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Dr. Sharp: [00:00:00] Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

PAR offers the RIAS-2 and RIST-2 remote, to remotely assess or screen clients for intelligence and in-person e-stimulus books for these two tests for in-person administration. Learn more at parinc.com.

All right, everyone. Welcome back to another episode of The Testing Psychologist. Hey, today is a happy hour episode, which is some of my favorite episodes because these are the times when I get to sit down with four of my favorite psychologists and friends, and just talk about whatever comes up. I’ve got Dr. Andres Chou, Dr. Laura Sanders, Dr. Chris Barnes [00:01:00], and Dr. Stephanie Nelson hanging out with me, talking about business, clinical work, personal lives, really anything that gets on the table during the discussion.

So just a few things that we talk about today include tips for internship applications. We talk about how in the world Stephanie remembers everything in the universe. We talk about TikTok and its seemingly growing influence on our clientele. We talk about technology and other tools that are helping us and many other things. So, if you have enjoyed the previous two happy hour episodes, this one will not disappoint. And if you haven’t caught the first two happy hour episodes, they will be linked in the show notes. So go check those out. We try to do them once every quarter, and it’s just a nice time to connect and talk in a little [00:02:00] more informal manner.

Now, if you’re a practice owner who is looking to grow your practice and wants some accountability in a group setting, I’d love for you to check out The Testing Psychologist Mastermind groups. You can go to thetestingpsychologist.com/consulting and schedule a pre-group call. We have groups for every level of practice and we’d love to chat with you and see if that might be a good fit.

All right. I won’t keep you any longer. Let’s get to this happy hour discussion with my four psychologist friends.

Hey, welcome back to the podcast y’all. Good to see everyone. [00:03:00] So here we are with another happy hour episode. For anyone who hasn’t heard of a happy hour episode in the past, these are episodes where I get to hang out with four of my favorite psychologists and talk about anything that comes up, whether it’s professional, personal, business, clinical, we’ll dive into everything. So could you all run through and introduce yourselves real quick just so everybody can get a sense of your voices and who’s here with me. Andres, you want to go first?

Dr. Andres: Sure. My name is Andres Chou. I’m a clinical psychologist in Pasadena, California, the LA area. I work primarily with adults and I’m in private practice.

Dr. Sharp: Awesome. Stephanie.

Dr. Stephanie: I’m Stephanie. I have a small clinical practice in Seattle. I do mostly consulting with other neuropsychologists at this point and other testing [00:04:00] psychologists over the internet.

Dr. Sharp: Hey, internet. Laura.

Dr. Laura: Hi, I’m Laura Sanders. I am a licensed psychologist and school psychologist. I am located in Colorado, but I’m also working in Texas though.

Dr. Sharp: Amazing. Did you get a haircut?

Dr. Laura: I did. Thanks for noticing.

Dr. Sharp: Yeah. Looks great. Love it. Chris.

Dr. Chris: I’m Chris Barnes. I’m a psychologist in Kalamazoo Michigan. I do quite a bit of assessment for the diagnosis of ADHD and all those roll-outs. And I also brought my dad’s joke bingo card with me today, so I’m curious how quickly Andres can get us there.

Dr. Sharp: Ooh, fantastic. Can you read us a sample off of the bingo card?

Dr. Chris: I was actually just joking.

Dr. Sharp: Oh, okay. That joke just doesn’t add. You’re a concrete thinker here.Okay. Thanks, y’all. Well, welcome back. It’s good to see all [00:05:00] of you.

I thought we might start as we have in the past with a general check-in. It’s been 3 or 4 months since we’ve done something like this. I’m curious where everyone’s at. Getting back to school or not, anything happening in your practice. Any updates, anything new in your lives right now. Chris, do you want to go first.

Dr. Chris: Sure. I feel like it’s been a bumpy two months here on so many different levels. My kids were all virtual last year. My middle kid started kindergarten last year, so this is her first year going to 1st grade but being in person rather. And my oldest is in 4th grade, so we’ve seen all sorts of emotional stuff in our home and extra drainage when it comes to all the energy. So that’s always fun to watch and be a part of.

In the business sense of things, I’m [00:06:00] purchasing a building apparently. I just put an offer on a pretty fantastic building not too far from my home just this week. So to add to all the chaos of the home emotions I get to be a part of, I’m a contributing variable to that now because it’s a pretty big rollercoaster but it’s exciting. And it’s a really good opportunity for me to tease apart how much of my decision-making is emotional because I want it, and how much of it just makes sense. It’s a fun thing to go through.

Dr. Stephanie: Chris, you told us that you were putting this offer on the building but not sure what the vision is. What’s going to be in this building?

Dr. Chris: I’m moving my practice there. It’s a building right now that has tenants in it already. It’s a hair salon, to be honest. And so they’re vacating and moving into a smaller suite and then I’ll be taking over the big side of it. It has lots of opportunities there. It’s going to be a rebuild on the inside.

The vision is to create my dream [00:07:00] practice there but there’s a lot of hoops to jump through to get there. We’ve accepted offers and we’ve talked about what we want to do and how it all shakes out. But with lending and with all the things that go into it, who knows where it’s going to go. But nonetheless, at the 30,000-foot view, it’s super exciting to go through and equal parts terrifying. Let me be honest.

Dr. Sharp: I’m looking forward to watching you go through this process so that I can do it in about a year. So let me know. I’m very curious how this works. You went first, which is brave, and I’m going to continue to shine the spotlight on you, but you say this is going to house your dream practice. What’s your dream practice?

Dr. Chris: I use the word holistic very loosely, but it’s going to be an assessment practice and there’s going to be all specialties in there as well hopefully. We’ll have some speech-language pathologists. We’ll have some folks that can work at the emotional behavioral level, looking for a [00:08:00] prescriber right now. That’s everyone’s dream, I think, is to have a prescriber on board. It’s difficult to do, but I’ve got my 5-year plan out and I know that I need to get in there and get some more assessments pumping out of there. I hired a few psychometricians recently to help with that.

And so assessment is going to be the main thing we’re going to then add on therapeutic services. And then after that, we’re going to dive into all the other stuff that’s out there in the 5-10 year plan. But getting the space is the most important part right now. I vacated my last lease and I’ve been working on my basement and subleasing office one day a week for the last 3 or 4 months. So that’s going to be great to get out there and have like my own little spot

Dr. Sharp: That’s amazing. I’m excited for you.

