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[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

Many of y’all know that I have been using TherapyNotes as our practice EHR for over 10 years now. I’ve looked at others, and I just keep coming back to TherapyNotes because they do it all. If you’re interested in an EHR for your practice, you can get two free months of TherapyNotes by going to thetestingpsychologist.com/therapynotes and enter the code “testing.”

This podcast is brought to you in part by PAR.

The NEO Inventories Normative Update is now available with a new normative sample that is more representative of the current U.S. population. Visit parinc.com/neo.

Hey, y’all. Welcome back to the podcast. Today is a pretty special episode y’all. It’s episode 500. [00:01:00] I can’t believe that I’m saying that out loud. It started in 2017, 8 years later, 500 episodes down the road. It’s been a wild journey, a lot of ups and downs, and many beautiful moments. I’m happy to be here with you celebrating 500 episodes and reflecting back on what it is like.

First of all, super grateful to all of you. I hope I say that often enough, but this is definitely one of those moments to look back and embrace that gratitude. I appreciate all of you who are listening and have reached out for consulting and came in person to Crafted Practice, just building this business and helping to be a part of this experience for me.

I’ve connected with a ton of incredible people over the years from the [00:02:00] guests to y’all out there listening. And like I said, I’m very grateful for that. So thank you for listening. Thanks for being here. Thanks for doing this work.

My guest today is probably the most special. If you saw from the title, I’m talking to my wife, Carrie Haynes.

Carrie is a Licensed Professional Counselor here in Colorado. She got her Master’s in 2006 from Colorado State University. She served as the Director of Group Services at CSU’s Counseling Services from 2010 to 2017. She was an Adjunct Professor at the University of Northern Colorado and CSU during that time as well. In 2017, Carrie transitioned to private practice where she specializes in group work.

I’ve worked with Carrie for a long time. We were in graduate school, took classes together, and did practicals together before we started dating. [00:03:00] I’m not joking when I say that she is the best therapist I’ve ever seen. She is so intuitive, and she knows what to do with it. People love her, and her group work is even a step above that. She was born to do group work, and she’s fantastic at it. So I’m super lucky to get to hang with her all the time and run our little family group day to day.

Carrie specializes, like I said, in groups. She is an EMDR-trained therapist. She is trained in IFS. She was one of the OG ketamine-assisted therapy practitioners, has been trained since 2021, and like I said, just an amazing person.

I’m happy to have her here today. This is a personal conversation. We talk about the business. She’s a podcaster and has a private practice as well, but we talk about the personal journey and what [00:04:00] it’s been like over the last several years as primarily, I’ve built The Testing Psychologist, but she’s built her business as well and how we integrate business and family, and ups and downs associated with that.

I don’t know that there’s a ton to take away in terms of practice management or business strategies, necessarily, but I wanted to give a little peek behind the curtain of what’s happening in our lives and how we navigate this two-entrepreneur household.

So, without further ado, this is my conversation with my lovely and brilliant wife, Carrie Haynes.

Carrie, hey, welcome to The Testing Psychologist podcast.

Carrie: Thank you. Thanks for having me.

Dr. Sharp: I’m glad to be here with you. I’ll start with the [00:05:00] question that I ask everyone when they come on the show, which is, why do this work? Out of all the things that you could do with your life and your time, why this?

Carrie: It’s an easy question to answer because I believe that connection and human relationships are what make life meaningful. The work that I do with clients, especially in groups, is all about that. It’s all about helping people to connect more deeply with themselves and others, which to me, life would be not meaningful, and not fulfilling if it wasn’t for our deep connections with other people. So that’s why.

Dr. Sharp: It makes sense. People have asked me a lot [00:06:00] when I talk to them about what you do; they ask me what Circlework is, what kind of groups you lead, and what they’re like, and I don’t actually have a great answer to that. And so, I thought that might be a good place to start. I would like to hear how you describe Circlework to people who might be interested or curious about it.

Carrie: I think it helps, especially for your audience, probably the people listening to this; they have some context. So the way I describe it to people who are in the field might be a little different than the way I describe it to people who are not. So I’ll describe it that way.

And what it is, is when I started working in group therapy, which a lot of your listeners probably understand more like psychodynamic groups, I felt magic that happened when people would connect in that space of intimacy and [00:07:00] the here and now, and being authentic with one another. That was the magic but there was something missing for me.

At times, I would question sometimes things that happened in groups that felt harmful or not as helpful, and wonder what created that magic. And so when I left the university, I went out into private practice. I was looking for filling in those gaps of the parts of group therapy that didn’t feel so helpful.

I had a sense of what might make them more helpful. I found Jalaja Bonheim. I found her through Tara Brach, which some of your listeners may know Tara Brach. She’s always been an inspiration to me.

What Jalaja Bonheim Circlework training taught me was how to bring the body more into group work, which I hadn’t really learned explicitly of how to do more [00:08:00] somatic practices. So Circlework adds the somatic practices.

The other piece that Circlework brings in is ritual. It brings in meditation and spirituality, not any particular form of spirituality, but it explicitly emphasizes the importance of some connection to something greater than ourselves.

These tenants of Circlework were what balanced it for me because I still had the connection, the intimacy, and the authenticity that I got from all the other group work. But now Circlework brings in the body, the spirit. So it felt like a more holistic approach.

The other thing that Circlework does that other group modalities that I’ve been trained in didn’t do as well is it starts with the assumption of wholeness. So we’re not trying to figure out what is the pattern? What are you doing that isn’t working? We’re reminding you of who you [00:09:00] are, which is whole and complete and perfect as you are. So those tenants. That’s how we practice Circlework.

So what if you were a fly on the wall and you came into one of my circles? The kind of things you would see is a really spacious environment, slower, oftentimes, we’ll sit on backjacks on the floor with a blanket. So there’s a comfiness. There are a lot of practices that are movement-based. There’s more silence. There’s some ritual. There’s also the sharing, connection, and processing that happens in other types of groups as well.

Dr. Sharp: I think about the distinction sometimes between therapy and therapeutic, and I wonder how do you think about that with Circlework? Would you call it therapy, or would you call it therapeutic, or both, or what?

Carrie: I think it depends on the type of circle that you’re [00:10:00] offering. Circlework can be adapted to be therapy. I’ve used it many times in that way.

There are times when I offer circles or groups that are more what I would consider therapeutic. They can go more on those lines of psychoeducation or restorative practices. And so I think it’s really about the skill of the facilitator, what your intention is, and how you’re going to use it.

Dr. Sharp: You talked about some of the harms of traditional groups. When we say traditional groups, I think we’re talking about Yalom-style interpersonal process therapy groups, more depth-oriented traditional therapy groups. I’m curious, when you say that there are some harms that Circlework might help with or avoid, what are you talking about?

Carrie: There are times in the [00:11:00] group work that I saw, part of the process would bring up people’s defenses instead of lowering them because people would be giving feedback or maybe it felt like an environment where we were looking for what are you doing that isn’t working? I’m not saying they’re all interpersonal because I think interpersonal groups can be amazing, especially when facilitated skillfully.

There were times, though, that I felt like people might just recapitulate their experience in a group and end up not getting that corrective emotional experience. And so that could be more harmful.

In Circlework, there’s a way of being that we focus on in the facilitator that is more heart-centered, that’s more present, that [00:12:00] minimizes the chances, but I am not under any illusion that Circlework could not also be harmful. I feel like any group work is a risk, and it can be used for better or worse. In any group environment, harm can happen.

For me, the ways that circles were facilitated complemented what I had learned. I still use all of my process-oriented skills. It’s just that I feel more balanced in having this more holistic approach, and it fits more with what’s been healing in my own life. The work that I’ve done.

Dr. Sharp: I think that’s a big part of it. You’ve done a lot of this work personally, and you’ve experienced it before offering it. I think that’s important.

I have to admit that when you first got into it, I didn’t know what you were talking about. It sounded pretty wild compared to [00:13:00] certainly the groups that we were used to and that we were trained in.

The audience doesn’t know, I don’t think, but we went through graduate school essentially together. You were in the Master’s program, and I was in the PhD program, but we overlapped a lot. We were trained by the same person and the same style of group facilitation, which was fantastic.

Carrie: Yes.

Dr. Sharp: And really the foundation of our relationship because we always joke that we met in group therapy and have been running our own little group for almost 20 years now with our kids and family. This is a vast departure from what we were used to. It was really interesting to see you go through this process. It feels like it fits your personality and the folks that you’re working with.

Carrie: What was it like to have me come back from that and just seeing my [00:14:00] excitement for it? Were you like, oh, is this going to stay or what?

Dr. Sharp: I knew that it fit for you. That was never really a question. I could tell this was something that really resonated with you, but I’m sure folks are not going to be surprised to hear that my mind was like, what is the evidence for this? What’s the research behind Circlework? Do we have anything to say that this is helpful or is this just women dancing in the woods or whatever? Which would be fine, but that’s where I went with it.

Over time, it’s clear whether there’s peer-reviewed research to support it or not, you can argue that it’s helpful and that it gives people something that they’re missing.

Carrie: I think that there is. I don’t know that anyone has [00:15:00] done peer-reviewed research on Circlework. More and more, we’re seeing all the modalities moving this way. IFS talking about Self and that’s research, that’s about connection to something greater is a big part.

So I think the aspects of Circlework do have research embodiment using polyvagal and all of these things are being incorporated; the meditation, the silence, all of that stuff, we can look at but it’s just like taking pieces of this modality and then seeing that they have been researched in other modalities. I think the combination makes them uniquely powerful.

Dr. Sharp: I think that’s true. I hear you describe these experiences and there’s a part of me that’s terrified at thinking about being in a group like this because like you said, there’s dancing and singing. [00:16:00] The meditation feels comfortable, but the dancing and the singing, that’s a little …

Carrie: It was terrifying for me the first time, too. Having been in a university for the first 10 years of my career, this was not the kind of stuff that I had done. We move into it really slowly. The dancing started out with just shaking with a lot of people, which a lot of people know that our nervous systems respond to just shaking.

So people aren’t asked to free dance right away, but I get it. That’s not something that most people are comfortable with. Singing was not comfortable for me, but it was incredibly freeing after challenging myself in that way to be able to move into being more self-expressed and noticing now that I love those practices, and they [00:17:00] were really hard before.

Men’s circles, I think there’s another edge that we’re working within men doing free movement, singing. You have probably some more cultural and social barriers there.

Dr. Sharp: We’ve talked about it mainly in the context of women or women-identifying individuals.

I wonder, what does it look like for men if it’s different?

Carrie: I have not facilitated many circles with men. I do modify it because some of the practices don’t seem to fit all gender groups. And really, at the heart, it’s the same thing. Men need to be in their bodies. And so, how do we find ways for people to get embodied? It doesn’t [00:18:00] have to be dancing. It could be stretching. It could be attending to what’s happening in the body.

So there’s a lot of ways to modify these practices to fit the audience because the last thing you want to do is get the audience that you’re serving out of their window of tolerance. I would probably be thinking about who are these men. What are they here for? What fits this group? And then how can I incorporate their body in ways that might be a little edgy, but wouldn’t be the deep end?

I think it’s interesting because in a lot of the psychedelic work that I’ve done with ketamine-assisted psychotherapy and having a lot of men in those spaces, and a lot of these practices are used for integration, at least the men in those spaces that come seem to yearn for spaces where they can be more free and where they can [00:19:00] move, sing, drum and do things like that just express themselves a little more freely. So I think it depends.

I modified some of the practices because some feel more “feminine” in nature. Although, I believe we all have all those aspects. So depends is probably the best way to put it.

Dr. Sharp: That’s reasonable. I think there’s something, we could go down that path for sure with gender norms and things like that, what’s okay and what’s not okay.

I think that’s the other side of the coin of the terror that I was talking about; thinking about being in a circle like that is that it’s terrifying, but I think that’s because it’s maybe not as okay for guys to let loose and be uninhibited in that way, [00:20:00] and in their bodies, feelings and all those kinds of things. But then the other side is like, oh, that sounds nice if I just had more maybe permission to do that. It’s also attractive in a way.

So, speaking of this kind of thing, who is an ideal candidate for a circle?

Carrie: That’s a difficult question. I think that anyone could be a candidate for circles. There has to be a bit of openness to this type of work.

For me, I believe that circle work is no different than any other type of group work. It’s just really the basis of how you’re doing it. So I adapt circles. What I’ve learned in the Circlework training, I have combined with all my group therapy training. I teach and train people to do this.

So I have people who are doing this [00:21:00] with middle schoolers, and they’re adapting it to middle schoolers. So how do we help middle schoolers be embodied? How do we add in just some movement? How do we talk about connection to something greater than themselves or nature? How do we do interpersonal practices so it works for middle schoolers and it can also work to utilize it in meetings? How do you make a meeting feel more intentional?

So, anyone is a good candidate for circle. It’s more the skill of the facilitator and the intention. For me, my focus has been mostly therapeutic work because of my background as a therapist, but Jalaja has trained a lot of people in doing circles for activism, for peacemaking.

So there’s a lot of ways to use it, but my specialty is helping therapists bring it in [00:22:00] and serve their unique population. I find that a lot of people that are attracted to the training are often women who are interested in serving all kinds of different populations but in a therapeutic way.

Dr. Sharp: That’s fair. Since you bring it up, I would love to know how to bring some of this work into my meetings. How does one bring some circle experience to a work meeting?

Carrie: I’ll just walk you through what I would do if I were facilitating a meeting and I wanted to shift it. Usually, the intention is like our meetings are too heady in the sense that we want to get things done, but we want to do it in a way that feels a little more intentional. And so I might put something, one part of Circlework [00:23:00] is beauty is an intentional part. So, bringing in beauty.

One thing that my teacher Jalaja says is beauty is love’s twin. Appreciating beautiful things, art, and not just for capitalistic use, but just for it being itself. So I might bring in flowers or something to have in the middle of the table, just add something small.

I would make sure that we’re sitting in a circle rather than sitting lined up or all scattered out because there’s something about being seated in a circle that feels different. You can just feel an energy that shifts when we’re all sitting that way instead of someone standing in front of the room.

I would take two minutes to help people drop in, and that doesn’t mean you have to do some long meditation, it can just be as simple as let’s just [00:24:00] take a deep breath and show up, and maybe check in and see, how are folks coming in today? With one word, how are you coming into this meeting? Just attend to who’s there.

In a lot of meetings, we need to get things done. So that might be enough; that in and of itself just shifted the energy and then we maybe facilitate it in a way that has some spaciousness. So maybe I want to try to make my meeting a little longer, to try not to be going as quickly, allow people a moment to breathe in the meeting, and so it can feel more nourishing and connecting for them. And that is the energy of bringing in a little more of a circle energy to a meeting space.

Dr. Sharp: If folks want to learn more, read about this, do you have any resources then?

[00:25:00] Carrie: They can go to my website, you have it, carriehayneslpc. And also Jalaja has written several books. I want to be clear that while she created Circlework, I have adapted it and it’s my own expression of multiple different types of group work I’ve trained in. So that’s one of the strongest pillars or foundations of the work that I do now, but the interpersonal process is also strong.

I’ve done some work with psychodrama, the Way of Council. So I’ve done a lot of other group work that informs the way I do it, and unfortunately, Jalaja is not teaching anymore, but someone could come to my website. She has written books on her way, which might not be exactly the way I’m describing it, but it provides a lot of foundations and understanding about group work.

[00:26:00] Dr. Sharp: Well, I encourage anybody to go check it out. It’s been remarkable just seeing and living vicariously through you over these past several years and seeing how this works out and how you’re bringing circle energy to our family.

Carrie: I have. We’ve done it as a family. I love those moments. I’ve done circles with the kids and you and it’s great.

Dr. Sharp: I’m very grateful.

Carrie: So now it’s my turn…

Dr. Sharp: Yeah. I think so.

Carrie: …To turn the tables.

Dr. Sharp: Yeah.

Carrie: Yes. Well, I’m excited about this, that I get to interview you.

Dr. Sharp: I’m scared.

Carrie: You should be. I just want to acknowledge that this is the [00:27:00] 500th episode of The Testing Psychologist podcast and brings us right there to what achievement that is.

Dr. Sharp: Thanks. It’s persistence, if nothing else.

Carrie: Yes.

Dr. Sharp: Or stubbornness.

Carrie: It’s something that you have. So looking back on this whole journey, 500 episodes, take us back to starting the podcast and what was going through your mind. What was the inspiration for doing this?

