee Yermish [00:41:00] who is a psychologist over on the East Coast and specializes in assessment with gifted and twice-exceptional kids. So I’m really excited for that conversation as well.

All right. Hope y’all are doing well, enjoying spring, whatever that looks like where you are, and hope to talk to you next time. Take care.

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