Dr. Chris: Like I said, I’m excited in equal parts, maybe 60/40 leaning towards a terrified.

Dr. Stephanie: Jeremy, you hinted that your practice is making some planning, some big moves?

Dr. Sharp: Yeah, our lease [00:09:00] runs out in our current space in October 2022, so about a year, and it’s crazy to think we’ve been here for five years. My plan is to buy a building at that time, or in the next 12 months so that we can move into our own building and have a little more space to grow as well. So yeah, it’s exciting, but also overwhelming. I have a dentist friend who has gone through this process and it’s just been a complete nightmare here in town. I’ve got multiple stories to consider as far as how this might go. So I hope yours goes well, Chris, that’s a positive influence in this whole process.

Dr. Chris: I’m sorry, it’s been weird so far that everything is just falling in line. So I’m just waiting for all things to go too smoothly. So that’s my own [00:10:00] anxiety. I’m sure playing out there but I always had to pull myself back to just looking at the numbers and the process.

Dr. Sharp: I like that.

Dr. Andres: Is this your first time hiring? I don’t know if you’ve had…

Dr. Chris: No, it’s not my first time hiring. It’s my first time purchasing something gigantic. That’s for sure. And it’s like, bringing up a little bit of PTSD of my own home purchase and all that stuff. You want something and you want it so badly because it seems so perfect. And I’d have to keep pulling myself back to like, this is all a numbers game at this point. And the location is very important. It’s like that third variable, but it’s really just a numbers game.

Dr. Andres: Yeah. Living in LA. I don’t know what it feels like to buy anything.

Dr. Stephanie: Well, if you want to move to Seattle, my house just went on the market this morning. 

Dr. Sharp: Would you like to say more about that?

Dr. Stephanie: I have moved out of my house. My husband and I are living in an RV at least [00:11:00] temporarily, and we’re going to try and sell our house and do some traveling and things along those lines. But it’s a big process to move house. My husband has lived in that house for like 20 years and I think he just spent all of that time just hoarding things to put in various rooms in the house. So we’ve been working on it for months and months. So to see the pictures this morning was pretty exciting.

Dr. Sharp: Oh, it is exciting. I feel like we talked on a previous podcast about this drive of humans to clean up messes. I think you were the one that actually said that and you got to go through this process on a very big scale.

Dr. Stephanie: Yeah, but I think people like to clean up small messes. This is overwhelming.

Dr. Laura: How are you feeling now that it’s done?

Dr. Stephanie: I think I [00:12:00] still have just a few little more residual things. We actually covered one whole wall of our living room with just sheets of paper with things to do, tasks I needed to do, things that needed to be relocated, things that needed to be sorted, and just crossing those things off. We’ve done 98% of them, but I feel like I can’t quite relax until we get all 100% done. So the relaxation hasn’t hit me yet.

Dr. Andres: It’s amazing how much stuff we can gather just living in a place, not even for 20 years. I’ve only been in my place for like 2 or 3 years and so much junk.

Dr. Sharp: Yeah. We’re forced to clean a little bit. We finished our basement over the pandemic and it was so nice to just like clear things out [00:13:00] because that was our main storage spot for stuff. And there was something very satisfying about that. And now we have very little storage space to work with.

Dr. Andres: But what’s going to happen now, that doorstopper you were storing for like 10 years, you’re going to need it now and you can’t find it.

Dr. Sharp: Oh yeah. My worst nightmare. Laura, what’s going on with you?

Dr. Laura: Similarly to you guys, you have kids back to school masked. We’ve dealt with some… The beginning of school and sleep routines and all of that. So about personal stuff. Professionally, I brought on an extern. I’ve got her two days a week which has been really nice.

Dr. Sharp: What is she doing?

Dr. Laura: She’s doing it all. She’s starting with testing and we’re working up to the interview part because that seems to be where we’re struggling a little bit. [00:14:00] But she’s been great. And so it’s been nice. I’ve got a whole camera system going. I can watch her and barge in when I need to. And that has been such a relief. I didn’t realize how much I missed having a psychometrician. It just frees up so much more time to get the reports written and to plan and just do all the random stuff we have to do. So that’s been really nice.

Dr. Sharp: Can I ask you a question?

Dr. Laura: Yeah.

Dr. Sharp: I was just like, what if she said, “No.” My question is, this question actually comes up a lot. So I’m very curious about this. What kind of camera system did you set up where you can watch her in real-time that is not storing that information on the cloud in an unsecured way?

Dr. Laura: Wyze is the name of the camera? And I [00:15:00] don’t have storage capability. It’s just streaming and I plug it in the other room, and turn on my phone and that’s it.

Dr. Sharp: That’s just it. It’s an internet streaming camera that doesn’t go anywhere except to your phone through the app. There’s an app I assume?

Dr. Laura: Yeah.

Dr. Sharp: Okay.

Dr. Laura: Yeah, you can purchase the storage piece of it, but I’m not fancy. I don’t want that.

Dr. Sharp: Yeah, that’s totally fair.

Dr. Stephanie: For a hot moment. I was picturing your extern with a GoPro camera on her head.

Dr. Andres: Just to jump on that Jeremy. One option is baby monitors.

Dr. Sharp: I’ve heard that too.

Dr. Andres: Because they don’t use WiFi and that’s a pretty secure way. The ones that don’t have  WiFi, I should say.

Dr. Sharp: Yeah. Nice. Thanks. Hey, that’s awesome, Laura. Where did you find your extern?

Dr. Laura: [00:16:00] UNC.

Dr. Sharp: Yeah. For anybody who doesn’t know, Laura and I live in the same city, so we can have these local questions and it actually makes sense.

Dr. Laura: But I’m still learning. Thank you for guiding me.

Dr. Sharp: Yeah. Let’s see. Who else, Andres.

Dr. Andres: I’m a little bit different from everyone here. I’m mostly in therapy. But in the summer, like most, I imagine most therapists, my caseload slows down because people, I guess everyone’s caseload slows down and if you’re doing assessment too, caseload slows down with therapy but then one of the assessments I do is with clergy ordinations and those pickup for some reason. I guess they have a bunch of conferences in the fall, so they need to meet those deadlines. So I’ve been doing a lot of them.

Personally, our kid, we have a son who we sent to, I don’t know if it’s preschool. [00:17:00] He’s 2years old, so it’s like, what school are you really going to? But it’s technically preschool. And that’s been a rollercoaster for us, of course. And that’s been really good for him. He’s just like speaking so much more now, and that’s also weird in this climate but he actually wears his mask now. We can never get him to do it. But of course, it comes with all the ups and downs. I was just telling you guys that some kid bit him yesterday and kids like to bite him for some reason. And here’s my dad’s joke because he’s kind of sweet.