Dr. Sharp: It’s crazy to think back that far. That was 8 years ago. It was January 2017. I’d started the process probably 6 months before that, so that was the time when I first got in touch with a business coach and went that route because I’d had my [00:28:00] practice for 6 or 7 years at that point and felt like I had it down, which seems silly now in hindsight and knowing everything that happened after that.

But at that moment, I felt like I’d mastered private practice and I was ready for something different. So I hired this business coach to figure out what to do with the practice. I knew that I enjoyed teaching, but I did not want to be a teacher. I didn’t want to do an adjunct or go do a formal professor thing at the university, but I knew that I liked teaching.

Luckily, this coach, Joe Sanok, he was my first business coach. I’ve talked about that. He hosts the Practice of the Practice, which I think was one of the original mental health business-oriented podcasts. And to his credit, he said, well, there’s no podcast in this testing space. So why don’t you go that direction?

[00:29:00] At that time, I had no idea. I follow directions well though. He said, “Do a podcast.” I was like, let’s give it a shot. I remember thinking, I don’t know what in the world I could talk about related to testing for more than 10 or 15 episodes. So in the beginning, there was a lot of just, hey, we’ll just see if this works and if it doesn’t, that’s fine. It was an experiment, if nothing else.

Carrie: If you could go back, just imagining now that your 8 years ago self that’s starting this podcast and now that you’ve had the experience of 500 episodes, what would you tell yourself? What advice would you give to that newly first 3 episodes? What have you learned?

Dr. Sharp: Oh gosh. [00:30:00] Three things come to mind right off the bat:

1. Don’t do any editing yourself. I should have hired an editor or a post-production person from the very beginning, but of course, nobody ever does that. You have to do it yourself.

2. Don’t be afraid to challenge your guests a little bit more. I think my default is to be more agreeable than not. I’ve found that over the years, that makes for a little bit of a richer discussion to offer different viewpoints, or at least ask more challenging questions.

3. And then the last thing, at least right now that comes to mind is, that I probably tell myself to not be afraid to get more personal and be more vulnerable on the podcast and share personal struggles or difficulties. Those have [00:31:00] been some of the episodes that have been most popular and resonated the most. When I started, I felt like I had to be an expert. I think people like to see the humanity at the same time.

Carrie: How do you balance that now that you know that people want to see the humanity, want to know you and also there is a part of people learning and getting expertise?

Dr. Sharp: I think the frame has shifted a little bit for me where in the past I would just present the information as here’s what you could do, here’s what the research says, here’s what the business books say, or whatever.

Now my frame is more like, hey, I’ll present that information, [00:32:00] but I have very little trouble weaving in the personal stories of, here’s where I messed this up. This is the way I did this wrong, things like that, and just trying to be a little bit more deliberate about sharing all of the things that I talk about on the podcast.

I have done wrong or messed up at least once, usually multiple times. I hope that that’s coming through and it’s not just, here’s what you do, but this is what I did. Here’s how I learned from it, or here’s how I’m still struggling with it.

Carrie: I think that takes a lot of courage to show where you’re messing up and publicly state that. So I admire that. I think it’s hard to do. [00:33:00] I do think we all want to hear that; we want to hear the vulnerability and know that I’m not the only one messing it up.

How do you think having our two children and having this family life because 8 years ago, our daughter was three and our son was five, how has having a family affected you? Because it’s not just the podcast. I think your listeners probably know, you got a group practice and now Reverb. How do you think our lifestyle has affected your work? Talk a little bit about the challenges of having young kids and doing everything you’re doing.

Dr. Sharp: Let’s take a break to hear from a featured partner.

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Let’s get back to the podcast.

That’s a big question. The first thing I think of is just that I couldn’t do it without being in a great partnership. We’ve had to do a lot of negotiating over the years with time and how I’m spending time, how you’re spending time.

It’s not for the [00:36:00] faint of heart, I don’t think to have two entrepreneurs in the family or two business owners. That’s the first thing. I definitely could not have done it without just being supported, which I really appreciate.

I’m trying to think. It’s hard to remember back then. I remember working on the weekend. When I started the podcast, there was a lot of weekend stuff because I was doing the practice at the same time.

There’s always been this thread, I don’t know if you remember, but back when I started my private practice, the one thing that I said was, I just want to be able to pick them up from school every day. That’s a goal for my schedule.

And even though I was working on the weekends and sometimes [00:37:00] at night after they would go to bed and stuff, I feel like I did okay. I did pretty well at sticking to that. And that’s been important and invaluable.

There’s this whole other dimension of how to share about our personal life and our kids on the podcast because parenting has its own struggle and I’ll talk about parenting here and there with my guests. We talk about kids’ development a lot and I’m always negotiating how much I share about our kids versus keeping it pretty general or academic.

I think I’ve erred on the side of not sharing a whole lot. I’ve commented two times here and there, but I think that’s something that probably anybody in the space works with. [00:38:00] A lot of the audience knows how much you share about your own family and your own kids if you have them, and personal experience with clients and things like that.

So I’m going through all of that as well. I don’t know if I answered that question at all, but those are some things off the top of my mind.

Carrie: Well, and some things I want to name is that you’ve had to be a lot more thoughtful about your time, your balance, and being very efficient. You definitely are skilled in those ways that it makes sense that Circlework might feel a little harder, like the dancing because the way your brain works is efficient, which is great. That’s why we’re a good match.

But what I have witnessed from the outside is I see how hard you work at time management and then also being able to set things aside and tend to the kids [00:39:00] or to me or to the family. None of us are perfect at it, but I feel like that’s something that if anybody, it’s not easy, but I’ve seen you’ve had to work really hard to be able to be present.

We’ve had so many conversations about not regretting that you’ve worked during their childhood. And so you’ve been very intentional at, well, that email is not going to get sent out, or that things not going to get done, or someone else is going to be disappointed because I’m picking them up from school, and I have to leave this time.

I think that that’s something I’ve seen you struggle with because it’s like you’re always having to see who you’re going to disappoint and you made a line in the sand about not disappointing them or yourself. I’m sure there are times that you’ve had to work that you wish that you didn’t, but I feel like [00:40:00] I’ve watched you walk that line of trying to show up as a partner and a parent while also trying to show up for the podcast, the episode you said was going to be out, the employee, all that stuff. So that’s felt like a big balancing act.

Dr. Sharp: I appreciate you saying that. That means a lot. I’m always thinking about it, but I’m glad that’s what’s coming through.

And you’re right. I think a lot of us work with that as just making those choices. I think when you have kids, and you have a business or multiple businesses, and a partner and personal commitments, and all those things, nothing’s ever 100%, or if something is 100%, then something else is 50%. It’s always this balancing, [00:41:00] taking from one to build the other. It’s important. I’ve tried to be present for them as much as I can. It’s good to hear that comes through.

Carrie: This is a shift, but I’m just curious, what has been the most ridiculous, silly, or if there was a blooper or something like recording the podcast or during this time working that you’re like, oh my gosh, if people could see this now. Do you have a moment that you think this is ridiculous?

Dr. Sharp: Oh my gosh. I don’t know if it’s a single moment, but if people could see the number of times that I rerecord an introduction or something. There’ve been times I’ve sat in front of my computer for 30 minutes trying to record a 1.5-minute introduction.

[00:42:00] It just gets progressively more ridiculous, and you know this, you have a podcast. You do it two times, you’re like, okay, now it’s going to be good. And then you do it again and you’re like, ooh. I’m talking out loud to myself. I’m like, what are you doing? Get this under control. And then it just amps up even more and then it’s more that it messes up.

Those are probably the silliest moments when I’m here alone in my office cursing and rereading the script or whatever, and just trying to nail those introductions. That’s happened many times.

Carrie: Many times. Yes. I just did that the other day. It’s like, you don’t want to be reading, but you don’t want to say, um, 100 times. So you have to get it just right. And the more you do it, the worse it’s getting. I’ve been there.

Dr. Sharp: Yeah. I don’t know though. The episodes have been pretty, as far as I can remember, I’m sure there was some craziness at some point, but [00:43:00] it was pretty straightforward. Guests are pretty accommodating and polite.

Carrie: What’s your favorite thing about doing the podcast?

Dr. Sharp: I don’t know. I love it. I always say it’s my favorite part of the week. I think that’s still true. There’s probably two things. We’ve talked a lot about me and my personality is I love learning things and mastering things.

And so that process of being able to talk with experts and ask them any question that I want, learn about things and even researching the solo episodes and digging deep into a topic and finding out like, well, what is the science behind Google reviews, consumer pricing or whatever it may be? I love gathering knowledge in that way.

[00:44:00] And then, like you said earlier, the connection has been fantastic. The podcast has been an avenue to not just connect with the guests who on the whole have been fantastic. They’re all so knowledgeable and great guests, and making connections one-on-one, but then the podcast being an avenue or vehicle for connecting with other folks around the country; the podcasting other consultants. It’s opened up the world a lot.

I don’t take that for granted at all. The fact that I could go to almost any part of the country and I would probably know someone and be able to go to coffee or whatever, and just have a connection. That’s pretty special. The podcast has done that.

Carrie: When did you realize that it was making a difference [00:45:00] or that people were listening? Because there’s a moment where you’re just talking into the void and then it becomes something. I’m curious about that time.

Dr. Sharp: I forget the date. I think it was around COVID maybe. So that was 3 years in. I don’t know. I’d have to go back. I might be getting this wrong, but there were two things that happened. One was, I did this episode 119 with Donna Henderson, Autism and Girls and Women. That really blew up. It’s still my most downloaded episode and in large part due to Donna’s expertise and just people interested in that topic.

But that blew up. I was looking at the downloads and I was like, oh my gosh, this is a ton of people. And then right around that time, we got into COVID. I was doing more episodes on remote [00:46:00] assessment and partnered with Pearson to do some episodes on how to administer the WISC over telehealth.

People needed that right at the moment and just started getting more feedback and more outreach for speaking and things like that. And so that may have been a little bit of a turning point. It’s still easy to forget though, honestly, that there are real people out there who listen.

It’s been nice to get into Reverb, which is our software company. I think a lot of people know about that by this point and jump on our sales calls. I would say 80% of the folks that I talked to will say something about the podcast or the Facebook group. And that’s been really nice to just be able to connect with folks who are out there listening. It makes it more real.

Carrie: I think it speaks to the persistence because for 3 years, [00:47:00] just day in and day out, and that’s something that I’m guessing your listeners know that you’re a long-distance runner. Do people know about that?

Dr. Sharp: I think so. I think I’ve talked about it.

Carrie: Talk a little bit about that and how that running is meaningful for you because I think it translates a lot into what you used to maintain the Facebook group, the podcast, and the group practice, even when it gets hard. I’m curious for you to talk about that. It’s such a big part of your life, running.

Dr. Sharp: For sure. I don’t know that I have anything revolutionary to say about this, but it’s all the things, all the clichés that go along with running. You get up and do it even if you don’t want to do it.

There are many days, especially in the Colorado winters where I do not want to get up and run in the morning, but I know that it’s going to be better [00:48:00] after I do it. That’s a parallel for sure. There are times when I’m like, oh my gosh, I have so much to do. Can I take the time to research all this and put these episodes together? But it’s always great when it’s done.

I think it’s, gosh, maybe Seth Godin. Did he write the book? Maybe it’s called the practice, anyway, or the work or something like that. He talks about how you just do it.

That’s built into my personality. Maybe it’s stubbornness, maybe it’s rigidity, maybe it’s inflexibility, but for better or for worse, I pick things and I do them, and running is a big part of that. It’s just the practice. I know I’m running four or five days a week. And then it’s the same with the podcast. I’m dedicated to it and I know I’m going to do it. And that’s [00:49:00] a big part of doing anything. If you’re going to do it, you got to do it.

And then there’s all this stuff around pain endurance and getting through hard stuff, not quitting when you want to quit. I think all that’s probably relevant, and baked in there somewhere. It’s also my stress relief too. And that it helps me think more clearly. So on the days when I run, I feel like I show up a little sharper.

Carrie: Yeah. I know this, but I think the listeners might be interested. That’s your strength, but every strength has a challenge. So what’s your growth? Where have you seen these ways of doing things, or you look back and some of that persistence, you would do it differently or that you need to work [00:50:00] on? What’s your …?

Dr. Sharp: I would probably experiment a little bit more. I think that’s the other side of that equation of being persistent and routine is that, I don’t experiment a whole lot. I like to stick with what works. So I would have experimented earlier, different types of episodes or trying to launch that in-person event quicker instead of waiting so long. It’s all just fear. Being worried that it wouldn’t work out or people wouldn’t like it or something.

Again, probably challenge my guests a little bit earlier, but I think that’s the flip side of the routine, the predictability and the persistence are getting locked in and being a little more rigid, like I said. [00:51:00] So anything to break out of the box a little bit, like trying new formats or maybe do video earlier or something like that.

Carrie: I’m hearing a lot of quicker too, not just doing different things, but doing it faster.

Dr. Sharp: Yeah. You know this, the audience probably doesn’t, but I take a long time to make decisions. I’d like to be quicker with a lot of these things.

Carrie: What is it like to be married to me who is the opposite? When you’re saying all that, I’m like, that’s interesting. I know this stuff, but …

Dr. Sharp: What is that like? At times exhilarating and at times infuriating.

Carrie: Same, same.

Dr. Sharp: Exactly. I think it goes both ways.

Carrie: Yeah.

[00:52:00] Dr. Sharp: I think it’s okay that we’ve influenced one another. I like that we’re able to talk to one another about what we do, especially now over the last few years. You understand the podcasting element, the consulting component, and private practice.

I think we influence one another in good ways. You’ll throw these ideas out there and get me to consider different things. And then I’ll percolate for a long time and then you push a little bit more, and then I’ll make a decision, and vice versa maybe.

Carrie: Definitely.

Dr. Sharp: We slow things down.

Carrie: I would not have started my podcast had it not been for you starting yours. A lot of the things that you’ve done, I’ve taken inspiration from. I do think I’m the force of the spontaneity in the family and I challenge you that way. I’ve learned a lot from your consistency.

And while we [00:53:00] drive each other nuts with those same things, they can be a source of contention in our relationship. They’re also a strength in the way that we come together, so it’s been good.

I’m curious, if you had to pick because you have these three major roles that we’ve talked about; you’re the podcast host, you are Reverb, and also group practice owner, I guess consultant. Are any of these feel closer to the true you? If you were only allowed to do one, which one feels closest to your natural way in the world?

Dr. Sharp: Wow, that is a hard question. I think they all have pretty strong elements, and different components. I really don’t know. [00:54:00] If I had to pick, I don’t know that I can answer that question.

That’s really tough. This is deliberate. I have crafted them in ways that work. I’m 25% extrovert, 75% introvert, or maybe I don’t know, 60%, 40% or something. And they’re all like that, I’m around people with my practice, but I also do a lot of independent work as part of that.

It’s the same with a podcast. I do a lot of independent research, but then have a portion that’s face-to-face where I’m interviewing or consulting with folks. I love the connection part, but I do love independent research time and personal project time.

Reverb’s the same way. I [00:55:00] spend a lot of time on sales calls, but then the majority of my time is probably independent projects and working on things for the business. So that’s funny. I haven’t thought about that, but they all have this probably 60, 40-ish mix of independent versus connected or people time. And I’m sure that’s not a coincidence.

Carrie: And clinical work felt like straight clinical work that wouldn’t have fit.

Dr. Sharp: I don’t think so. I don’t think I could do full-time clinical work at this point. There are too many other things to learn, engage in, and people to talk to, but I love it in moderation. I don’t think I’ll ever give it up, but I don’t know that I’ll go back to full-time clinical work at this point.

Carrie: Is there anything that you think [00:56:00] your audience would be very surprised to know about you outside of the podcast?

Dr. Sharp: I don’t know. Maybe my preferred music genre is rap and hip-hop. I don’t know if that’s surprising or not. I’ve been a total rap, hip-hop fan since I was 14, that hasn’t changed since high school. I don’t know what else? You probably know better than I do.

Carrie: Well, the hard part for me right now is I don’t know what you’ve shared. I haven’t listened to all the podcast episodes. So there is a little element of mystery of like, I am trying to get into the minds of the listener, and at the same time, you’ve started to do more personal episodes. And so you may be sharing more than I know.

It’s interesting too, to be me interviewing you because I know all these [00:57:00] things about you. So I’m asking you questions, some of them I don’t know the answer to, and some of them I do. It’s just an interesting place to be.

I do know that in my experience in our life friends and whatever are curious to know about you because you’re not the first person to share a bunch of intimate details or your inner workings that it takes someone asking you questions. It takes someone being interested for you to share about yourself. So my guess is that there’s a lot of things you haven’t shared that people might be curious about.