Dr. Chris: Yeah. I’m working on the postage stamp here.

Dr. Sharp: What was that? 10 minutes in?

Dr. Andres: Let me see. We’re expecting our second child in January, so that’s exciting. So I’m looking forward to that.

In terms of the [00:18:00] practice, I’ve always been part of group practices and organizations, and this is my first time doing private practice and I’m coming up on my one-year anniversary of the practice. So super exciting.

Dr. Chris: And you have reflections on the first year?

Dr. Andres: Yeah. The one thing that comes to mind has always been like, oh man, I wish I started this earlier just because it just suits my personality and my lifestyle way better. I’m by no means saying if you work for an agency, that’s lower or anything like that, but for me, it just makes sense.

I was always the guy at any agency, you can ask any of my supervisors, I would always want to change things. I’ll be that annoying trainee or employee that was like, can we do this? What do you think about this? Should we try these Wyze cameras instead? [00:19:00] And now I get to do all that because I’m the boss. But that’s also the problem. I’m the boss. I’m a neurotic boss.

So, that and I think just getting in the rhythm of understanding that business goes up and down. People come in waves then not to panic. And getting that work-life balance is really important, right? It’s so easy when you own your own practice to be consumed by your work because it feels like it’s all dependent on you and so just trying to figure that out still, but it’s been amazing. I love it.

Dr. Sharp: That’s great to hear. I always tell people when we’re talking about private practice and I frame it like, after the end of internship and post-doc, I was like, I don’t want to attend any meeting that I’m [00:20:00] not running from this point forward. And that was good that was plenty of motivation to get out in private practice. I was tired of meetings and tired of not making decisions. So let’s see. I think that’s everybody. Nice.

Dr. Stephanie: Except you, do you want to tell us how things are going for you?

Dr. Sharp: Oh, sure. I can do that. Our biggest thing on the personal side right now is that we transitioned our kids from Montessori where they’ve been since they started school, to public school, which has been an interesting transition. And the reason that I’m bringing that up is because I’ve stepped on the other side of what we do because a big motivation was our daughter has been struggling in Montessori. Stephanie, you know [00:21:00] that. We talked to you about her two years ago. She was having a hard time and we just figured out Montessori maybe wasn’t the best environment for her.

And so that culminated in getting her tested recently. And so it’s been really eye-opening maybe and illuminating just to be on the other side and be digging into all the data and recognizing what a hard job we have. I think that’s what I’m taking away from this. I’m like, this is my own daughter. I know exactly what all of these numbers mean and it’s still really hard to pull things together. But she’s been having a little bit of separation anxiety like I was talking about as well. So we’re just being challenged as they transition back to school, I think it’s looking up though.

Otherwise [00:22:00] professionally, we have our annual staff retreat every year in late August, early September, and we did that last week on Wednesday. And it was just an amazing experience. I love my staff and we just had a really amazing experience. And I rolled out our plan for the next three years. We’re looking to grow and like I said, buy that building and have some space to expand. So that was super cool.

Dr. Stephanie: I’m so curious about that. What happens at a staff retreat?

Dr. Sharp: At our staff retreat, we spend the morning time, let’s say 9-12 in a hot seat style sharing situation. So we have this kitschy ritual. One of our staff brings [00:23:00] this drum and we beat the drum and then you get to talk and we pass the drum around the circle. And so people share where are they at personally, where they at professionally. There’s I would say a fair amount of crying and bonding and supporting one another. So we do that for the first three hours. 

Dr. Stephanie: Are we in a staff retreat right now?

Dr. Sharp: Surprise. I’m leading us in that direction. I hope you all have tissues.

So we do that in the morning just to reconnect with one another and strengthening our connections. And then we take a break for lunch. And then our afternoon time, usually it’s 13:00 to 15:30, we talk about business stuff and what we’re doing in the practice and what’s working, what’s not working what we want to add [00:24:00] change.

The staff gets to pitch in on ideas for growth, who we might want to hire, and services we might want to start offering, things like that. This year, it was a little more processing because we expanded to a second location over the past year and a half. And there was some, what’s the word, not conflict, but there were some things that weren’t totally clear to all of our staff about that process. So we talked through that and got everybody on the same page. So that’s the general structure. That’s great. And then afterward, we got a party boat which was really the jewel of the day, just the time for people to unwind and have a good time.

Dr. Andres: My staff retreats just involve me going to Target.

Dr. Sharp: Also relaxing and rejuvenating [00:25:00] maybe.

Dr. Stephanie: At a party boat though, right?

Dr. Andres: Yeah, party boat by myself.

Dr. Sharp: Yeah. So, this is an interesting podcast. This is the first time that we’ve tried to crowdsource some questions from the Facebook group to see what other folks might want us to talk about which is a dangerous proposition but I actually think it went well. We didn’t get any crazy curveball questions or anything but we have a few things that people might be interested in.

So I wonder if we might start with the one that’s maybe a little easier just to get us warmed up. And that’s the internship question. So this is the most recent question that we got but a good one because it’s very topical. We have a lot of grad students who listen who are going through that internship application process right now. So I’m curious for y’all, if you can think back, what reflections do you have [00:26:00] about the internship application process? What would you have done differently? What did you hate? What went well? An open call for advice or guidance through this process.

Dr. Chris: I loved Katie’s question. I thought it was so like, oh, why didn’t we think about that? Because we’re on the other side of it. Where my head always goes when I’ve been asked this just even locally by local graduate students is like, what are you trying to communicate? When you’re writing, when you’re answering questions, what are the 3 or 4 main things that you want to communicate about what you can bring, how you can match the goals and the vision of that department.

And every question that’s asked to you, you always bring it back to those things that you can bring. So it’s like playing a little bit of verbal ping pong but what can we bring to this program? That’s a really easy to easy question to answer. What are your values? Well, here are my values and this is how they can apply to the program and what I want to bring in research and all these different things.

So, I just think that’s such a cool way of thinking about what can you bring to the program but every question that’s [00:27:00] asked you, you always ping pong it back to them, and you’d sprinkle a little bit of your own stuff on top of it. So you’d create this really strong message. And you can do that in your writing too, but the interview is pretty important.

Dr. Sharp: Yeah, absolutely. I love when people, I was going to say because we have an internship site here, so we’re interviewing every year and the things that stand out are the ones that are more personal certainly. So if I read the first, whatever one or two paragraphs of an essay and don’t get a sense of who the person is, it’s game over. And then, the folks who show up for the interview and bring some personality and show that they have researched our site and actually have good questions for us, those folks really stand out. Those are just two things off the top of my head that catch my eye.

Dr. Andres: I could speak to this a little bit. I [00:28:00] think I’m the most recent graduate here out of the group. My story and I share this openly is that, well, my first year, when I applied to the internship was that huge site and applicant disparity. I think we had something like a thousand fewer sites in the applicants or something like that. APA raised some money to solve that problem or resolve it more.

So my cohort, despite having year to year, and especially the years after having really good match rates at our school, our cohort, our first round, I think something like 50% of us did not match. It was so devastating. I don’t know if any of the staff members are listening, but they did this thing where all the people who didn’t match would get together for dinner. They would take us out to dinner to talk about it. It’s meant to be like comfort or anything, but it felt a little bit like, in our minds, we’re like, y’all, [00:29:00] here are all the losers that kind of thing but that was a really big learning experience for me.

I went into my doctorate program with MFT. I was a little bit arrogant. I have more experience than everyone. And I thought it was so smart. And then I got interviews and I did a match. And it really got me to rethink, what was I doing wrong? And I think what Chris said is one of the biggest things that you have to really know if you’re a good match for that site. Don’t just apply to a site. You have some dream sites, of course, but don’t apply to a site just because it’s a hot name or something like that where it sounds like a cool place to live.  I mean, those are important things but you have to be a good match too. It’s a job, right? You’re trying to apply for a job.

And another thing I learned is, it really comes down to those few things, your CV, your cover letters. A lot of times [00:30:00] applicants focus so much on the things that they matter, right, like the hours and things like that. But then those letters are huge. That’s the first interaction they have with you. And if you think about it, a lot of these sites have 100, 200, 300 applicants.

I’ve been at sites where we would review cover letters. Trust me, no one’s going to read them thoroughly. You need to capture their attention right away. And so even with their CV, your first page should have all your good stuff. If you speak another language, put it right there. If you have some specialties, put them right there. Don’t let people scour for it. And so that’s the practical tip, but ultimately it’s like knowing your goodness of fit and like where you fit in, what you want, what’s your focus in terms of what you want to [00:31:00] get out of the internship. That’s what I think a lot of these sites want to know.

And then I think in the Facebook group, I know some people mentioned this too, if you’re doing a lot of assessment, have some therapy experience too. That’s huge. I think when I hear a lot of your guests come on the podcast talk about how they assess, they’re talking a lot about these therapeutic skills conceptually and things like that. And you don’t want to just be one-dimensional. I know some people, like this not that thing but you can learn something from the therapy side.

And then ultimately, expanding your net would help. I know sometimes people just want to stick to some cool cities and stuff like that or even in your local area but expanding your net a little bit might give you some chances. And then practicing your interviews, letting people read your essays, getting a [00:32:00] lot of people to read them because we could get really stuck in our own mindset.

What I did was I found my friends who are in HR, who have done literally thousands of interviews, and I just go, “Interview me.” And then they would just give me the most challenging questions. And then I’m like, “Oh my gosh, I wasn’t prepared for that.” And I think that was a big mistake on my first round of applications is like, I’m a cool guy, I’m easygoing, go into this interview. I know enough about this site. And then they would ask me questions and I was completely winging it. And so I learned in my second round, I was like don’t wing it. Just be honest, that’s an area I’m working on. Here’s what I do know.

Anyway, I won’t get too much into the details of that but those are the things I really learned. And I think I did really well in my second round of applications and on an awesome internship in Chicago met my wife and my life has been fantastic ever [00:33:00] since. So there you go.

Dr. Chris: Yeah. You bring up a good point though, Andres. It’s like, just say, you don’t know if you don’t know. If you get to the interview and you don’t know an answer, hey, that’s a great question. And this is how I’d figure out the answer instead of just making up something because it just shows like your critical thinking and it shows that you’re willing to also not know everything because I didn’t know a damn thing when I went to grad school and to be honest, I was pretending I was trying to be a doctor, my first year of school. And boy, we were getting roasted. You’re not supposed to know anything in your first year. You’re also not supposed to know anything your first time in an internship either.

Dr. Andres: That’s a great point. And building on that, don’t just say you don’t know. What you said and how you’re going to solve that problem, I think that’s what these interview questions are really about. I used to work at a graduate program. We’d take on practice students all the time, practicum students, and we would ask [00:34:00] questions expecting the students not to know them. And I would always tell them, I don’t expect you to know the answer, but I want to see how you think. I even tell them that. And the students that do well with that, I go, okay, because that’s going to happen in your placement.

The clinical situation is always going to be different and new and unique. And you’re not going to know the answer on the spot. I still don’t know the answer on the spot. I have to call Stephanie, but then that’s the thing, like, how are you going to navigate that? And a lot of sites are looking for that. And I would say that it comes across even the wrong way. If you’re presenting yourself as trying to have the answer for everything, then why are you going to internship, right?

Dr. Sharp: That reminds me, I’m going to take a small digression to illustrate how badly this can go. In my experience, I had to apply for grad school [00:35:00] twice. I didn’t get into grad school the first time around. So I had to take a gap year and then go back. And during one of those interviews, one of the interview questions to get into grad school was what is your theoretical orientation? And I remember this, this is Southern Mississippi I believe it was. It was a group interview. I was there with two other candidates and they said, what is your theoretical orientation? I had no idea what that meant, like literally zero ideas of what that meant. And my answer basically amounted to what that guy said over there and I just basically copied the guy and it was so bad.

This is still one of those moments that haunts me at night. It was so bad but it illustrates that point. Like if you don’t know it just makes so much more sense. Just say like, I’m not sure. That’s a really great question. Here’s what I might do to figure that out and talk your way out of it a little bit. Don’t try to stumble through it.

[00:36:00]Dr. Laura: I might go to grad school to figure that out.

Dr. Sharp: Yeah. If I’d only known, right, like hindsight’s 2020.

Dr. Andres: You should know your theoretical orientation when you’re applying to a program.

Dr. Sharp: Thank you. I appreciate that validation, but yeah, somehow the other two knew the answer and they sounded very polished. So, I felt like a complete idiot. This is not about me.