What’s something you wish people would ask about? Is there anything in your life that you’d like to talk more about or that you feel like no one ever asked about?

Dr. Sharp: Oh, I don’t know. Not really. I feel like I’m a pretty simple person. Honestly, [00:58:00] I like to learn things. I like to talk to people in interviews. I like to be good at what I do, but it’s pretty circumscribed. I don’t know that I’m a super interesting person, necessarily, man.

I don’t know what else I would want people to ask about. I could talk about running all day. I could talk about silly things, crossword puzzles, scrabble strategy, and things like that.

Carrie: What consumes your thinking when you’re not thinking about work?

Dr. Sharp: Oh, gosh. That’s a hard question. Books to read. Topics to research on the internet. Coding software. I do a lot [00:59:00] of random, oh, probably personal improvement stuff. I’m looking at what these rucksacks to carry weighted plates around, the benefits of cold showers versus warm showers or whatever, random stuff like that. I do a lot of that kind of stuff. What else? Soccer strategy, how to score gymnastics events, things that relate to our kids for sure.

Carrie: And what’s your, why? The question you ask is, why do this? Why are you doing all this?

Dr. Sharp: I want to give the virtuous answer and say it’s to help people, to spread knowledge, to distribute free information and those things. All that’s important, but if I’m being honest, [01:00:00] I just love it. It’s a lot of fun.

Like I said, I get to learn as much as I want to about whatever topics I want to in this realm. I get to develop skills. It’s challenging. It keeps me interested. It’s motivating. All those things.

Carrie: I want to ask another, maybe it’ll be a hard question, but I want to know what has been the hardest time on this journey, the most challenging parts?

Dr. Sharp: With the podcast specifically?

Carrie: No, I don’t think you need to stick to the podcast because you talk about all your work, so if something stands out; the group practice, Reverb, I think those would all be interesting.

[01:01:00] Dr. Sharp: I’ve talked about on here, probably the last year or so with the practice before making that transition, that’s the toughest time. As I think I talked about, it was challenging to navigate.

The worst thing in the world for me is feeling like people are mad at me. With the practice, toward the end especially, it got to the point where it felt like 90% of my job was just working through what it’s like for people to be mad at me, which you could argue is like a cosmic karma thing. This is the work that I need to do, but frankly, I just didn’t want to do that work anymore. And so I would rather practice working on that [01:02:00] here, or in my close relationships or something. So that was hard.

Carrie: You get enough of it for me. I can work on …

Dr. Sharp: I get enough practice.

Carrie: … when he’s mad at me or when the kids are mad at me, that’s good.

Dr. Sharp: Ultimately, just feeling like I was disappointing people. That was really hard over and over. It was stressful. It wasn’t super fulfilling.

Like I said, a big part of my job was just navigating problems, and there wasn’t a whole lot of joy there, but I stick with things. I had a really hard time making that decision to change things up and scale back for a lot of reasons. That was probably the toughest. There are a lot of layers to that: working through failure and what that means about me and my identity as a business owner and all those things. That’s a lot.

Carrie: And what’s it like now to [01:03:00] be in a different place than that?

Dr. Sharp: It feels better. Thankfully, you were super supportive and patient in all those conversations. My consultation group was fantastic in helping me work through some of those things. It was really tough.

I’m almost a year on the other side of when I first started telling people that we were going to scale back, and it feels totally different. It’s much less stressful and more joyful. I think the people who are here are more content, doing good work, and feeling connected to one another.

Carrie: It’s huge.

Dr. Sharp: That’s important.

Carrie: Yeah.

Dr. Sharp: It’s been a journey.

Carrie: It has. So one final question is, what do you think the key has been [01:04:00] to us staying married through all of this?

What do you think? Though, a lot of people ask me about that, about us both being ambitious and having the careers that we have, kids, and all that we’re balancing. I do think we’ve done some things intentionally. I don’t know if you’ve shared some of that stuff with your listeners, but I’m curious to hear what you’d have to say.

Dr. Sharp: Clearly, my sense of humor and ability to keep us on track. I think we’ve both been pretty patient, forgiving of one another, and understanding when we’re under stress, needing certain things, need more time or whatever it may be, and that’s [01:05:00] helped a lot.

I think the dedication to our kids was pretty; they are our anchor. We show up for them, and I think that pulls us together to a degree. However, for many years, we’ve been doing these standing weekly day dates. I can’t remember if I’ve talked about that here, but the day date is underrated for sure.

So we do this weekly date on Fridays from 1.00 PM to 3.00 PM while our kids are at school because we’re so busy at night with activities and stuff. That’s been really nice. If nothing else, we know that we can come together for two hours once a week and just catch up, check in with one another, and ground a little bit, and I think that’s helped [01:06:00] a lot.

Carrie: I think the weekly meetings are a big deal. It goes even back to some of that stuff I talked about with bringing circle energy. We’re very intentional. We walk a lot of the time. We have intentional prompts. So we’re not just talking about business, how are you? How are you really? The intentional connection has gotten us through.

They haven’t always gone well, but to feel prioritized even in the midst of all the craziness and that we’re prioritizing our relationship, and then to also make sure that we’re dropping in at a place that isn’t just, are you picking up from soccer? Are you going to this? I feel like it’s a game-changer. And to know that we have that space has made all the difference.

I think it also helps that I [01:07:00] respect and admire what you’re doing. I’m on board with what you’re doing and it feels good to feel proud of you. And that matters.

Dr. Sharp: Likewise.

Carrie: It has always been easy. There’s been rough times but when it’s gotten hard, we’ve doubled down and done what we needed to do to take weekends away also, an overnight or a weekend away, and even times by ourselves, that we’ve supported each other go to a hotel in town, I’ve done that. And you’ve supported me in like, I need to go work in a hotel. That balance has made a huge difference for us.

Dr. Sharp: 100%. It’s funny to think of it this way, but [01:08:00] I have a lot of respect for what you’re doing. And like you said, proud of what you’re doing. I think that goes a long way. It does help get on board and support one another.

But I want to be super clear. I feel self-conscious. We’re just glazing each other all day here, but it has been hard. There’ve been a lot of hard moments, but it’s cool to reflect back and recognize, especially at this point in our lives, we’re at that age where not all of our friends are doing super well. It’s been cool to recognize that something’s working. I am very grateful.

Carrie: Me too. So what’s next? Do you imagine 1000 episodes?

Dr. Sharp: Oh gosh. Eight more years.

Carrie: Yeah. Do you know?

[01:09:00] Dr. Sharp: I don’t know. I’ve said this to a few people who I have interviewed at our practice. They say, what’s the long-term plan? And for the first time in a long time, I don’t have a really clear long-term plan. Usually, I’m a big one-year, three-year, five-year kind of person. It feels nice to just be settled in some equilibrium, I guess.

The practice feels very stable. We’ve self-limited by moving into one office suite so we can’t keep growing. We have limited office space. So we’re not growing. With the podcast, I am happy with what it’s doing. I’m going to continue to try to get fantastic guests and try new formats here and there.

I’m excited about my in-person Crafted Practice, which will be happening for the 3rd [01:10:00] time this year, and keep doing that. Maybe add some more little in-person events throughout the year.

And then, of course, Reverb. We’re putting a lot of energy into Reverb, and who knows where that’s going to go, but we are growing steadily and quickly, and getting great feedback, and that’s super exciting too.

So I don’t know that I have a clear long-term plan, but that’s okay. I’m rolling with it. I feel like I’m putting more energy into long-term family plans than anything. As our kids are heading into late middle school, and high school, we really got to be thinking about how we spend our time with them and what our summers and vacations are going to look like, and things like that.

Carrie: I’m loving that the focus is turned to our adventures and our trips. That’s what’s consuming my outside of work times; how do we make some memories with these kids? [01:11:00] Because it just goes so fast. It’s like once they’re in middle school, I’m like, the days were so long when they were in elementary and now they are flying by.

Dr. Sharp: Exactly.

Carrie: Well, this has been lovely. Congratulations on 500 episodes, and thanks for having me. I think I took it pretty easy on you. I don’t think I was too hard.

Dr. Sharp: Yeah, it could be a lot worse.

Carrie: It could have been worse, right?

Dr. Sharp: Yeah.

Carrie: But I’m like, oh, you said challenge your guests. I don’t know what more challenge I could have given you.

Dr. Sharp: It’s okay. This is fun.

Carrie: This is fun.

Dr. Sharp: Thanks.

Carrie: Thank you.

Dr. Sharp: All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.

If you like [01:12:00] what you hear on the podcast, I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcasts.

If you’re a practice owner or an aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice development: beginner, intermediate, and advanced. We have homework, we have accountability, we have support, and we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call, and we will chat and figure out if a group could be a good fit for you. Thanks so much.

[01:13:00] The information contained in this podcast and on The Testing Psychologist website are intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. 

Please note that no doctor-patient relationship is formed here and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

Many of y’all know that I have been using TherapyNotes as our practice EHR for over 10 years now. I’ve looked at others and I just keep coming back to TherapyNotes because they do it all. If you’re interested in an EHR for your practice, you can get two free months of TherapyNotes by going to thetestingpsychologist.com/therapynotes and enter the code “testing.”

This podcast is brought to you by PAR.

The Neuropsychological Assessment Battery offers the combined strengths of a flexible and fixed neuropsychological battery. Now, you can score any of the NAB’s six modules on PARiConnect, PAR’s online assessment platform. Visit parinc.com\nab.

Hello, everyone. What’s going on? Welcome back [00:01:00] to The Testing Psychologist. We have another business episode for you today. No, no, no, no. What am I talking about? It’s a clinical episode. Oh, my gosh. Clinical episode for you today.

We are talking about one of the most exciting and rapidly evolving areas of testing. That is Virtual Reality and Holistic or Ecologically Valid Assessment. Traditional assessment methods are incredibly valuable, but they often have limitations.

There are all these questions about how well these standardized tests translate to real-world functioning. Are we truly capturing the full picture of a client’s needs? What if we could combine some of these VR techniques and a comprehensive holistic approach to bridge those gaps?

So that’s exactly what we’re exploring today. If you’ve ever wondered how technology and psychology can merge to create a more accurate, immersive, and personalized assessment process, this episode is for you.

If you would like some support with [00:02:00] building your practice, scaling your practice, hiring in your practice, systemism in your practice, really anything related to your testing practice, I would love to work with you with a strategy session.

So strategy session is an hour where we will dive in and get through as many questions as we can. I’ll try to give you some solutions and some ideas that you can walk away with. They’re pretty action-oriented without having to commit to a full consulting package. You can go to thetestingpsychologist.com/consulting and book your strategy session right there.

And while you are considering that, we will jump to our episode on VR and Holistic Assessment.

All right, people, let’s get right into it. As always, I’m going to start with [00:03:00] the idea of VR in psychological assessment. Many of you have probably heard of the Nesplora. The Nesplora is one of the best examples of using VR or virtual reality in the assessment process.

VR essentially allows clinicians to put clients in the real world interactive simulations rather than relying solely on self-report measures or traditional testing environment. So instead of asking a client how they feel in social situations, we could theoretically place them in a virtual party setting and measure their reactions in real time.

In the case of the Nesplora, which I’ll talk about a little bit more in just a bit, it places kids or adults in a real world environment and then introduces a number of distractions to see how they react to those distractions.

So what does the research say about VR and assessment? Studies have shown that VR- [00:04:00] based assessments provide higher ecological validity, which means that they more closely resemble real-life experiences compared to traditional testing methods.

For example, a 2022 study published in Frontiers in Psychiatry found that VR-based cognitive and emotional assessment correlated strongly with real world behavioral outcomes, which tells me that there’s a lot of potential there.

In the case of the Nesplora, like I said, it’s geared toward assessing executive functioning and specifically, ADHD in kids and adults. It’s probably one of the best real-world applications of VR in assessment right now.

It’s a test that doesn’t rely solely on parent or teacher reports at all. Clinicians can immerse kids or adults, but let’s stick with kids, can immerse kids in a [00:05:00] simulated classroom environment where it will track shifting of attention, impulsivity, and response time in a way that mirrors a real school experience.

There’s always going to be gaps there in virtual, at least at this point, virtual reality, I don’t think has come that far to completely mirror a real-life experience. There’s going to be some awareness that it’s not real life, but it’s pretty close. The idea is that this provides a much richer data set than traditional paper and pencil tests alone.

And so the question is, why is this important? It’s important because there are a lot of questions, a lot of uncertainty about whether the tests that we are giving are measuring what happens in real life and whether we can translate what we find in testing to [00:06:00] real life.

I’m not saying this is a perfect solution by any means, but introducing something like VR does take a step toward more of a real-life, ecologically valid assessment. You can dive a little deeper, though I’ll link to the Nesplora in the show notes.

I also did an episode on Continuous Performance Tests, probably six months ago with Dr. Chris Mulchay. It was really good where we dove deep into the research behind the Nesplora and other Continuous Performance Tests. And the research is pretty good.

I will say, for our practice, we are moving to the Nesplora because the Conners CPT moved to an online format where they’re charging per use instead of an unlimited use model and the Nesplora is also pretty cost effective. I think it’s $180 for an unlimited use model per month. For us, [00:07:00] that’s a steal compared to $10 per administration of the Conners CPT.

I’m not endorsing the Nesplora, I’m just saying that’s where we’re probably moving to, and it dovetails nicely with this episode on VR and ecologically valid assessment. So again, not sponsored by Nesplora. I don’t get anything from referring to them or anything like that.

So that’s VR. We’re coming along there. There are also some advances in VR treatment. So VR for OCD, for example. In terms of exposure and response prevention, there’s some cool stuff being done there. I’m not going to dive deep into that because it’s not assessment related, but a lot of people are doing some cool stuff with VR in both treatment and assessment.

The other half of this episode is on holistic assessment, and why context matters. I don’t think VR alone is enough [00:08:00] by any means. So even with these highly realistic simulations, we have to go beyond isolated test scores, and that’s where this concept of holistic assessment comes in. It’s all under this umbrella of ecologically valid assessment. So are we tapping into behaviors, attitudes, experiences, and abilities that match real life?

So holistic assessment considers the full picture. It’s a client’s medical history, psychological profile, social environment and daily functional capabilities. So we pull all these things together to try and create a comprehensive, personalized treatment plan.

You might be saying, oh, I already gather all of that information, but it goes a little deeper than just a questionnaire like the ABAS, for example, to measure adaptive functioning or the SRS for social functioning.

[00:09:00] So why is this important? I want to take two clients with similar ADHD test scores. One lives in a highly structured home with a lot of family support. The other is in a relatively chaotic environment with little routine. You could potentially get the same test result, but vastly different treatment needs. And so, considering the environment and these outside testing factors can be super important.

We’ll go a little bit more in depth to figure out what this might look like. Let’s just say during the initial consultation, like our interview, I think a lot of us are doing this. It’s gathering client background, medical history, and lifestyle factors.

So something that can often go overlooked is the lifestyle factor part. What does their life actually look like? What are their relationships like? What is their living situation like? What is the home environment like? [00:10:00] It’s endless what you could ask about in terms of lifestyle factors.

You could also go down the path of culturally responsive assessment and use something like the ADDRESSING framework from Pamela Hays and dive deep into those cultural and environmental factors that shape this client’s experience.

If you have the capability to collaborate with other providers like multidisciplinary collaboration, this is a place where you can work with teachers, medical professionals, and any others involved in the kids’ or adults’ care to get more of a 360-degree view of the client’s needs. So a lot of us conduct collateral interviews with these additional folks involved in the kids’ care.

It’s just a reminder to go deeper if you can. If you’re not at least sending questionnaires to these to teachers, if you’re not doing [00:11:00] collateral interviews with other providers or folks involved with them, then this is just a reminder to do so, assuming they have the time and the energy and of course can bill for that time, that’s important as well. Multidisciplinary collaboration is a big part of holistic assessment.

When we get to the actual assessment component, there is a real-world functional assessment piece to consider here. If you want to get fancy, you could use something like an Ecological Momentary Assessment tool, like a mobile tracking app, something like that, to collect real-time data on attention, mood, and behavior in daily life.

Let’s take a break to hear from a featured partner.

Y’all know that I love TherapyNotes but I am not the only one. They have a 4.9 out of 5-star rating on trustpilot.com and Google, [00:12:00] which makes them the number one rated Electronic Health Record system available for mental health folks today. They make billing, scheduling, note-taking and telehealth all incredibly easy. They also offer custom forms that you can send through the portal. For all the prescribers out there, TherapyNotes is proudly offering ePrescribe as well. And maybe the most important thing for me is that they have live telephone support seven days a week so you can actually talk to a real person in a timely manner.

If you’re trying to switch from another EHR, the transition is incredibly easy. They’ll import your demographic data free of charge so you can get going right away. So if you’re curious or you want to switch or you need a new EHR, try TherapyNotes for two months absolutely free. You can go to thetestingpsychologist.com/therapynotes and enter the code “testing”. Again, totally free. No strings attached. Check it out and see why everyone is [00:13:00] switching to TherapyNotes.

The Neuropsychological Assessment Battery, or NAB, is a comprehensive instrument offering the combined strengths of a flexible and fixed neuropsychological battery. It lets you administer the full battery, any of its six modules, or individual tests. And now the NAB modules are available for scoring on PARiConnect, PAR’s online assessment platform. Learn more at parinc.com\nab.

Let’s get back to the podcast.

There are a lot of examples of EMA apps that you could potentially use, depending on what you’re trying to do. So there are a ton of mood tracking apps. Mood tracking is essentially considered Ecological Momentary Assessment. It’s just checking in with a patient at any moment in time and asking them to self-report their symptoms.

There are also a few tools that are geared more toward executive [00:14:00] functioning and other neuropsychological constructs. I’ll provide a list of some of those tools in the show notes. I’m not going to list them all here, but rest assured that there are a lot of options out there to explore real-world functional assessment.

I also talked about the social realm. So social environment. There are a lot of social evaluation tools out there, but structured interview and validated scale is something like the Social Support Questionnaire, which helps to understand the client’s support network. It’s not just the client’s social functioning, but what their social support network looks like, which can be valuable when we’re making recommendations.

And then if you’re looking at real-world executive functioning assessment, you could use something like the Test of Grocery Shopping Skills. This is [00:15:00] a little bit of an extension of something like the CVLT where you’re memorizing a grocery list for kids. It’s a Test of Grocery Shopping Skills to measure real-world executive functioning beyond cognitive assessments.

All right, so let’s talk about how to integrate VR with holistic assessment. We’ll bring it all together here. When we can combine these technologies, I think it can be a powerful client-centered approach that gets closer to real-life assessment, gets a lot closer to capturing the complexities of real life than testing someone in a sterile office with these standardized measures that we’ve relied on over the years.

So how might this work? For example, a client struggling with social anxiety might undergo a VR simulation in a virtual coffee shop where we can track eye contact, physiological responses, verbal engagement, and at the same time, [00:16:00] we can use these holistic assessment tools to look at their medical history and their social support system, their executive functioning, and pull it all together to create a little bit of a richer picture of this person’s functioning.

Now, do I know of an app right now that creates a virtual coffee shop where you can track eye contact and physiological responses? No, I do not know what that app is, but we’re dreaming folks. This is theoretical in large part.

So I would love to see more companies put energy into this and utilize VR to recreate some of these scenarios that would let us measure some of these abilities that we tend to look at.

So as you’re listening, I’m guessing that you have some questions, maybe some objections. I did too. One, is VR technology feasible for small practices? I think so. At this point, you can get a [00:17:00] VR headset, like the Meta Quest 3S, is $300. So it’s about the cost of an iPad.

Then in terms of getting into the software, Nesplora, like I said, is $180 a month for unlimited administration. So that’s not too bad. So I think it is probably feasible for small practices. It costs less than it would cost to get up and running with Q-interactive.

Another question is, how do you ensure VR assessments are ethical and protect client privacy? So this is just one of those places you want to do your due diligence and look for any HIPAA compliant VR platforms and make sure that you get informed consent from clients. So any software that you’re using, it’s worth a mention in your informed consent or office policies to make sure they’re aware of that.

Training is another factor. Most of these VR assessment tools will come with built-in clinician training and most of them are designed to be pretty intuitive for psychologists [00:18:00] without a technology background. So they’ll walk you through the setup process and make sure you know how to implement these technologies.

Just to recap, I think VR based assessment is coming along. Nesplora, like I said, is the biggest step in that direction. I think it’s just going to get more and more populated in that category. They do provide higher ecological validity and richer data sets than traditional testing, as best we can tell.

And then you can combine that with this holistic assessment model, where you’re looking at context for clients, looking at their social, their functional, their medical background and environment. It’s going to help round out the client picture and help us do better work.

But then when you combine the two, it’s like you get a real world picture via the virtual reality simulation, but then you can also pair that with the ecologically [00:19:00] valid assessment. I think it becomes cool when you can combine the two, where you get the virtual reality simulation and see how people react in real life, so to speak, but then you’re also diving deep and getting a good sense of their environment and contextual factors.

You compare those two and that creates a little more powerful recommendation engine and gives us more insight into what’s happening. And it helps answer that question, why are people different in different environments or different contexts? Ultimately, our job is to provide helpful recommendations. And this is a big step in that direction.

All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and your life. Any resources that we mentioned during the episode will be listed in the show notes so make sure to check those out.

[00:20:00] If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcasts.

And if you’re a practice owner or aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice development; beginner, intermediate, and advanced. We have homework, we have accountability, we have support, we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call and we will chat and figure out if a group could be a good fit for you. Thanks so much.

[00:21:00] The information contained in this podcast and on The Testing Psychologist website are intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric or medical advice, diagnosis or treatment. Please note that no doctor-patient relationship is formed here and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

Click here to listen instead!

[00:00:00] Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

Many of y’all know that I have been using TherapyNotes as our practice EHR for over 10 years now. I’ve looked at others and I just keep coming back to TherapyNotes because they do it all. If you’re interested in an EHR for your practice, you can get two free months of TherapyNotes by going to thetestingpsychologist.com/therapynotes and enter the code “testing”.

This episode is brought to you by PAR. The new PAR training platform is now available and is the new home for PARtalks webinars, as well as on-demand learning and product training. Learn more at parinc.com\resources\par-training.

All right, folks. Welcome back to The Testing Psychologist podcast. [00:01:00] Glad to be here. Today’s episode is a business episode, and we’re going to stick with the theme of negative reviews.

A few weeks ago, I talked about negative reviews and how to handle those within your practice. Today, I’m talking about negative reviews in the context of podcasting or other services that you might offer. This was spurred along by a negative review that I received back in July 2024. This review stated that I had sold out by running sponsorship ads here on the podcast. I understand that this is a change for folks when that came on board a few years ago, but sponsorships are what help me to continue to do the podcast and produce it at a relatively high level.

So today we’re going to break down the science of [00:02:00] sponsorships and of negative reviews. I’m going to talk about the psychology of customer reviews, especially the star rating system that has become so ubiquitous and how we can reframe negative feedback as a sign that our audience actually cares deeply about what we’re doing.

Before we get into that content, you’ve heard me mention these strategy sessions. I’m having a lot of fun doing these strategy sessions, just diving in with folks for an hour and trying to solve some problems, offer some solutions, and sending folks on their way to hopefully improve their practice or their lives. So if you want to dive in and do an a la carte hour without committing to a full consulting path, that’s totally doable. These strategy sessions are available on the website, thetestingpsychologist.com/consulting. You can book a strategy session right there, send me some information about what you want to talk about and we will jump in and try to work our way through those issues.

But for now, we’re going to [00:03:00] talk about the science of negative reviews and what selling out really means.

Okay, people, we are back. As I said, this episode is totally motivated by a negative review that I received back in July 2024. So I’ll say right off the bat, I stopped reading reviews a long time ago. I think part of that was just being content with the reviews. For the record, on Spotify, I’ve got 5 stars out of almost 100 reviews and on Apple podcasts, 4.8 out of almost 200 reviews.

So I think I got to the point where I felt pretty content with the reviews and relatively secure in the content. [00:04:00] But then lo and behold, four weeks ago, my wife of all people was reading through my podcast reviews and she reached out to me and said, “Oh my gosh, have you seen this review?” Of course, I hadn’t and had a miniature heart attack in that moment.

I went to read the review and had this initial reaction, there was a total mix of things. I don’t know, maybe you all experienced this as well. My initial reaction when criticized is to immediately try to find all the ways that this person is wrong and there’s no way that they could be correct about their opinion.

After that initial defensiveness dissipates, I wanted to dive in and really think through what this review was saying and use it as a little bit of a motivation to explore the science of reviews and customer feedback, the psychology of reviews [00:05:00] and present you with some research- guided information on the review process and how we might handle some of these things.

So to kick this off, I’m going to read this review. The title of the review is Oh Brother…. “I’ve always been skeptical when someone is called a sell-out. Everyone has a right to make money and make hay while the sun is shining, but wow, this podcast used to be so good. Now, however, I understand that the host needs to make money to pay for the time, et cetera, of doing a podcast, but come on, talking about how honored you are to work with so and so, please, spare us. If that’s how you feel, that’s a little weird. If you’re just trying to sell it for the sponsor, dial it back.”

Okay, there is a lot to dissect here. I am going to go line by line and address some of these things. So selling out, first of all, let’s talk about [00:06:00] podcast sponsorships in general and a little bit of the evolution of podcast sponsorships. Why do podcasts have ads in the first place? Well, the reality is that podcasting, just like any other form of media, takes time and money to produce. So in my case, I did not start sponsorships until 2021 or 2022, which was a full 4 to 5 years after I started the podcast.

And during that time, I haven’t talked about this a lot, but I turned down a lot of sponsors during that time. I was staying true to the game, as I say, and didn’t want to run the risk of alienating members of the audience or ruining the podcast by putting ads in there. So I stuck to that for a long time. Around 2021 or 2022, I started to change my thinking a bit. A reason for that is it is financial.

So for my podcast [00:07:00] specifically, each episode takes between 1 and 2 hours, sometimes more to plan, record and edit. So with my hourly rate at this point being somewhere in the range of $300 to $350 an hour, that means that even before production costs, I’m investing between $350 and $700 of my “time” per episode. And then there’s post production. I pay someone and it costs at least $50 per episode to handle that. So at minimum, each episode is costing $400 to $750 to produce.

In terms of the actual content and the ads themselves, I run 60 to 90 seconds of ads per episode with the episode links ranging from like 20 to 75 minutes. So that means that about 2-5% of each episode is actual advertising, which is significantly lower than what you’d hear on the radio, [00:08:00] television shows, or YouTube, places like that, or podcasts. So when I check the statistics, it said that about 8-10% of podcast time is dedicated to ads among those shows that do run ads.

But on a broader scale, the podcast industry has seen a major shift. In mid to late 2024, like I said, ads made up about 10.9% of total podcast runtime, which is up from 7.9% in 2021. 55% of listeners have purchased a product that they heard advertised on a podcast. I think what I’m taking from this is that most listeners actually engage with podcast ads more than traditional advertising, especially when those ads are relevant and the host is endorsing a product.

In my case, I was very selective about who would sponsor the podcast. I’ve gotten outreach [00:09:00] from a number of different companies and many of them are not related to testing whatsoever and so I went the route of taking on sponsors who are relevant with an EHR sponsor and a test publisher sponsor.

So all that to say this idea that running ads is a sell-out move, you could make that argument certainly. And to me, the truth is that that is essentially what keeps this content free and accessible for everyone because there are two alternatives; I could do this for free and many people do and it takes up a pretty big portion of my week at this point between recording, editing, producing, looking for guests, doing research and so on. So I could do it for free, but I’ve chosen not to.

The other option is that I could put it behind a paywall and require a monthly subscription [00:10:00] of however much money to gain access to the podcast. I don’t want to do that. I would much rather have 60 to 90 seconds of ads in the podcast to support the time that it takes to make it. So that’s the first step; what do podcast sponsorships even mean and what does it mean to sell out and so forth?

Then I wanted to go a little deeper. I read through the review again and there’s some emotion here. I know y’all can’t see it, but there’s a fair number of exclamation points, double question marks and so forth in this review. So then I thought about the emotional stuff and that led me down this path of the psychology of customer reviews. And that’s both sides.

So one side is, should you read your own reviews? I got to thinking about that after having my own [00:11:00] emotional reaction to this. And then the other side is what even goes into customer reviews. So let’s start with the question, should you read your own reviews? With your practice, I think you have to. Google notifies us anyway when we get a review. So that’s important.

But this is something I’ve heard a lot of creators, business owners and podcast hosts struggling with. I’ve heard people who say I am sober from reviews; they just do not read reviews. And then I’ve heard others who say that they get totally lost in the reviews, for better or for worse. On one hand, reviews offer valuable feedback, but on the other hand, they can also be emotionally draining, especially when they are negative.

And this makes me think of a review that I got way back. This is probably 2 years into the podcast, so 2018 or 2019, something like that. And that review was negative, but it was balanced and it felt helpful. This review said [00:12:00] something like, I was spending too much time in the introductions and there were too many filler comments in the episodes. I wasn’t getting to the good stuff quick enough.

I was able to read that and say, okay, I get that. That makes sense. Let me try to change something based on that feedback. I think it was a 3-star review, whereas this review that I read earlier was a 1-star review. So we’re going to get into that and the extremes that people tend to take when they make reviews, but what does the research say?

The emotional impact; research shows that reading negative reviews as a business owner can trigger a much stronger psychological response than reading positive ones. I think we all know this. It’s due to the brain’s negativity bias, which makes us more likely to dwell on criticism. Many of us have this problem. I certainly do. Clearly, I’m ruminating on this negative review so much that I generated a whole [00:13:00] podcast to work through it.

The other aspect is constructive versus harmful feedback. Studies would suggest that feedback framed in a constructive way can help improve the content and engagement, but overly harsh criticism without actionable takeaways can actually lower motivation and self-confidence. And so looking back at this review, rereading it, there is not much constructive feedback.

So the parts that veer into the feedback realm are, “if that’s how you really feel, that’s a little weird.” So maybe that’s a suggestion to not talk about being honored to work with these sponsors. “And then if you’re just trying to sell it for the sponsor, dial it back.” I wouldn’t call that super constructive or helpful feedback.

One, because I am actually honored to work with these sponsors. As [00:14:00] someone who has a hard time believing that anyone actually enjoys what I do or that I’m producing anything of value, I am actually honored to be partnered with these folks who “believe” in the podcast and are willing to invest money to support it. So there’s no exaggeration there. I am honored to partner with these companies and so I find it hard to buy that back. To be honest, I want to express that feeling.

Let’s take a break to hear from a featured partner.

Y’all know that I love TherapyNotes but I am not the only one. They have a 4.9 out of 5-star rating on trustpilot.com and Google, which makes them the number one rated Electronic Health Record system available for mental health folks today. They make billing, scheduling, note-taking and telehealth all incredibly easy. They also offer custom forms that you can send through the portal. For all the prescribers out there, [00:15:00] TherapyNotes is proudly offering ePrescribe as well. And maybe the most important thing for me is that they have live telephone support seven days a week so you can actually talk to a real person in a timely manner.

If you’re trying to switch from another EHR, the transition is incredibly easy. They’ll import your demographic data free of charge so you can get going right away. So if you’re curious or you want to switch or you need a new EHR, try TherapyNotes for two months absolutely free. You can go to thetestingpsychologist.com/therapynotes and enter the code “testing”. Again, totally free. No strings attached. Check it out and see why everyone is switching to TherapyNotes.

I’m excited to tell you about PAR’s all new PAR Training Platform, an elevated online learning environment with everything you need in one place. This is the new home for PARtalks webinars, many of which offer APA and NASP approved CEs, and [00:16:00] also houses on-demand learning tools and PAR product training resources. Best of all, it is totally free. To learn more, visit parinc.com\resources\par-training.

All right, let’s get back to the podcast.

Getting back to the constructive versus harmful feedback, overly harsh criticism, like I said, without action can lower motivation and self-confidence. There’s also the idea of selective reading. So some experts would recommend only reading reviews at scheduled intervals to avoid the burnout that can go along with reading reviews as a business owner. For example, checking reviews once a month rather than daily can help maintain some perspective and still gather some useful insights.

This led me into this whole thing of how to handle [00:17:00] reviews. I don’t honestly know if I’m going to be doing this because I don’t get that many reviews that frequently and we’re not getting that many reviews in our businesses daily or anything, but you could have a system. So assign someone on your team to filter the reviews and highlight the constructive ones while shielding from the unnecessarily harsh criticism. I like this idea. I might employ my assistant to take on some of that.

Looking for patterns. So a single negative review might not mean much, but if multiple listeners are saying the same thing, then it’s definitely worth addressing. So I’m open to that. And then you can engage selectively. Unlike our client reviews, we can respond to reviews from other businesses when appropriate, but trying to avoid getting defensive. Express gratitude for the feedback even when it is critical.