Dr. Laura: When you guys are talking about all the internship sites and the different facets of them. It just struck me how different it is on the school psychology side because school is a school, right? They might have a little bit of different programming. They might call it something different. It might be contained in all the schools or maybe just one school, but they all have essentially the same program and I think that was a hard question for me on those interviews was like, what do you hope to get out of this? What do you hope that we have that you can do? Well, damn![00:37:00] There’s not a lot of different views in there. But that was really tough. I don’t have any suggestions for that.

Dr. Stephanie: But Laura, I think you bring up a really good point. We’ve been talking about ways you can sell yourself to internship sites but don’t lose sight of the fact that you’re also interviewing them. Like when I picked an internship, they were like, oh, you’re going to be doing three full neuropsychology a week plus a full day of didactics, a small therapy caseload, some research, and going to the clinic on Friday, and I didn’t stop and do the math and be like, wow, that’s 100 hours a week. I’m going to die.

So don’t forget to think about what they’re offering not in terms of necessarily the activities that you’ll be doing, but how much are they going to invest in you as a trainee? How much room for growth is [00:38:00] there? Is it the place where they’re going to be asking you your theoretical orientation before you should even know that or is it a place that has ways to build your weak spots in ways that are going to feel supported and like they’re a good fit for you too?

Dr. Sharp: Great point. And I appreciate those questions too. Going back to the question suggestions, people are really dialed in and they are asking how is this going to work for me? And what boundaries do you have around, at least for our site? That’s important to see an intern who’s thinking about themselves a little bit.

Dr. Andres: So, Laura, I was just going to ask before you jumped in, can you give some insight into what the school psychologists internship process might be different than maybe some things that you’ve learned from the process for those that might be applying?

[00:39:00] Dr. Laura: I did sit on the other side of the table, and it interesting from what I saw, and these are not my decisions but it seems like if someone was applying to a school site who was a clinical person, unless they had a significant chunk of assessment experience, it was almost like, sorry, this isn’t going to work. And so they were pretty automatically excluded.

So if you are interested in applying to a school psych0ology site, make sure you really beef up those testing cases because otherwise you’re just not going to be a good fit. I do think though like you were saying Andres, that having some of that therapy background is also really helpful too because as school psychologists, we get called on more and more to do some of the therapeutic intervention. But again, it depends on the district you’re in and the state you’re in and how they [00:40:00] divide up related services, and who else is on the team. 

Dr. Andres: And so knowing your sites is really important. I think that’s across the board.

Dr. Laura: But it’s harder and harder with the school systems system to figure that out. To pass through like, well, who’s actually doing what services, because it’s not going to be listed on the website necessarily. I guess that’s a good question. It’s a good way to learn the site while you’re there.

Dr. Sharp: Yeah, nobody has really mentioned this yet, but the letters of recommendation are pretty crucial as well. I know we’re spanning the entire application here, but generic letters of recommendation are a nail in the coffin, as far as I’m concerned. If your letters aren’t saying something unique about your personality or really show that this person has gotten to [00:41:00] know you fairly well, that’s really challenging from the application side because we are, I forget who said it, we’re reviewing tens, hundreds, hundredths of applications and all we have are those letters and the CV and the essays at first. So that’s really important. So choose your letter writers carefully.

Dr. Andres: So to add to that, again, from my own experience. I really appreciate my internship supervisor. We had a good relationship where we could be honest and she really wanted me to grow and learn. So I applied to that, my internship site that I matched at eventually, it was my second time applying and she remembered me.

I asked her the second time around, what changed, right? You ranked me this time [00:42:00] not last time. And she gave me some pointers. You had a great experience. We wish you had a little bit more assessment, but the main thing was one of your letters of recommendation. You weren’t described in a favorable light like that. And I was like, whoa. So I found out that one of my supervisors that I didn’t really know that well I didn’t spend that much time with, I was just desperate for a letter and I just thought, well, that is a fancy site. Just name was more important than a relationship. And I went for that.

And so, definitely, it’s one of those things. You want to get to know your supervisors. You’re going to be working with them at your practicum site. You should get to know them. And don’t just pick anyone to write it, pick someone that knows you and knows you well. Aside from just being generic and bland, and you don’t want something that’s working against you or criticizes you in your letter. I had no idea that [00:43:00] the letter had that in there until much later. Now., I know.

Dr. Laura: Will you be offering a virtual dinner for all the people we don’t match?

Dr. Andres: But even speaking to that, that was probably the best thing that could’ve happened to me in retrospect. I was joking about how I eventually moved to Chicago, met my wife, but that’s true. I would have probably not met my wife if I matched the first time around. But also the sites the second time around when I knew what I wanted to do more and I needed that extra year to polish my professional interests.

So if you don’t match, I know it seems devastating, you’ve worked so hard for this and then you got to wait. It’s just so devastating. But everyone I’ve talked to all my old classmates that didn’t match, it’s like this blip in their memory now, and then they’re doing amazing work now. Some are professors, some are [00:44:00] in their own practices, executives at hospitals and stuff like that. So it’s okay if you don’t match but learn from it, and grow from it.

Dr. Sharp: That’s a great point.

Dr. Laura: That’s a unique perspective. That’s really cool. I mean, it’s not cool at the time, but…

Dr. Andres: Yeah, it’s terrible. It’s the worst feeling.

Dr. Sharp: It sounds like the end of the world.

Dr. Andres: Yeah. And then speaking to that I absolutely know that it’s expensive not to match because you have to stay another year and defer your income and all that stuff. It’s hard. I’ve been very fortunate I was able to sustain myself through that. But you don’t want one year. An internship is just one year but it could dictate so much of your career. I don’t think it should be like that, but sometimes it’s worth getting a good fit rather than finding something that doesn’t fit and then [00:45:00] struggling for the next five years after internship because you didn’t get the training you wanted.

Some people might have a different philosophy. They just want to get out there and that’s okay too. There is no right or wrong way to do it. And it’s okay if it takes you a little bit more time, at least that’s what I tell myself.

Dr. Stephanie: Yeah. We definitely have a fixed mindset in this profession, right? We self-select for people who did well in school and got a lot of gold stars and got a lot of A+, and then you come up against your first grad school choice that you didn’t get into, or the internship that you wanted that you didn’t get, or the article that you submitted that didn’t get published, or you don’t match for an internship, or you do board certification and don’t pass the first time. And it can feel like such a huge failure. It can activate every little last cell of your imposter syndrome. And then everyone you talk to you find out actually has one of those in their career as well and [00:46:00] ended up often being a positive often something that helped them find the right fit later.