So all this to say, reviews can be valuable, but if you consume them mindlessly, it can be detrimental to your mental health. So you got to be [00:18:00] strategic about when and how you engage with listener feed.

We all rely on reviews whether we’re looking at restaurants, amazon products or podcasts, but have you ever really thought about how people decide how many stars to give? Have you thought about that for yourself? I think about that a lot. I’m actually a relatively active reviewer on Google, especially of restaurants and especially of places that I like.

I also think about this dilemma of, okay, I just had a mediocre experience; how do I write a review that feels fair? Because in my mind, I won’t go anywhere that has less than a 4-star rating. I wanted to learn a little bit more about that and what the science is behind that. So let’s break that down a little bit.

First, like my experience, people are more likely to leave reviews when they have an extreme experience, either really good or [00:19:00] really bad. And if the experience is just fine, they often won’t bother to do that. The trouble is that people often go to extremes, not necessarily based on the experience or not doing an objective assessment of the experience; if it was great, it’s 5 stars, if it was less than great, it’s 1 star. That seems to be our experience when it comes to what people are doing with their reviews for our practice. People tend to leave reviews when they have an extreme experience,

Research shows that, this makes sense, the same exact rating, let’s say, 3.5 stars is perceived differently based on whether it’s presented visually as stars or numerically as a number. Visual stars will evoke emotions. People tend to assign more meaning to a 3.5-star rating when it’s [00:20:00] presented visually rather than numerically because they are associated with a more negative or positive experience based on personal bias, essentially. However, numerical ratings feel more precise. So when customers or consumers see a 3.5 numerical rating, they interpret it in a more logical, neutral way, rather than emotionally associating it with past experiences.

There’s also the phenomenon of rounded perception. Studies would suggest that people perceive a 4.0-star rating much more favorably than a 3.9-star rating, even though they’re nearly identical simply because of how the brain processes rounded numbers as more trustworthy or “complete.” I’m totally guilty of this; I will not go anywhere that has a 3.9-star rating or below. It’s only 4 stars or above, and preferably 4.5 stars or above, and if I’m being really honest, 4.8 stars or above. [00:21:00] So lots of emotions here.

Other factors that might influence star ratings include this whole thing; Expectation Confirmation Theory. So if an experience meets or exceeds expectations, people will leave higher ratings, but if it falls short, even slightly, they will leave lower ratings. That’s the phenomenon I was speaking to earlier, where if things were great, that’s good. It’s 5 stars. If it was less than great, it can be 1 star really easily.

There’s also social influence bias. So if you get early negative or positive views, it can sway later ones. So if the first review is glowing, future reviewers tend to be more positive, but if it’s bad, the negativity spreads.

And then there’s the halo effect where a single positive or negative aspect can color the entire review. And this is also playing into that 5 star versus 1-star situation. So in my case, this listener who dislikes the ads apparently ignored the rest of the [00:22:00] content and any value that might’ve brought because it ended up as a 1-star review.

The takeaway is star ratings are not objective measurements of quality. They’re pretty emotionally and socially driven. That’s important to remember when receiving or giving feedback.

So what do we do? I’m just walking through the journey here in terms of reframing this negative feedback. I had a pretty substantial emotional reaction at first, and had to work through that, but then, recognizing the flip side, negative reviews are largely emotional, then how should we handle them?

I like the idea of reframing. We all know this concept. When somebody takes the time to leave a review, positive or negative, it actually shows that they really care about the content. So in this case, this listener who left the negative review was clearly invested in the podcast. They said at one point, this show used to be so good, which tells me, hey, they’ve been listening for a long time. They [00:23:00] felt ownership about the content. They felt connected to the content. And then introducing the ads was like a big personal change for them.

And that to me, in this reframe model, is a sign of strong audience attachment and not indifference. And so I would much rather take attachment and engagement versus indifference. So that’s what I’m trying to do, instead of viewing the negative reviews as personal attack, which is easy, I can try to see them as a reflection of deep listener engagement. You could do the same. That could apply to your business, your practice, it could apply to other businesses or other content that you’re putting out there as well, or even with your kids.

So a disengaged audience won’t care enough to leave feedback at all. Any feedback really helps shape the direction of the podcast, so try to pull any nuggets of helpful feedback or constructive feedback. It’s impossible to please everyone, but to try and understand the common concerns can help improve the [00:24:00] experience of everyone.

To start to wrap up, the place that I’ve landed is that I’m going to pay a little more attention to the reviews. I realize I’m doing myself a disservice by not reading the reviews, because people put time and energy into leaving reviews and I need to respect that. I want to cruise through and take anything that I can from the reviews. It’s part of my personality, for better or worse. It’s a flaw to some degree that if a review is positive, it’s like a sigh of relief. I see the 5 stars and I’m like, Oh, thank goodness and move past it.

My goal here is to dive a little deeper into all the positive reviews and take the feedback from those. I want to know what’s working well and I’m also respecting the time and energy that people put in to leave those reviews. [00:25:00] For those of you who are out there who are listening who have left reviews, I really appreciate it. It helps and like I said, I’m recommitting to reading those reviews and incorporating that feedback. As always, I’d still invite you to share those thoughts and I really appreciate it.

At the end of the day, the goal is just to provide valuable, free content to all the listeners. Sponsorships do make that possible. Of course, I genuinely appreciate the community that’s grown around this podcast and the Facebook group. Whether y’all love every decision I make or not, I know that not everything’s going to land 100% awesome with everyone, but I really appreciate the engagement and all the time and energy that y’all put into listening and reviewing the podcast. Thank you.

All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some [00:26:00] information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes so make sure to check those out.

If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcasts.

And if you’re a practice owner or aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice development; beginner, intermediate, and advanced. We have homework, we have accountability, we have support, we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call and we will chat and figure out if a group could be a good fit for you. Thanks so much.

[00:27:00] The information contained in this podcast and on The Testing Psychologist website are intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric or medical advice, diagnosis or treatment. Please note that no doctor-patient relationship is formed here and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. [00:28:00] Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

Click here to listen instead!

[00:00:00] Hello, everyone. Welcome to The Testing Psychologist podcast. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

Many of y’all know that I have been using TherapyNotes as our practice EHR for over 10 years now. I’ve looked at others, and I just keep coming back to TherapyNotes because they do it all. If you’re interested in an EHR for your practice, you can get two free months of TherapyNotes by going to thetestingpsychologist.com/therapynotes and enter the code “testing.”

Thanks to PAR for supporting our podcast. The BRIEF2A is now available to assess executive functioning in adult clients. It features updated norms, new forms, and new reports. We’ve been using it in our practice and really like it. Learn more at parinc.com/products/brief2a.

[00:01:00] Hello, testing psychologist audience. Welcome back.

Today, I’m talking about the idea of the ADI-R and the ADOS-2 as the “gold standard” in autism assessment. To do so, I am reviewing an article by Somer Bishop and Catherine Lord from 2023.

If you’ve ever wondered how tools like the ADOS-2 and the ADI-R fit into the bigger picture of autism evaluations and whether they are truly considered the gold standard, this episode is for you. We’ll be discussing their intended use, their limitations, and best practices based on this 2023 article. So, if you’ve used the ADOS, used the ADI-R, run into issues with insurance requiring one of these instruments, this is definitely the episode for you.

Before we get started, let’s talk about support for your practice.

At this point, mastermind groups are full; the coaching [00:02:00] experiences that I run twice a year, but you can still get a strategy session. To do so, you can go to the website, thetestingpsychologist.com/consulting, and you can book a strategy session right there. This is an a la carte hour that we can dive into any questions that you might have about your practice. We’ll troubleshoot. We will brainstorm and hopefully send you away with some helpful ideas to move forward.

All right, without further ado, let’s talk about the ADI-R and the ADOS-2 as the gold standard of autism assessment.

Okay, everybody, we are back. Again, we’re talking about the ADI-R and the ADOS-2, how they came to be known as the gold standard, and whether that is an accurate description.

Before we dive into the nuances of how these [00:03:00] tools should and shouldn’t be used, let’s take a quick step back and discuss what standardized diagnostic instruments actually are. I think we all have a good idea of this, but I want to set some groundwork here before we totally dive in.

Standardized diagnostic instruments are structured tools designed to aid in the assessment of autism.

Now, when the ADOS came onto the scene, I think it was a little bit of a revolution because it tried to standardize and structure the assessment of reciprocal communication, stereotype mannerisms, repetitive behaviors, and other aspects of autism that, to that point, were captured with checklists and behavior questionnaires. And so this was, I think, the first large-scale attempt to operationalize some of these behaviors, codify these behaviors in a scoring rubric, and [00:04:00] standardize the observation of these behaviors. So huge deal. This is back, I forget if it was late 90s or early 2000s, but when the ADOS-2 burst on the scene, this was a bit of a revolution.

But right now, I think the most well-known examples of these standardized instruments, like I said, are the ADI-R and the ADOS-2; now in its 2nd edition, has been for probably 15 years now. There are some others that are on the market, of course. I’m not going to count the MIGDAS; it’s not standardized necessarily, and it’s more of an extended interview, and other things like TELE-ASD-PEDS, those are out there for virtual assessment. We’re going to stick with the ADI-R and ADOS because this is the framework that the article adopted.

The ADI-R, if you don’t know, is a structured interview conducted with parents or caregivers assessing the developmental history and behavior [00:05:00] patterns of a child. It is relatively long and pretty nuanced to score. There are some very detailed questions that dig into all the different aspects of potential autism spectrum behaviors.

Then we have the ADOS, or Autism Diagnostic Observation Schedule. A direct observation tool assessing social communication, restricted interests, and repetitive behaviors in structured play and interaction settings.

Again, why were these developed?

They were created to try and bring some consistency and reliability to the autism diagnosis. They provide a structured method to gather information across different settings and clinicians. If you’ve taken the research training for the ADOS, you know that a big goal is to get your scoring to the point that it’s research-reliable, where you could match with other clinicians. This is one of the big problems with the ADOS: the subjectivity on [00:06:00] different ratings and how different clinicians can rate very differently.

These were initially intended for research, but they have been widely adopted in clinical settings. In those settings, clinicians typically administer the ADOS with the child and the ADI-R with the caregivers to try to systematically assess ASD traits. And then the results, of course, help to provide some structure to clinical evaluation. They’re just meant to be one component of a comprehensive assessment, but along the way, that changed a little bit over the last 20 years or so.

Looking back at the article written by Somer Bishop and Catherine Lord, Catherine Lord was a developer of the ADOS, one of the key messages from the article is that these tools were never meant to replace clinical judgment.

What was their intended role?

They were intended to help organize [00:07:00] data without necessarily dictating diagnosis. So, clinicians should still use their expertise to interpret the results within the context of developmental history, real-world behavior, environmental factors, ecological factors, and so forth. These instruments were designed to try to reduce some of the subjective bias in the diagnostic process and organize these observations and caregiver-reported concerns.

As I said earlier, it’s also meant to increase reliability in research settings to improve the research process and characteristics of autism, diagnosis of autism, and so forth, and then by virtue of all of that, strengthening the empirical understanding of ASD symptom presentation.

Now, I’m not going to go down the rabbit hole of the limitations of ASD research. I think we [00:08:00] are mostly familiar with the idea that autism research has heavily favored boys and males and that we’re working hard to catch up on research on autism with girls and women. So I’m not going to go down that rabbit hole, but again, the original idea with the ADI-R and the ADOS was to increase reliability and conduct better research. Whether you agree with that or not, as the outcome, that is another conversation.

Let’s talk about the limitations and misapplications of these instruments.

We have an idea of what they were intended for, but like I said, along the way, over the past, probably, I don’t know, 15, 20 years, I can’t remember when the term gold standard first started to be applied to these instruments, but that did start to happen, and I think what came of that is an over reliance on these instruments in [00:09:00] diagnosing autism.

What are some of the pitfalls of relying too heavily on these tools?

Some clinicians treat the ADOS or the ADI-R scores as definitive rather than being part of a holistic evaluation, which, in either direction, risks the increase of false negatives or false positives if the other clinical context and clinical judgment is ignored. There is also a lack of validation for certain populations.

In the article, Somer Bishop and Catherine Lord talk about how the ADOS is not well validated for individuals with severe motor or sensory impairments, those with challenges in verbal expression. So, assessing minimally verbal individuals or those with complex co-occurring conditions can also be pretty tough.

During COVID-19, we ran [00:10:00] into the issue of using personal protective equipment, or PPE, during ADOS administration. That certainly did not do us any favors. Back then, I think Catherine Lord came out and said that any ADOS results obtained while using PPE were not valid.

And then another factor, of course, is that compliance varies. Kids are going to be at differing levels of interest in the ADOS. And so, when you have behavioral compliance varying, that’s also, of course, going to affect kids’ performance on measure.

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All right, let’s get back to the podcast.

There are also some ethical and equity considerations here in overrelying on the ADOS. One of those is that mandating these tools can limit access to diagnosis. The article does talk about how some of the insurance panels are mandating the use of these instruments and the authors argue against that. It can limit access to diagnosis.

Financial and logistical barriers can prevent a lot of families from accessing [00:13:00] these instruments as well.

Let’s talk a little bit more about the implications of mandating specific tools like the ADI-R and ADOS.

A major issue that was raised in the article is this problem with requiring specific instruments for diagnosis. So there are some consequences there, right? Some insurance panels, again, require the ADOS for reimbursement, even when it might not be necessary or feasible for a clinician to administer the ADOS. This puts clinicians in a bad place because there are many clinicians who either lack access to training or materials, or, for any number of other reasons, just cannot properly administer these tools. And then they’re backed into a corner and can’t get reimbursed for the work.

There’s another issue with equity and access to assessment, like I mentioned earlier. Relying rigidly on a few tools can delay diagnosis for [00:14:00] a lot of individuals who don’t fit “standard profiles”. Again, we need a flexible assessment approach that can accommodate these diverse presentations of autism.

There is a policy consideration here. So we’re starting to trend into what to do about it. I think that, as a field, the article suggests that we advocate for policies that recognize clinical expertise in autism assessment and not over-rely on these instruments.  They encourage a more inclusive approach to diagnosis beyond just using the ADOS and the ADI-R.

What else can we do as clinicians? How do we use these tools effectively without falling into these traps?

There are several best practices in this article. One is training competency in autism assessment. If you’re going to do the ADOS and the ADI-R, they emphasize [00:15:00] that formal training is crucial. There are a lot of trainings for both of these at this point. I know of, gosh, it seems like there’s at least 4, 5, 6, maybe even 8 to 10 trainings that pop up over the course of the year. There are options for virtual and in-person. So, you can likely find training on the ADI-R and the ADOS. It’s going to cost you, I don’t know, $500, $600, maybe $700, depending on where you go for ADOS-2 training, but those options are out there. And then, of course, ongoing professional development helps keep you sharp.

My favorite option for this is the GAIN program through Cornell. They do a quarterly focus on a different ADOS module. It’s a pretty deep dive into administration for each of these modules with video, real clients, and working with experts to score the ADOS together. [00:16:00] So if you haven’t heard of the GAIN program, definitely go check that out for ongoing professional development within the ADOS.

Now, what else do they recommend?

Integration of multiple data sources. Combining the standardized testing results with parent reports, teacher observations, and clinical impressions. You always have to consider cultural and linguistic diversity in assessment. I did a podcast a long time ago with Bryn Harris from Denver, and she talked about culturally and linguistically appropriate ADOS or autism assessment, so you can go check that out. She has continued to do research in this area, so you can look up her work as well.

This makes intuitive sense, but I know that a lot of us either work in settings or maybe get into the practice or habit, I’m not sure what to call it, of it’s easy to default back to the ADOS or the ADI-R and take those as gospel. [00:17:00] What we’re hearing from this article written by two individuals highly involved in these instruments and their development, was, you got to combine those results with many other aspects and sources of information in the assessment process.

They also talk about contextualizing standardized scores. Interpreting the results within the broader context of adaptive functioning, for example. Recognizing that autism traits might present differently across settings.

Finally, they talk about avoiding over-pathologizing or under-diagnosing. You don’t have to rigidly adhere to the cutoff scores in either of these instruments. You can consider the full clinical picture and be mindful of subtle social communication differences that may not register on formal assessments. I think this is their nod to the idea that some individuals who require less support may fly under the radar a little bit and [00:18:00] not reach the cutoff score on either of these measures.

Let’s wrap up with a little bit of a recap, I suppose.