And we don’t often talk in this profession, we do for our clients but not for ourselves, about these times when things don’t match our growth and learning experiences. Andres, you did just such a nice job of talking about how you learned how to interview and sell yourself through that process. And everybody has talked about what they’ve learned from failures. So if you don’t match, it’s a growth experience. It is not an indictment of who you are or some sort of failure. It is an opportunity. It may not feel like it at the moment, but it really is.

Dr. Chris: One of my favorite quotes, I’m sure it’s not his, but Gary Vaynerchuk said it, and he says, I’d rather try something 10 times and fail at 8 of them than try it twice and crush it because there’s so much learning that happens in those eight, what we call failures, Everyone’s alluding to it. It’s so freaking hard to see it at the moment. [00:47:00] But here we are all post-grad for a while and we can look back on it and say, man, that sucked, but here we are.

Dr. Andres: And the world of relational psychodynamic therapy, the idea of countertransference, your own experience being a form of empathy. I’m just thinking about if we are assessing clients who are struggling and going through perceived failures, what better way to understand their experienced and to have gone through it yourself and to pull from that. So when my clients go, I’m having a really hard time applying for jobs and I keep messing up because I keep acting impulsively or something like that. I could identify with the part of not getting a job, I get that, and then I could empathize with them and build that connection and rapport. And you can totally use that.

Dr. Stephanie: Yeah. It also relates to assessment in the sense that we often want to get the right answer for [00:48:00] assessments as well. And having the experience of like, oh, sometimes it doesn’t work out as well as we wanted it to. And it’s still a helpful experience for everyone to have gone through. We don’t always have to get the exact perfect diagnosis and the report that could be published somewhere in order for it to have been a growth experience for you and hopefully for our clients as well.

Dr. Sharp: Yeah. We talked about that a bit last time as well.  It’s okay to say, I don’t know. It’s okay to mess up or to revisit in two years or whatever it might look like. But yeah, I think the theme from all of this was just permission to not nail it every time. The first time you don’t have to be perfect. It’s totally okay.

Dr. Andres: And what’s that quote, I’m going to butcher this, but if doing, [00:49:00] oh my gosh, like, if you do perfectly every time, that’s not your best or that’s actually your average or something like that.

Dr. Stephanie: Yeah. It becomes your new average.

Dr. Andres: Yeah, I just butchered that. But you know what I mean folks.

Dr. Stephanie: I was talking to a friend of mine prior to this podcast and asking what she wanted us to talk about, shout out to Alison. And she was like, oh, imposter syndrome. And I was like, I’m pretty sure that’s all we talk about, but it is something that I think we all feel compelled to bring up in these podcasts because our profession doesn’t have a lot of room for it. Otherwise, we really aren’t having a lot of bigger conversations about that. So I really appreciate this space to continually bring it up.

Dr. Sharp: Right. Yeah, that’s such a good point. It’s so interesting to hear that. Out of all the things Allison could’ve said, Allison who was on this podcast, is clearly an expert, and she says imposter syndrome, it’s like [00:50:00] this thing that all of us are working with but nobody is really talking about is…

Dr. Stephanie: She said imposter syndrome and shame which I think we’re also touching on here, right?

Dr. Sharp: Yeah. Seriously.

Dr. Stephanie: Something I think we’ve all experienced in this group, but you just can’t do this job without bumping up against it. You probably can’t be human without bumping up against shame but it feels like we’re supposed to at this job do it without experiencing any kind of failure, any kind of regret, or any kind of personal failings or not have it altogether 100% of the time.

Dr. Sharp: Yeah. It reminds me of two of the questions that came up actually. One of those is maintaining culture in a remote environment. And one thing that we have been doing in our practice is these things called, [00:51:00] it’s whatever day of the week somebody chooses to post it, but it’s like a Thursday poll or a Tuesday poll or whatever. And the questions inevitably lean toward this, like share something shameful with us basically. Our question yesterday was, what memory from middle school or high school still keeps you up at night? And people were like sharing all these stories.

That’s one way that we have found I think to connect with each other when we’re not in the office together but it really gets at that. I think there is something somewhat compelling about sharing these things that lurk within us. And knowing that other people can support that and that you’re not alone.

Dr. Andres: You guys ever heard about the mortified podcast?

Dr. Sharp: No.

Dr. Andres: I recommend it. It’s a podcast where people would just go on stage and share their junior high embarrassing stories. It’s the most cringing. [00:52:00] It’s so awful, but you connect with it. And you’re like, oh yes, I’ve had that experience before. And every time we look at our past selves, it should be a little cringy because we’ve grown. Absolutely.

Dr. Sharp: I’m going to bring this into the moment and ask what each of you is struggling with in your practices right now? What are you struggling with the most in terms of your clinical work or development or on the business side too, I suppose?

Dr. Chris: I’ll fill the blank. I’m usually a little impulsive when it comes to that stuff. There’s so much ambiguity in my future when it comes to what the practice is going to look like, where it’s going to be, who’s going to be a part of it, all of that. So that’s something that keeps me up at night because I have a vision and I think I know which direction it’s going to go. It’s just how it’s going to shake out like that. Not being more acutely aware of all those details. In my own clinical work, [00:53:00] I’m just absolutely overwhelmed and burnt out.

And so it’s like, how am I trying to balance all of my stuff and still do good enough without feeling that I have to wake up super early or stay at my computer super late. So I’ve gone from last year trying to chill a bit and actually being able to chill, and this year like, oh shit, I better chill. There are going to be maybe long-term physiological or emotional effects. It’s hard because I love working and I love being busy, but it’s taking its toll recently.

Dr. Sharp: I’m guessing you’re not alone in that especially with the diffuse boundaries between work and home that we’ve experienced that’s easy to just keep going.

Dr. Andres: We were just in an interesting time too. At least in LA, we’re still in the pandemic but it’s like life goes on, and [00:54:00] things feel normal, but not really. So there’s just this underlying trauma that we’re all experiencing still, and then trying to run your own business and take care of your family and all that stuff underneath, that’s a continual challenge for me personally.

If I don’t catch myself attending to those things and attending to myself care, seeking my own therapy, it could really creep up because I could easily, anyone who runs their own practices, you could easily get immersed in your work as a way of an escape and distraction if you will. I know we’ve spoken to this before, but that keeps coming up for me. It’s like, wait, we’re still in this thing. And it hasn’t gone away. And at least here, I know some parts of the country it’s like it was never here.