What they’re saying essentially is standardized tools like the ADOS and the ADI-R are valuable, but they should not replace clinical judgment in the assessment of autism. These instruments have limitations, particularly for certain populations. Best practices involve integrating multiple sources of information for accurate assessment. They also argue against the idea of policies requiring these specific tools because they create barriers to diagnosis and should be evaluated. We can do some advocacy there to argue against the requirement of these tools.

This is an interesting article coming from individuals who are highly involved with these instruments. They’re essentially saying, Hey, please stop saying this is the gold standard and [00:19:00] overrelying on our instruments because the assessment process is much broader than that and requires us to think critically as clinicians and integrate many different data sources when we’re doing an autism assessment.

Essentially, assessment is as much an art as a science, and we have to balance the use of these structured tools with our clinical experience and do a holistic assessment process.

Now, another conversation that we could have and may have one day is then what do we do? This is where I get to a lot with these conversations. If we can’t totally rely on these standardized instruments, then what are we left with? Especially with a relatively subjective and moving target presentation like autism, where the diagnostic criteria has maybe not changed that much over the years, but the clinical [00:20:00] presentation and expansion of that diagnostic umbrella is certainly a factor where it’s getting wider and wider, and we have to stay on our toes in terms of what is considered what is considered to qualify as autistic right now.

That’s another conversation, another podcast, and like I said, this is getting to be a bit of an existential dilemma, I think, in the assessment world, where many of us like to rely on standardized instruments, and there is a place, and the authors are saying, let’s expand our repertoire and make sure not to rely too heavily on those instruments. So, an ongoing conversation. My guess is that many of you have wrestled with this and will continue to wrestle with it, but this is just a piece of the puzzle that you can incorporate into your assessment.

[00:21:00] All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.

If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes, Spotify, or wherever you listen to your podcasts.

If you’re a practice owner or an aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice development: beginner, intermediate, and advanced. We have homework, we have accountability, we have support, and we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call, and [00:22:00] we will chat and figure out if a group could be a good fit for you.

Thanks so much.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional psychological, psychiatric, or medical advice, diagnosis, or treatment.

Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of [00:23:00] any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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[00:00:00] Dr. Sharp: Hello everyone. Welcome to The Testing Psychologist podcast. I’m your host. Dr. Jeremy Sharp, a licensed psychologist, group practice owner, and private practice coach.

Many of y’all know that I have been using TherapyNotes as our practice EHR for over 10 years now. I’ve looked at others, and I keep coming back to TherapyNotes because they do it all. If you’re interested in an EHR for your practice, you can get two free months of TherapyNotes by going to thetestingpsychologist.com/therapynotes and enter the code “testing”.

This episode is brought to you by PAR.

PAR offers the SPECTRA – Indices of Psychopathology, a hierarchical dimensional look at adult psychopathology. The SPECTRA is available for paper and pencil assessment or administration and scoring via PARiConnect. Learn more at parinc.com/spectra.

[00:01:00] Hey, folks, welcome back to the podcast. I’m glad to be here as always with you.

Today’s guest is a professional, a colleague, a friend, and someone I’ve spent in-person time with, which makes it all the more special. I’ve got Julie Herres from Green Oak Accounting here to talk about Profit First and Beyond, is the way I think of it. I think many of you have probably heard of Profit First as a financial management or accounting system for your practice.

We talk about profit first, but then we also go beyond the basics and talk about what happens if you’ve mastered Profit First or just mastered the finances in your practice, you have good money problems, and you need to figure out what to do about that.

We do a beginning section where we talk about the basics of Profit First, financial management, and things like that. And then, we flip the script and talk about more advanced strategies, things to think about when things are [00:02:00] going well. We talked about expanding into a group practice. We talk about mistakes that people make when hiring. We talk about the expected profit margin for different stages of practice. We talk about what to pay people and compensation.

There are a lot of great points and pieces of information to take away from this podcast, as usual, but Julie brought it today. I think you’ll enjoy this one.

If you’re a practice owner, you know the drill here. If you’d like support in your practice, feel free to reach out. At this point, my mastermind groups are closed, but I am offering strategy sessions, which are one-off hours to drill deep into a particular question or two and give you some support to get you on your way. You can go to thetestingpsychologist.com/consulting and book one of those strategy sessions if you would like.

In the meantime, check out this info with Julie Herres [00:03:00] from Green Oak Accounting.

Julie, hey, welcome to the podcast.

Julie: Hey, good to see you.

Dr. Sharp: Good to see you as well. I feel like I’ve been thinking about having you on the podcast for a long time. I have seen, heard, hung out with you, read your book, and all these things. People talk about Profit First all the time. This has been a long time coming. Thanks for being here.

Julie: I’m really glad we could make this work.

Dr. Sharp: Likewise. I’ll start with the question that I always start with, which is, of all the things that you could be doing with your life, why focus on this?

Julie: I’m an accountant, first and foremost. I like to joke with my team that my superpower is numbers, [00:04:00] specifically, seeing the story within the numbers. When I look at a profit and loss, a balance sheet, or any financial report, I vividly see what is happening in a business. I think that is a superpower in a lot of ways.

Helping business owners with their businesses, make sure they have a profitable business, increase their profit, I see that as a service to the business owner, their communities, their teams, their clients, and everyone around them. That’s my jam.

I grew up in a house with a mom who is a serial entrepreneur who did not understand the financial side of running a business. I’m probably very cautious because of that, but the numbers can help you in whatever you’re doing in business.

Dr. Sharp: I love how you frame that and say that you see a picture in the numbers or see a story in the numbers. I don’t think [00:05:00] that a lot of people have that superpower, but it’s very descriptive. I like it.

Julie: That’s how I see it in my brain, at least. Some people hear colors or something like that. This is my thing.

Dr. Sharp: It’s a special version of synesthesia. We’ve already piqued my audience’s interest and are thinking about what’s going on in your mind.

Tell me a little bit about the focus with mental health folks and Green Oak as your firm. How did you come to dial in on mental health folks specifically?

Julie: Initially, when I started my firm, I was a generalist, but I realized quickly that it is challenging to work with all different kinds of businesses. A mental health practice versus a restaurant versus a car dealership. They’re all very different in the challenges that they face, all the other little pieces. And [00:06:00] so, I knew early on that I wanted to focus on one specific area.

At the point that I was making that big decision, I had several therapist clients, and they were all so lovely. I really enjoyed them. They had all come to me through referrals. I started with one and then it turned into 5 and probably 10.

Here are the characteristics that I loved. They were all obviously highly educated, very smart people, but really with a lot of insecurities when it came to money and managing the financial side of the business. They were also very receptive to the information. They wanted to learn. They were keen to understand what was going on under the hood of their practice. They were also willing to do the work of changing things, adjusting, and listening to advice.

I will say, I can’t think of a single client that implemented everything we ever said, but they were generally willing to do the [00:07:00] things. That created a lot of positive impact, and I just find that very fulfilling. I tend to like that educational relationship where we’re working together. We’re going to do the work for you, but I want you to also understand what is happening and why we’re doing what we’re doing. The mental health community was receptive to that. And so that became our main area of focus.

The further down that path we went, the more we realized that we could make a big impact because we know how to run a private practice so well at this point. You get on the financial side, but still, that’s a big piece, like cash flow, taxes, and how to hire people. Those are big, important parts of running a practice. That’s why we ended up sticking with that. To this day, that’s all we serve. We only work with private practices, and they’re related adjacent businesses, right? [00:08:00] There’s a lot of real estate transactions that happen with that or maybe coaching businesses that are just adjacent, but we don’t take on any clients that are not therapists.

Dr. Sharp: Right. It’s a parallel with our clients for those of us who do therapy. You want to work with folks who are receptive to what you are putting out there, open to change and self-reflection, all those things.

Julie: Yes. I imagine that is what you would want. That’s also what I want as well. 

Dr. Sharp: Yeah. Good general qualities. Do you find… I don’t know, in talking to a lot of businessy folks outside our field, it seems like healthcare people, whether it’s physicians, dentists, therapists, psychologists, or whatever, have less of a mind for the practice management side, the financial side, than say a restaurant person or a car dealership person. I don’t know. Would you say that’s true?

Julie: I guess I would [00:09:00] personally disagree. That’s from my lived experience, not any specific data other than that. I think in any industry, there can be folks who are financially minded. There are plenty of doctors, dentists, and restaurant owners that are. There are also, in every industry, plenty of people who are not.

I think therapists specifically tend to give themselves the label of Oh, I’m not good with numbers. I’m bad with math. Usually, it’s just because you haven’t tried yet, right? You are very capable of understanding. Sometimes, maybe it’s just a story they’ve told themselves, or they were not good at math in school. 

But there’s very little actual calculating or multiplying or any of that in the financial side. It’s just looking at what is happening and course-correcting. And that’s a skill that you use a lot [00:10:00] as a business owner, period. What is happening? How do we adjust? You’re always moving. There’s never a status quo for too long. And so, it’s a very transferable skill. I think most therapists are very capable of learning and getting to that point as well. There’s also plenty of doctors and dentists that are very bad with their money.

Dr. Sharp: That’s fair. I think there’s an emotional component involved with everyone probably, but money’s pretty emotional, and it can be something to be avoided or revered and any number of things in between.

Julie: I think maybe also doctors and dentists perhaps get away with it. People think they do better with it because they generally tend to make more money. That is a service that is more valued by health insurance companies and by society. I’m not saying that’s a good thing, but in general, a doctor can go out there and generate multiple millions of dollars per year in [00:11:00] revenue, whereas one single therapist can typically not do that. So I think the doctors and the dentists of the world maybe can outearn their lack of knowledge sometimes. It doesn’t show quite as keenly. 

Dr. Sharp: That’s a good way to put it. Yeah, more money can hide money mistakes sometimes. 

Julie: It absolutely can. You can outrun bad financial decisions.

Dr. Sharp: It’s a good way to put it. Maybe we’ll come back to that at some point. This sounds good.

I do want to talk a little bit about Profit First. I don’t see this interview as a Profit First primer necessarily. Your book is great for that. I’ve recommended it to a million people. There’s the general profit first book, of course. There’s a lot out there on Profit First. I don’t want to go super deep into it, but for anyone who may not have heard of it and have some idea what we’re talking about here, I think it is probably important to lay a little bit of groundwork. Can you do a high-level overview of this Profit First [00:12:00] system and what it is?

Julie: Yes. Profit First is the general premise that we are building in profit into your practice from the very beginning to make sure that there always is profit.

In the mental health industry specifically, there is a lot of guilt often around profit. Oh, I’m not in it for the money. I’m in it to help people. That’s very kind, generous, and noble, but in the real world, if you need money to live, which most of us do to pay the bills, support yourself and your family, put food on the table, gas in the car and all the things that need to happen, making a profit is necessary for business to survive.

There’s not this mythical pot of money where you’re going to go grab extra cash because you’re running your business poorly, right? There’s a point where the business fails, it closes, it does not survive, and then it helps no one. So, to help your clients, you have to have [00:13:00] profit in the practice.

Within Profit First, we turn the traditional accounting equation upside down. Instead of looking at income minus expenses equals profit, the profit first equation is income minus profit equals expenses. We are building in profit, and that means you have less available to spend on expenses, but that means that you’re always building in profit.

Typically, what most business owners do in that case, when there’s less available for expenses, is to get creative, and naturally, you will spend less because this is what you have available. It’s just like when you’re a kid, if your parents give you an allowance, that’s what you have available to spend. So you have to figure out how to make that work. I don’t know about you, Jeremy, but my parents, if I went to them and said Hey, I already spent my $10. I need more. They would say, “That’s a you problem. We’re not giving you more money.” Were you in that same boat?

Dr. Sharp: Oh, yeah,100%. I said that to my kids 3 days ago.

[00:14:00] Julie: Yeah. It’s like, oh, that sounds like you need to go do some chores or do something else. The business is the same. When there’s no more money to spend, in the current economy, it’s easy to go out there and get credit cards and loans and all that, but when there’s no money left in the business, it’s the business telling you something is going on. Something is wrong that you need to fix. You can’t just keep doing the same thing, borrowing money and hoping that it will magically get better. You do need to correct course. 

In a nutshell, Profit First is a system that gives you buckets or allocations of money to spend on various things in your business. There are five of those things.

One is operating expenses: your overheads like your rent, your software, your liability insurance, the things that it takes to run your company.

Then, there is your payroll. If you have a group practice, you will have payroll. It will likely be the single largest expense on [00:15:00] your P&L, so that is for your clinicians, for your admin, for your leadership. Then there is an owner’s pay bucket. So how much do you save to pay yourself for the hard work that you do in the business? 

There’s a tax bucket or allocation, and then there’s a profit allocation as well.

We assign a specific percentage to each one of those things, depending on the size of the practice and the specifics. But that means that it’s easy to know at a glance how much you have available for each thing. Where is there opportunity? Where can you no longer spend anything? That’s the nutshell version of it.

Dr. Sharp: That was a great summary. I think a lot of people probably have some idea of Profit First and what it is, or they’ve read one or both of the books and get excited about it and then get overwhelmed by it. I’m sure you’ve heard this [00:16:00] 100 times more than I have, but do I really have to open five bank accounts?

Julie: That’s a question that comes up often. A lot of business owners remember the first time you go to the bank to open up your business bank account, it’s a pain. I will admit it is. It is a pain. And in part, that’s because of banking regulations, anti-money laundering. They have to make sure that you are who you are and you know who you’re supposed to be. But opening additional accounts is usually a much, much smaller lift. It is usually a 10-minute visit or even a phone call instead of a 90-minute situation. I just want to put that out there because adding accounts is not as big of a deal. 

But Jeremy, there’s something really powerful about seeing the money in the different bank accounts, doing profit first on paper or in a spreadsheet or your [00:17:00] head does not. When you’re doing it on a spreadsheet, it’s easy to say Oh, this is not quite working. I’m just going to change this number over here.

I’m like, oops. Oh, look, now there’s plenty of money for all the things where you’re “borrowing” from your tax account for something else. You’re like, because you’re not going through the pain of logging into your bank and transferring money from your tax account to your payroll account because that doesn’t feel good, right? It feels like, why am I having to do this? But that’s the point. That is the system telling you something is up. Why are you having to use your tax money to make payroll? What is happening?

Profit First won’t fix the project magically, but it will tell you there’s a problem, and it’s over here. Go look over here; this is the account that’s giving you a problem, and so something has changed, good or bad. Sometimes it is, hey,  [00:18:00] why is there no money coming into the practice? Is there a billing problem, or did you hire more admin than you really can afford? Did you increase leadership at a rate that doesn’t make sense? Is overhead increasing exponentially faster than your income? Something is up, and it will point you in the right direction so that you can, as the business owner, make the best decision for your business.

Dr. Sharp: Yeah. That’s one of the things that I love about it. Full transparency: we’re not running Profit First to 100% fidelity. This idea of knowing where the money should be going, in general, I think is a lovely idea, and it can throw up those red flags because, like you said, there’s information in the numbers. If you have a sense of where the money should be allocated and how much should be in each place, if it’s not there, that’s a real sign that something is going wrong [00:19:00] or going well; sometimes it goes in the other direction.

Julie: That’s true. Yes. I love those scenarios way better. I also live in the real world. I own an accounting firm, and we work with hundreds of clients. And so we see the reality of sometimes you just have to take the tax money to run payroll. Sometimes, that is the situation that you are in, but because it’s not all commingled, you are so much more aware as the business owner that something is up, and we cannot keep going in this direction. That in itself is powerful.

I was just working with a team on a new-to-us client who took on a ton of debt in the last year, and we all collectively were raising the flags that this is not a healthy situation. We have to be able to course correct this in a very short amount of time, or else [00:20:00] there’s a day very soon where there are no more loans to be had. There is no one else who will loan you money, and if you haven’t stopped the bleeding before that point, that could be the end of the business.

There are plenty of scenarios where we catch a practice early enough that we can help with that course correction, and there are some cases where it’s just so far in that we can’t move fast enough to do that. I hope this is not that kind of situation. But there are a lot of changes that have to be made in a very short amount of time to get this back on track.

That’s often a painful process for the owner because there are changes in the business. There are also usually changes personally that have to be made as well. There’s often some personal spending that has ballooned, or something else has been going on; the personal [00:21:00] expenses have expanded faster than the profit of the business. It’s not an easy scenario to be in, but Profit First can help. It cannot save a practice, but it can help get back on the right track.

Dr. Sharp: Certainly. There’s a lot of shame wrapped up in money. I’m sure that a lot. It’s people being afraid to share things with you or be transparent. It’s complicated. A lot of respect for the work that y’all are doing.

Julie: Listen, I could never do what you do. This is my jam, but the numbers don’t lie. Once we look, we see what’s going on. And these are not easy conversations to have, as I’m sure you can imagine, but there’s a lot of power in just saying it out loud sometimes. Hey, here’s what we’re seeing. Does that feel true to you? [00:22:00] Does it feel like we’re explaining what you’ve been feeling but not necessarily able to put it into words? It can be a relief to know and have someone on your side helping you out.

Dr. Sharp: For sure. One of the things that I like about Profit First is that it is pretty clear about different stages of practice and what allocation of your revenue should be going to different places like overhead or profit or owner’s pay, taxes and so forth. One of the questions that people ask me that I don’t know the answer to is, how do you arrive at those percentages? How do we know that those are “accurate” for mental health practices?

Julie: Or, how do we know you’re not full of it, Julie?

Dr. Sharp: Right.

Julie: We do a lot of research internally every single year and have come [00:23:00] up with these allocations based on many years of data.

When we work on this, this is not just what the top 5% of practice owners are doing or the bottom 5%. We look for statistically relevant practices. If someone had a loss of $200,000, we cannot include them in here because it’s going to skew the averages so much more. Also, there are some practices out there that are insanely profitable, that’s amazing for them, but that is not the average, so we exclude those as well.

So we end up in this middle of what are most people able to do realistically? What is a realistic, reasonable expectation? We arrive at averages. We look at the median and the mean and then look at do 90% of our middle fall in that range. Typically, that is possible. That [00:24:00] is the case. And so we actually have not changed the Profit First allocations since 2023 because they still continue to be relevant.

Now, I do often get some pushback of Oh, that’s not possible; you can’t possibly make that much money. Or you can’t have a 20% profit margin if you make $5 million a year.

I would say, if you were telling yourself that, then it’s probably true for you, right? If those are the words that you are using for yourself, you’re probably making that true for yourself.

We have these numbers because we know that they are possible. We can’t share that data, but for every size of practice, we have dozens of practices doing just that. And so, we know that it’s possible, and we know that adjustments sometimes need to be made to arrive at that. If you’re willing to do that, you can do that too. If you’re not willing, you can choose to have a lower profit margin. That [00:25:00] is a choice that you can make, but I’m going to advocate for profitable practices until the day I hang up my hat because that is in service to everyone. 

Dr. Sharp: I like your use of the word choice and choose. I think we get locked into things. We get locked into: I have to have this much admin support. I can only charge this much private pay, or I have to take insurance, or I have to pay for this EHR or whatever. Choice is a big part of this. There are a million choices that we can make along the way with how we’re spending and making money in our practices. So I just want to highlight that and encourage folks to always have the possibility of choice on the table.

Julie: It’s so interesting to hear that business owners feel like they are trapped. I have to give them a raise or they’re going to leave, but are they? Sometimes that’s true [00:26:00] but if you’re building a business that does not rely on one specific person, including you in the best case scenario, then it does suck to see someone leave, but it’s not the end of the world. You have to make the decisions that are best for the business, and that’s what the gig is. When you’re the business owner, sometimes you have to make a decision that’s going to be not good for one specific person but for the benefit of the whole team.

If you’re okay throwing off all of your ratios or paying someone a dollar amount that does not make financial sense for the practice, that is to the detriment of the entire business and everyone that it supports. And sometimes you have to make that hard call and say, I feel like I can’t and I’m going to lose them, but I still can’t do that.

Dr. Sharp: You’re bringing up so many good points. I am going to [00:27:00] highlight two things that are maybe basic-ish, and then we can move on to some more advanced stuff. One thing people always ask is, what is my profit margin supposed to be? It has become a measuring stick, I think, for practices and a point of pride and so forth.

So just for the record, can you share some information about a “typical” profit margin for a testing practice. You know testing; you work with a bunch of testing practices now. What should we expect for a solo practice, maybe somebody with an employee or two, and a little admin support. We can take each of those.

Julie: We look at testing practices on a regular basis as well. We don’t have enough solo testing practices to have a recommendation. So it is not statistically significant. And so, I cannot make a pronunciation. When it comes to [00:28:00] general mental health, what we typically see as a solo practice is around 30% to 50% of income. That should be around your take-home pay. It can go higher than that, but that’s where we see most regularly or right around 50%.

When it comes to a small group with maybe one clinician, an admin, or something along those lines, that is usually closer to 30%. It just keeps going down just because you have to pay other people. And so that’s going to change. In a small group, the owner is still doing a significant amount of the work as well, right? And so 30ish percent is what we will often see. It’s not possible to have a group where there’s one or two part-time clinicians and the owner’s not seeing clients. That’s not a thing. There’s not enough revenue coming into the practice to support that.

Then, as we grow towards [00:29:00] a million plus dollar practice, we usually see, specifically in testing, a 20% to 25% profit margin. And in that, I’m including owner’s pay and profit margin. So, not necessarily from a Profit First standpoint, but I’m looking at the total taxable income that the owner reports.

So if they have an S corporation, for example, that will be their owner’s wages and benefits that directly benefit them plus the profit margin. If they had a single-member LLC or PLLC, that would be the profit on the profit and loss, right? Whatever mechanism or vehicle you use to take that money home, I’m combining all those to compare apples to apples, but you have 20% to 25%. It’s typically what we see. Whereas for traditional mental health practices, we see a number that’s lower than that. So there is the opportunity for more profit in a testing practice, [00:30:00] which came as a surprise to me, honestly,

Dr. Sharp: It is surprising because the overhead is higher, I would think, because we have to buy materials, whereas therapists don’t buy materials. Do you have any hypotheses about why the profit is higher even with the higher overhead?

Julie: The overhead is higher. However, we typically see clinical payroll be lower in general in part because of the way the services rendered where there’s theoretically more technician hours than direct one on one from a master’s level therapist. Because of that mix, the clinical payroll tends to be lower.

Dr. Sharp: That makes sense. If there’s anybody out there listening, thinking about taking on a psychometrist, it is more financially viable.

Julie: Yeah, it is. I have to turn the [00:31:00] table on you a little bit. Have you found that to be accurate in your practice?

Dr. Sharp: Oh, sure. We compensate psychometrists less than licensed clinicians, certainly. From a financial standpoint, psychometrists are a great choice for a testing practice. There’s some debate about the clinical accuracy, but that’s a debate that we don’t have to get into […].

Julie: Yeah. I am not completely for that piece of it. But we generally see testing practices have a clinical payroll that’s around almost 10% less than a traditional mental health practice. 

Dr. Sharp: Got you.

Julie: So that’s where the difference is. Yes, you are higher in overhead, but you compensate for that in the reduced payroll.

Dr. Sharp: I could see that. I could be [00:32:00] totally missing this, but I wonder too, if there’s something around like the private pay rates for testing typically go higher than for therapy, and then payroll as a percentage of income might be relatively lower because the income is higher, the fees are higher. So you can maybe pay people a little bit more, and it’s still not as much of payroll, if that was followable.

Julie: That’s a really great point. I always find that it’s just a little bit harder to track directly for testing practices because it’s usually we’re going to do all of these things. And if there is insurance involved, the way they get submitted to insurance, it’s it’s just a little bit less obvious. It always feels like… It’s not just, okay, this hour was for this code, right? It’s multiple codes all the time. It’s just a little bit harder to trace.

[00:33:00] Dr. Sharp: Yeah. I hear you.

The other thing I was going to ask you about that we were touching on is, I know there are people out there who are listening and are on the edge of their seat about am I doing okay? Are there any red flags that people need to be aware of? If they’re looking at their numbers or if they’re even looking at their bank accounts or whatever in running their practice, money issues that you can identify. Hey, if this is happening, you should probably take some action and do something different.

Julie: Probably talk to someone.

Okay. Two things. First of all, if you are hit with NSF fees, non-sufficient fund fees, on a somewhat regular basis, something is up. You’re spending more than you make if you have negative profit on a regular basis. But sometimes you don’t even get to that point because you’re just [00:34:00] not looking and so, the NSF fee is a better canary in the coal mine of okay, there’s not enough money in this bank account, especially if there’s just the one bank account. That tells you something. Something is up.

It’s not always what you think. Sometimes, the thing that is up is you’re spending way more personally than you thought you were, like you were taking so much out of the business that you are putting it at risk. I’ve seen that happen plenty of times. It could be so many things. It could be fraud, it could be a team member that’s getting paid for way more hours than you expected that they were; an administrative team member. It can be just so many different things. It could be Blue Cross has stopped paying you or you’re United, but you just haven’t noticed yet. It could be your biller disappeared. It could be a million and one different things, but if cash flow is really tough, you [00:35:00] probably need to take a close look at what is going on.

If you have a hard time paying for taxes, paying either your your tax due with your return in April or your quarterly estimated taxes is also a sign that something is up because if you are looking at the financials, if you’re saving on a regular basis for taxes, you should be in the ballpark, plus or minus a little bit, but it should not be a surprise. It should not be an unexpected thing because taxes are never unexpected. We know they’re coming. We know it’s going to happen. And so that probably just means you’re not looking closely enough.

I say that with absolutely no judgment. One year of really big unexpected tax payment or tax bill can set you back for literally years. It can take years to catch up from that.[00:36:00] So the more proactively you can take a look at that, the better off your practice will be. And then you’re not accidentally spending your tax money. I am using air quotes again, even though some of you might not be able to see it. Sometimes, it can feel like there’s money in the business that you can take out, but what you’re actually taking out is tax money because you just haven’t been thinking about it or planning ahead for it. It was never your money to start with, but it’s already gone. And so what do you do now? Those are two big items.

If you’re stressed out every time you run payroll because you’re not sure if the checks are going to clear, something is going on also. It’s time to take a cold, hard look at what is happening. If you find yourself writing manual checks because it’s going to give you two extra days, that’s not good. And so again, without any judgment, those are [00:37:00] flags that your business is waving, saying help me. I need something else from you at this point in time.

Those are all some signs that I can think of.

Dr. Sharp: Great. That sounds good. Maybe we wrap this basic intro section with, folks are hearing some of these things, and they’re like, I want to take some steps to be better about this. Is there an easy intro to Profit First or a way to get started?

Julie: Reading the book is a very accessible way to get started. Just hear more about it. There’s a paperback, an audio, and an ebook as well. So those are some items. I do think it’s better to read the book or have some kind of knowledge before starting so that you set it up correctly. But I am very much [00:38:00] okay, and I say this in the book, if you feel overwhelmed by the whole thing, start with a profit account and a tax account. Just add those two. Maybe you don’t go all in. Again, no judgment, just those two things: having a little bit of money in a profit account that serves as a reward and an emergency fund for your business and starting to put some money in tax, it’s not going to maybe cover your will tax bill, but something is always better than nothing. And so that’s a good way to gently ease your way into it.

Dr. Sharp: That’s very doable. 

Julie: Easy enough, right?

Dr. Sharp: It’s so easy.

Julie: Totally doable.

Dr. Sharp: I do want to flip the script a little bit. A big part of reaching out to you is that I think there’s a lot of basics out there and books, like I said, but I would love to talk about what happens next. What if it’s actually going well? What are some more advanced strategies [00:39:00] for folks out there who feel like they have a pretty good handle on the basics?

Maybe we start there with a general open question, which is, let’s say somebody is running Profit First and or has a good handle on their finances. They are pretty consistently hitting that 20% profit margin. What happens next in terms of optimizing cash flow or advanced fun things you could do with the money in your practice?

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All right. Let’s get back to the podcast.

Julie: I love that. There are two different options, and I want to just blurt them all out.

There is expansion, there is living your best life, [00:42:00] and replacing yourself. The three top things. One is, things are going really well. Do we want to do more of this? And there’s no right or wrong answer in my mind. It’s just, what do you personally want? It could depend on your age, on your family situation, just where you are in your life. Are you loving the business at this stage? Do you want to just keep doing this?

In which case, you could add, for example, an expansion bank account where you don’t need to take home more money. So you just start stockpiling money over there in this expansion account. We have several clients who do this, and when they get to a specific amount, then they start looking for a new location. For some, that’s $50,000, for some it’s $ 100,000. Okay, there’s $100,000 in this account. Let me go look at where we are going next. Is there a new city, another city close by that we want to expand into and open up a new office there?

Sometimes it can [00:43:00] be a building. There are a lot of practice owners who also own the real estate. I think you have to be in a really strong personal financial position for that to make sense just because you don’t want to contort your practice to fit the real estate, and that often happens when you own the building. I think you should just go to whatever location that is going to be best for your business versus the other way around, like restricting the business to fit in the real estate that you already own.

If you’re in a good financial position, you’ve got the 20% or 30% down that a commercial real estate deal is going to require, you’re doing retirement savings, you’re doing other things already, this is another great way to diversify your portfolio. Go for it. Do it. But sometimes, that could be a different kind of real estate deal that’s not commercial. Maybe you want [00:44:00] to buy residential real estate or a second home or whatever that may be. A home that you’re going to Airbnb, cool. Go ahead and do that. Save money to do that.

There are other cases where things are going so well. You decide, I love this business. It’s going. I’m willing to take a little bit less money home. I’m going to replace myself in this business, and I’m going to take a more passive role because I have this other cool project that I want to go work on over here, or I just want to golf or I don’t know, play pickleball or whatever that may be.

Again, I don’t think there’s a right or wrong answer. It’s just based on what you want to do with your life. All of those are options when you have a cashflow-positive business, which is a great place to be.

Which one of those resonates with you? I’m curious. Which one would you pick out of those scenarios?

Dr. Sharp: They all sound [00:45:00] appealing. Oh, gosh, that’s a tough question. You’re not allowed to ask questions, Julie. I’m the one that asks the questions. 

Julie: I know this. I like to turn the mic around for a second.

Dr. Sharp: Yeah. It’s a good one. I think the place that I’m at right now, I would honestly buy back time. So I would, maybe that’s replace myself. Maybe that is just not doing any more clinical work. I don’t do a ton, but gaining 5 or 8 hours a week would be helpful. I might funnel some to my personal life to hire, I’m just being direct, maybe a chef or an executive assistant or something. The biggest precious commodity right now is time. And so anything I could do to buy time would be amazing.

Julie: So you are not in the golf and pickleball place, but buy back time for yourself, maybe.

Dr. Sharp: Yeah. And then maybe I would play Pickleball.

[00:46:00] Julie: Oh, there you go.

Dr. Sharp: Buying back time would be amazing.

Julie: Yeah. And that’s often not as expensive as people think it will be. Sometimes, it’s just a time audit. What are you spending your time on? Could you hire an assistant who can do 5 hours a week of that stuff that you no longer have to do? Sometimes, it’s much deeper, like hiring a clinical director who is stepping into your leadership shoes as the owner, whether you’re seeing clients or not, and replacing you where you are acting more as an advisor to them. They are leading your company and you’re maybe in it two hours a week. We have multiple clients who are now in that situation as well, where it’s almost like a semi-retired position. There’s a lot in between those two things as well.

I’m in the stage of life where [00:47:00] my kids are all in school, and I’m realizing just how quickly they will be out of the house. I just have a handful of precious years. So I’m in the same boat as you. I want to be around, work a little bit less, have dinner with my family every night, travel a little bit less, and all of that. 

Dr. Sharp: I think we’re in a similar place. I think our kids are similar ages.

Julie: Our kids are almost the same age. My oldest will be a high schooler next year, which feels like the clock is ticking. 4 years will go so fast. 

Dr. Sharp: It really will. We sat down, my wife and I, probably two months ago and mapped it out and mapped out all the school breaks between spring break and summer. We get a Thanksgiving break. We figured out we essentially have 15, maybe [00:48:00] 18 opportunities to take a trip with our kids before they move out. That his home. I’m in the same boat. That really drives a lot.

Julie: 15. That’s just hit me right in the heart.

Dr. Sharp: Oh my gosh. I didn’t mean to…

Julie: No, that’s okay.

Dr. Sharp: … put this into an existential dilemma but that’s a big motivation.

Julie: Got to make the most out of our time.

Dr. Sharp: I’m with you. I love those options. It gives people a choice if things are going really well.

I want to detour a little bit into the expansion question because I feel like that is where a lot of people default to. If things are going well in a solo practice and the money is pretty good, then a natural question is, now do I have a group practice? Do I hire someone? Do I go in that direction? What have you seen people mess up essentially in that [00:49:00] transition to a group, especially from a financial standpoint? Are there any things that jump out when you see people start to hire and expand?