Dr. Sharp: Yeah. [00:55:00] I know that I’ve been working a lot with falling off on the clinical side of things which is crazy such a big part of my life for a long time but I’ve been trying to work up the motivation to really dive back into clinical growth and it’s been challenging lately. And so I’ve found myself more flustered, maybe it’s the right word, with writing reports and pulling data together and that sort of thing. I’m feeling I’ve lost two clicks on the fluency scale or whatever with doing that work which is frustrating for me. So that’s what I’m working on. I’m trying to carve out time to actually dive back in and polish up the clinical skills.

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Alright, let’s get back to the podcast.

Dr. Laura: When you were asking that question, immediately in my head I was like generativity [00:57:00] versus stagnation. And I was like, listen and then I had to like Google and I was like, oh, that takes place during adulthood, during ages 40-65. And I was like, crap. That’s me. They came full circle in my brain, but like trying to decide what to do with my business. Do I go Chris and buy a building? Because that has been on the radar and has been a thought, but then at the same time, I’m very reluctant to do anything in the pandemic right now. I just keep talking along, just doing my own little thing, just trying to keep it small and intimate and only be in the office a little bit.

And then when that person asks, where do you see yourself in 10 years? I will not be retiring in 10 years. BC done. I’m not that old. Yeah, I’m like, where do I see myself? I want to grow. I want to do things I have ideas and plans [00:58:00] but this whole pandemic is just like limiting everything and making it feel so small. And it’s just so much safer to just stick with what I’m doing but is it fulfilling? And is that what I want to be doing? I don’t know. And that’s my rant. You’re welcome.

Dr. Sharp: That’s all fair. It’s hard to make big decisions right now.

Dr. Andres: I won’t get into it now, but that just brings up maybe good to address and later the question of, so when I saw that question on the Facebook group, the retirement question, immediately what came to mind was that how a lot of times, because we deferred our opportunity to earn income by going to grad school and taking on loans for most of us and doing whatever, there is a cost to [00:59:00] entering this field. In general, we make more money than an average person. We should be, right? But we’ve deferred all the income. So I’m thinking about like, what kind of psychologists retires early? At least when talking about can you retire in 10 years and that’s not going to happen for me, at least not right now. But anyway, we can talk about that later, but that’s just what’s coming to mind.

Dr. Stephanie: To be fair to the question, I think she meant where do you see yourself in 10 years. And where do you see yourself when you’re around retirement age? Like it was two separate questions. She wasn’t suggesting for all. So, where do you guys see yourself?

Dr. Andres: That was a projective test.

Dr. Stephanie: Where do you see yourself in 10 years though?

Dr. Andres: Hanging out at Chris’s hair salon.

[01:00:00] Dr. Chris: I might be running the greatest one in 10 years. Who knows?

Dr. Sharp: Great point. I make no bones about it, is that the right phrase, about wanting to not work much. In 10 years, I sincerely hope that the practice is at a place where it requires a very little touch from me. And I was thinking about that question this morning because a big part of my life at this point is the podcast and consulting obviously. And it’s really hard to think about doing a podcast for 10 years. I don’t know what that looks like, but I also don’t know how to take that out of my life right now. So that’s a very challenging question.

Dr. Stephanie: You just become the executive producer.

Dr. Sharp: Maybe.[01:01:00] I don’t know. I guess people do that. It seems I don’t know. But that’s the thing. I think the older I get, I was having a conversation with my friend Kelly Higdon who’s another coach in this world and we were just saying like, I don’t know if it’s a point of this stage of life, but I’m like I just don’t want to be needed by so many people right now. I mean to step back a little bit. I’ve got my kids and of course the practice and different obligations I suppose. I don’t know what all that means, but right now I feel a pull to step back a little bit and let someone else make decisions, at least for a while. So, in 10 years maybe that’ll be happening.

Dr. Chris: Were podcasts even around 10 years ago? I’m trying to think.

Dr. Sharp: They existed

Dr. Andres: but not in this level of popularity. [01:02:00] So who knows? Hologram show is next in the next 10 years?

Dr. Sharp: Yeah, this is maybe taking us down a totally different path but I feel like our field is going, we’re going to have to figure out some way to embrace technology and get into that. I don’t know how that translates to assessment but does that mean we end up learning how to write little programs or software? I have no idea but I feel like we’re going to have to change in some way to go that direction and embrace some of the technology.

Dr. Andres: Can I jump on that tangent and ask, what are some problems, struggles, or challenges in our field that you feel like technology could easily fix that if someone’s willing to put in the time?

Dr. Chris: I took that question. There was a comment in your question. The very first part of that question was the biggest [01:03:00] part of the technology that I see going awry is TikTok right now. That’s such a mess for us. So the self-diagnosis problem and all that stuff but I don’t know if we can fix that side of things. I think there’s a lot of people working on how to fix it though. We’ll fix it, I used it very loosely on how to, I guess people are trying to really create some automation in our world that is hard to do because it’s so much art and science and simultaneously.

Dr. Andres: Can we jump on the TikTok question? Because I think that’s a hot topic in our Facebook group, right? Some people are like, no, it’s great. Some people are like, no, it’s detrimental. I’m curious what you guys are feeling about it or any thoughts or is it too hot of a topic to touch? Yeah.

Dr. Sharp: That’s what we do. We tackle hot topics.

Dr. Chris: Usually at the encouragement of Andres. That’s true.

Dr. Sharp: Then we burn our hands and we withdraw quickly. [01:04:00] If you think about any technology or any medium or any stimulus that gets people invested in their own mental health, maybe I’ll approach it that way first in a naive perspective and say like, okay, if this is just widening the net for people to pay attention to mental health and it’s spreading the word about mental health, maybe that’s a good thing. Maybe it’s growing into a monster but maybe on the surface, it’s also good that people are thinking about mental health in general. We’ll start there and you’ll agree or disagree as you see then.

Dr. Andres: I personally don’t get to TikTok because I’m old now. But now I’m thinking about it, but I tend to be very comfortable with technology. So I’m like, you know what? Maybe I just don’t understand it. And it’s cool. And like what you’re saying, Jeremy, people are talking about these issues. It’s great. But I’m curious too, like maybe [01:05:00] I’m not seeing some of the major concerns too. I think there are two levels with any medium, right? Like with telehealth, there are definitely benefits to it but there are also major challenges and ethical concerns. I’m wondering if you guys have encountered anything with the growing popularity of TikTok?