Julie: A lot. If I had a nickel for every time I’ve heard, I want to hire or I want to start a group practice because I want passive income, I wouldn’t have a lot of nickels. There is nothing passive about a group practice. There’s nothing. It is so much work. It is worth it, and you can make money, but there is a 0% passive. There is so much work to get done before that point of passive revenue.

Typically, to be able to step away from your practice, you will typically need to be making at least $3 million a year, if not more, the practice to generate that kind of revenue. Before that, you cannot afford all the pieces and all the bodies to replace the work that you do. You will not have enough [00:50:00] systems that you can truly step out and not enough redundancy, not enough overlap, right? You can maybe step out temporarily for a few weeks, but if your biller quits, there’s one biller. And so, guess what? You’re back in that seat. So it’s not long-term. You’re not long-term out. So, to have enough seats at the table to be able to truly step away, it takes a pretty large group practice. So the passive piece though is number one, like expecting that you’re just going to hire someone and then magically you’re going to make a lot more money.

Practice owners also underestimate how many clients they are going to need to see when they hire someone. If you’re seeing a full caseload and you hire one part-time clinician, guess what? You still have a full caseload. You can afford to reduce by zero clients. There is no room.

I often get that question from [00:51:00] small groups where they have two part-time clinicians. Hey, can I stop seeing clients? Absolutely not. The math doesn’t math. You can’t. I know it’s hard though, because that’s the hardest, like that small group practice where you’re just getting your sea legs and figuring out your processes and procedures and your handbook and your policies, that is by far the hardest part and it is the least rewarding. You are working so hard, you’re wearing so hats, and you are making marginally more money, if any. There are plenty of cases too where you’re making less money than before.

And so we often see at that inflection point that a decision needs to be made. Either you’re going to stick with this and keep growing where you have enough sessions, enough revenue to be able to afford a bill or an intake like additional services, or you have to make the decision that this is not for you and go back to solo and manage everything [00:52:00] yourself.

I remember I had a group practice client years ago who had 12 clinicians and was still doing all of the intake literally from 7 a.m. to 7 p.m. for 12 clinicians.It was never a seven days a week also. That was probably too long, right? She did that way too long. And one of the first things we told her is please hire an intake coordinator. You can afford it. Please go ahead. If you made $50,000 less next year, would that be okay with you to get your life back? And yes, that is absolutely what she wanted, but that in-between part, you are as the owner filling all of those seats out of necessity because there is not enough money to add a lot of things.

I think it [00:53:00] absolutely can be worthwhile, but you have to go in with a clear head and clear expectations. And if you’re not willing to put in the work to get to the other side of that, then maybe it’s not for you, or maybe now is not the right time for you. All of those things are completely okay. If you know what you’re getting into, it makes it a lot easier.

Dr. Sharp: Yeah. I appreciate you saying all that. The $3,000,000 number is interesting. I’ve never heard of that threshold as far as what you would need to step away. I don’t know how I came up with this, but a few years ago, I had it hit pegged at 7x your individual income would allow you to have some kind of passive. I don’t know. It’s not as precise, but that kind of makes sense. $3,000,000 is a solo income of $300,000 to $400,000, which maths.

Julie: Yeah, in that ballpark.

Dr. Sharp: I think that’s good to know.

[00:54:00] Julie: That’s not a perfect science number either, but it’s more of, is there a clinical director in place. At the $3,000,000 mark, there probably is. You probably have, if you have multiple locations, a site supervisor for each site because you’re not there as the owner every day. That site supervisor is seeing clients, but they’re not seeing a full client load. Do you probably have a 3 million, 1 to 2 intake, and 1 to 2 billers?

You have those redundancies in place so that if even if someone’s on vacation, you’re not the one being tapped on the shoulder to cover those pieces. There’s multiple layers at that point. There are good systems in place. It’s hard to grow to $3,000,000 a year without… You have systems around hiring and recruiting. The things are working like clockwork in many ways. It’s never perfect. Things are going to break, but there’s [00:55:00] generally a way to do things that other people know.

Dr. Sharp: Right. Systems are so valuable. 

Julie: Yes.

Dr. Sharp: Speaking of the group, the last question I’ll ask about expanding into a group is the compensation. The 60% number is floating around everywhere. It’s like, we need to pay our clinician 60% of revenue. I would love to get your perspective on the range of compensation, we’ll stick to W2 for now just to keep it simple, but the range of compensation that can be reasonable.

Julie: My recommendation is for a fully licensed clinician that they should be paid somewhere between 45% to 60% of the revenue they generate. 45% to 60% includes wages, payroll tax, and benefits. So that doesn’t mean a base [00:56:00] wage of 60% because that’s going to cost you closer to 72% all in with payroll tax and benefits. And so, that means it has to be lower than 60%. I’m sticking to it. That’s my line in the sand. I get a lot of pushback on that, and my response to that is generally, you’re the business owner. I’m going to make my recommendation. You can do whatever you want. That doesn’t change my recommendation.

If you decide you want to go higher than that, that’s great. You will have decisions to make as far as where are you going to go lower? If it’s nowhere else, then that means your profit is going to be low, and that’s a choice you’re allowed to make but not one that I’m going to recommend.

Dr. Sharp: Very reasonable.

Julie: Yeah.

Dr. Sharp: I just want to double-click on that 60% is the top of the range for you, inclusive of benefits and payroll taxes.

Julie: Yeah, including benefits. And so that also means, though,  [00:57:00] if you make the offer when you’re hiring someone at the very top of that range, guess what? There’s nowhere to go because that is all in unless you’re able to increase your rates or pay them with some other magic money that’s coming from somewhere else. At some point, that is going to cut into your profit margin. It just is. And so 20% turns into 14% and then 11% and then 7%, and they’re like, oops, we’re not making any money anymore.  And so there is, unfortunately, a cap.

I do wish things were different. I wish reimbursements were higher. I wish mental health was valued more. I do wish for all of those things. And yet the reality is that the math has to make sense. If you’re going to hire someone and pay them more than they generate for your practice, you might as well not hire someone. You would be better off financially not to hire them [00:58:00] because you or someone else in the practice is going to have to work harder to compensate for that.

There are plenty of situations where a clinician is making more money than they generate, and that doesn’t make sense. There is an end to that because at some point, you can’t sustain that long term.

Dr. Sharp: What are some of those situations? I can maybe see it with a leadership position or someone who’s not seeing as many clients. When are you seeing people being paid more than they’re generating?

Julie: I’m going to detour a little bit. In a leadership position, those are typically going to be break-even positions, right? So, like that site supervisor, I’m usually looking for them to at least bring in enough revenue to cover their wages, payroll, tax, and benefits. That means you have to have enough other people on the team to contribute to overhead admin and all the other expenses of the business. [00:59:00] Usually, for a leadership position, if they can at least break even, we’re usually in pretty good shape as long as the rest of the practice is healthy.

I have been doing this for a long time at this point. I’ve seen 85% splits, which at 85%, if you add payroll tax and benefits to that, you’re right up against 100%. The highest split I’ve seen is 100%, where they were getting 100% of the revenue they generated. They were doing a couple of additional duties in the business, plus payroll tax and benefits. So that’s just digging a hole that gets deeper and deeper. These are few and far between, but it does happen.

It also can happen if you’re paying for admin time. So, you are paying a clinician for the work that they do, let’s say you’re paying 60% base and they’re seeing three clients a week, and you’re paying them for eight admin hours. Guess what? [01:00:00] They’re very little profit margin that there was in that is gone.

Dr. Sharp: That brings back memories. That was one of my biggest mistakes. When we had therapists on our staff was paying for admin time, not to that, but paying for admin was a big income suck.

Julie: Yeah. If someone is pulling their weight, seeing 20 clients, three admin hours, that’s probably not as big of a deal, but especially with those very part time clinicians, there’s so little margin already in someone who’s very part time, and then you add that on top of it. You’d be better off just not having the mental load of having that person on your team.

Dr. Sharp: Sure. I think there are a lot of nuggets in this conversation and almost like throwaway lines, but they’re important. Just that willingness to make the [01:01:00] choice. You don’t have to have that person on your team. There is a point where an employee becomes profitable for the business, and when they’re not profitable and sometimes we overlook that, Oh, I have to bring this person on, or I have to keep this person even though they want to reduce their hours or whatever it may be. That’s not always the case.

Julie: Yeah, if we have time, I generally find that 10 sessions per week is usually the break even for most practices. Where if you have a clinician who’s seeing 4 or 5, 6 sessions per week, by the time you cover all those software expenses that don’t change whether someone’s seeing 1 or 18 clients per week, your EHR, your phone, like all the things, and then your support systems as well, below that, they’re not even contributing to your overhead at that point.

And so, what I also find though is that the mental load of managing [01:02:00] someone who is seeing 5 clients a week and 20 clients a week is very similar, if not almost more for the 5 hour a week person because if the owner, especially if they’re in that intake seat as well, if you’re always wondering, can I schedule them? Are they here that day? Can we make this work? It’s more work than someone who you just know is going to be there. You have their schedule. They’re always available. Whatever it says in the EHR is accurate, and so I think the mental load is often not considered enough. If someone is not contributing to the bottom line, not really around, and it’s taking you a lot of mental energy, why are we doing this?

Dr. Sharp: Why are we doing this? That makes me think about being deliberate in this whole process. I have run into, gosh, don’t get me wrong. I made a lot of decisions that were not as deliberate or thoughtful as they [01:03:00] could have been. And I think a lot of us, especially with hiring, it’s almost reactive, and a lot of it happens without being deliberate and considering everything that entails.

Julie: I have made these mistakes, too. I’m tough with numbers, but I’m also human. Sometimes you have someone on your team that you really like, and oh, I just want to keep making it work, and it just doesn’t work. Sometimes, it just doesn’t work anymore. It’s a sad and tough decision to make, but sometimes you’re just better off for it. 

Dr. Sharp: It’s true. Let me see. I may ask you one or two more questions, and then we can wrap up. This has been great. You talked about debt a lot in the beginning and how that can be a bad thing, right? Typically, people are over-leveraged and borrow to cover. Is there any situation that you have seen where taking on debt can be helpful?

[01:04:00] Julie: Sure. I’m not anti-debt. Because of my story of origin, I am financially cautious, is how I would call it. My mom went into these business ideas with abandon and not with consideration of how are we going to pay for any of this. How is this all going to work? And so I tend to be a little bit more cautious because of that.

When you’re taking on debt, you are spending tomorrow’s money today. That is ultimately what we are doing. It is possible for that to make sense. Lots of folks have started businesses by taking maybe a small $10,000 SBA loan just to get them over the hump, and then get the systems in place and have the time and space to get get everything lined up to start. But when you are doing that, I think you have to have a clear path to [01:05:00] a return on investment without money, right? It can’t just be, let me take on this loan and maybe I’m going to pay myself with it and maybe I’m going to do this with it. You have to have a good plan, and you should be spending that money on things that are going to make you money.

We’re not taking out a loan to go buy throw cushions for our room. That’s not going to make you money, right? What is going to make us money? A strong website where people are able to find you easily, with good SEO that’s going to make it very clear who your ideal client is. That’s a good investment that will make you money. Having that clear vision can be helpful. We’ll suggest an in-between step.

I’m generally a fan, if someone is borrowing to start a business, I would love to see them [01:06:00] save up first, save up money and then have some money saved up for themselves and then supplement that with a loan versus just a loan, because the ability to save up money means okay, you have carved out part of your budget already, and we know that you have this money available for the business, because when you borrow money, at some point in the short future, you have to start making payments on that.

And so if there’s not even a plan for, like, how are we going to make these loan payments? You can end up in a more difficult financial situation after the loan than before the loan. But if you’re able to start saving money and have maybe $ 5,000 saved, then you take on a loan for some of it. So you’re spending some of your own money, which feels different always when you’re spending your own cash and you have the loan, you not only have a smaller payment, you’re able to save that. You were able to save that money. So you can take that same amount and work towards the loan payment. That’s my more [01:07:00] cautious in-between recommendation.

Also, for expansion, I feel the same way when it comes to expanding the business. If there are zero dollars available for you to save for expansion, you probably shouldn’t also take out a loan to expand because in a time of expansion, usually there’s a 6 to 12 month period where you are actually going to make less than before. And so if there’s today no money to even save a little bit, what makes you think that during this expansion, somehow that money’s going to appear? It usually doesn’t.

Dr. Sharp: It’s like having a baby to save a marriage.

Julie: Yeah.

Dr. Sharp: Maybe that’s too intense, but it counts.

Julie: Yeah, babies are intense, and babies are so expensive, too. I was thinking about it. 

Dr. Sharp: Good stuff, Julie.

Julie: Babies make everything harder.

Dr. Sharp: Babies do make everything harder. Have you heard that Jim Gaffigan joke? We love Jim Gaffigan, [01:08:00] the Nerd Mouse, but he’s a comedian, and he has this joke that says. What’s it like to have five kids? And he said, it’s like you’re drowning and then someone tosses you a baby. I just resonate so much.

Julie: I think I’ve read that he lives in New York City in a small little apartment with his five kids, right? 

Dr. Sharp: Yeah.

Julie: A very challenging-sounding situation. 

Dr. Sharp: It’s a whole story. It’s a lot more.

Julie: And then you decide to have another baby. Someone throws you another baby. 

Dr. Sharp: Sure. 

Julie: All right. That’s fine.

Dr. Sharp: Yes. So anyway, if you’re going to expand, have some money saved.

This is great. I’m going to close with a personal question, maybe that hopefully we’ll wrap this up. I am curious. I know that, for me, the way that I’ve approached money in my practice and my life has changed pretty significantly, I think, over time. So I’m [01:09:00] curious for you being in this field, doing the work that you do, seeing all these practices, diving into the numbers, how has your own financial perspective changed over the years? Anything that you have learned along the way as a business owner yourself.

Julie: I would say I’m less debt-averse today than I was 10 years ago in the sense that I think more practice owners should have a line of credit and should get it when things are going well, right? When things are going well, we’re thinking, Oh, everything’s always going to be fine. In business, what I’ve learned is it’s not a question of if something will go wrong. It’s a question of when. At some point, something will go wrong. I just go into every day knowing that at some point, something’s going to go wrong this year. And so preparing yourself when things are going well can serve you when things are not going [01:10:00] not going so well. I have a line of credit for my business, which I did not have 10 years ago, and I always prefer not to use it, but I like knowing that it’s there just in case.

Dr. Sharp: Same here.

Julie: It’s always very interesting to see the financials and then make those micro decisions behind the scenes like, oh, I don’t want to do things that way, or, oh, maybe I could be a little bit more aggressive cause this has worked really well in this situation. I think I’ve just evolved over time, just like I have evolved hopefully as a parent, as a mom, and as a leader of the practice. I hope that I’m doing things in the right way. The right way might change over time, but at least I know that I’m doing it in a way that feels true to me and to who I am. I try to do things in a way [01:11:00] that helps me sleep all at night, and I sleep really well. I feel like if I know my team is okay and everyone is protected and my family is going to be okay, then I can sleep well.

Dr. Sharp: I like that gauge. Yes. Well, said.

Julie: And that includes life insurance and all of the things that go with that, emergency funds and the business, the line of credit, all of those things help pad everything. That’s my perspective on it.

Dr. Sharp: I appreciate you sharing that. This has been a great conversation, as expected. How can people find you if they want to talk to you or work with you or any of those things?

Julie: Yes. I also have a podcast called Therapy For Your Money. I would love for you to find that. I talk about all financial topics specifically for mental health, Therapy For Your Money. My firm is Green Oak Accounting. So feel free to check us out, GreenOakAccounting.com [01:12:00]. You can lurk and see. We have a lot of fun resources available there on the blog, but you can also schedule a free consultation with the team and see if our services might be a good fit for you.  You can also find my book Profit First for Therapists on Amazon or wherever books are sold.

Dr. Sharp: Fantastic. Thanks again. I’ve really enjoyed it.

Julie: Thanks so much.

Dr. Sharp: All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and your life. Any resources that we mentioned during the episode will be listed in the show notes. So make sure to check those out.

If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes, Spotify, or wherever you listen to your podcast

If you’re a practice owner or an aspiring practice owner, I’d invite you to check out The Testing Psychologist Mastermind groups. I have mastermind groups at [01:13:00] every stage of practice development: beginner, intermediate, and advanced. We have homework. We have accountability. We have support. We have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call, and we will chat and figure out if a group could be a good fit for you. Thanks so much.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a [01:14:00] substitute for professional psychological, psychiatric, or medical advice, diagnosis, or treatment.

Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with an expertise that fits your needs.

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