Dr. Laura: I think the problem is just the algorithm that feeds into whatever self-diagnosis or symptoms or it causes people to think that they’re struggling with something that maybe they are, maybe they aren’t. But once they get pigeonholed, with your Facebook ads and all your TikTok and all your different things, you go down that rabbit hole. And then, of course, it’s human nature to try to pigeonhole ourselves and see, oh yeah, that’s a benefit check, check, check.

And now I [01:06:00] have maybe a community or an identification or a way of thinking about myself, which might be awesome. It might be self-discovery, it might be perfect, it might change your life, but it might also harm you by causing you to think that there’s something wrong or something different or something that needs changing or fixing or helping, or I don’t know. I have just seen people come in who absolutely needed an evaluation. There were a lot of things happening and not going well and that was referred by themselves through TikTok. And then I’ve seen people on the complete opposite end of the spectrum. And I also have TikTok but I don’t get it.

Dr. Andres: I’m just bouncing off that, Laura. I’m just thinking of how we’ve had those experiences in our culture and society for a long time, right? If you’re in a certain community you might hear the same [01:07:00] message over and over again. I come from a more conservative Christian background and there’s a lot of those messages of like, whether intentional or not, messages about sex and sexuality that are repeated and that’s without technology. And so, I’m imagining there could be harmful messages about…

I’ll give you one example, one common thing that exists in a lot of modern evangelical Christian churches is this purity culture idea that if you think about sex that that’s impure or something like that. That’s very simplistic of course, but that happens a lot. So then you have kids who are growing up and thinking, oh, I just thought that guy was hot or I thought that girl was hot and I needed to get rid of that impure thought which is actually normal behavior. And then it becomes [01:08:00] like, I must be a sex addict because I keep thinking about how hot that person is.

And then with the algorithm of TikTok, I read something recently about its the fastest algorithm. It knows how fast you’re scrolling, not just what you’re clicking but what you’re scrolling. And so, it could calculate down to the millisecond or something like that which ads and which videos work. And so then it’s going to keep reinforcing those ideas. So then normal behavior could be pathologized. So, that’s a tricky balance because then it might bring some awareness to people, and at the same time, it might pathologize things that are, everyone struggles with that. That’s what we all experience. And then we have to put a label on it now. And I could see how it’s really a challenge.

Dr. Sharp: I think that may [01:09:00] be the downside of some of this, pathologizing of normal behavior.

Dr. Stephanie: Or the linking of trans diagnostic problems to one specific diagnosis. For example, attention problems equal ADHD or social problems equals autism or things like that. That also could be a downside. Although I was listening… Jeremy, you just recently interviewed Theresa Reagan, I think it was the last name, about autism. And you were asking her a question about this and she was giving the same answer we’re giving of like, there are positives and there are negatives. And I was walking around thinking about it and thinking that’s true. And of course, there are positives and negatives.

I was also thinking that a lot of our young people are just in crisis right now. There’s a lot of things that have changed. There’s a lot of instability. People don’t necessarily know [01:10:00] their future plan anymore. When my parents went to high school, you were just going to work at Boeing afterward because I grew up in Seattle. So like, there’s a plan for you. And it was understood you were going to get married to someone of the opposite sex and you were going to have 2.5 children. And now there’s a lot of uncertainty on a global level, not just depend on the pandemic, but everything. Global warming. Are we going to have a planet in 10 years?

And young people are expected to figure this all out right now without even much of a community except the community online and whatever TikTok is feeding them. And I’m wondering if TikTok is maybe just more of a symptom than it is the actual problem. Just a lot of teens and young adults who are like, wow, this is all really hard. I feel like everyone else is doing okay. I’m not. [01:11:00] How come? And the truth is, none of us are really doing that great right now but I think it’s just people who are in a really hard time who are being fed a possible reason for why that might be the case.

Dr. Chris: I think that translates into our clinical work too. I think I shared with you all on the slack, not too long ago, where people are just very frustrated if they’re not getting a diagnostic label that they came in for. As a clinician, I’ve really struggled with that over the last two months where people come in and they say, this, that, or that. On the surface, it may very well be, but let’s get some evidence to help support that. So, interview, your data, et cetera, and everything is pointing away from it and you show them all the data and you can have those conversations and you try to do it very delicately. And there’s been so much frustration and pushback. I use that word pushback very delicately, but like really difficult feedback sessions recently.

Dr. Laura: I would say that’s about 50% of my consult [01:12:00] work is people who have done an assessment and the client either they know, and the clinician knows in advance it’s not what the client wants to hear, or they’ve done the feedback and it has not gone well. And they’re struggling with that piece. Now it seems to be a big theme in the assessment world right now. So if you’re listening and that has happened to you, you are not alone.

Dr. Andres: Group hug, everyone.

Dr. Sharp: Yeah. It really gets at that question of how do you validate a client’s experience without necessarily providing the diagnosis that they want? Like, hit both ends. And how do you say yes, of course, this is hard. I get that. And I don’t think it’s whatever you think it is. If anyone wants to answer that question.

Dr. Stephanie: How do you do it?

Dr. Sharp: Well, I’m a very [01:13:00] transparent simple-minded individual. So it’s actually very similar to that. I will say something like, I totally get it. This is really hard. I am not saying this is not real for you. All these things are happening. And that sucks in some to some regard. Here’s what we know about, I’m just going to pick autism, that’s easy, that’s top of mind, here’s what we know about it, and I don’t think that’s what’s happening for you but that doesn’t mean that it’s not hard and that you can’t benefit from some support or that I’m not going to guide you in the right direction and help you feel better for lack of a better term.

But I think people want clarity and guidance and to know that they’re not crazy, and to know that there might be some hope, right? So that’s what I try to say. I’m not going to crush your dreams and just send you out [01:14:00] into the night without any sort of beacon. And I don’t think it’s autism. I’m curious how others approach that

Dr. Andres: It’s not just all in your head, I think that’s what a lot of clients are concerned about. I’m making this stuff up or I’m not trying hard enough.

Dr. Chris: One thing I’ve been trying to really focus on is like, okay, so we don’t have the answer yet but we can rule all these other things out right now. And we have enough evidence to rule out ABC X, Y, and Z. So we can put more clarity around what’s at play. And if we need to collect more data, that’s fine. If we need to jump into your experience a little bit more that’s fine too. So rather than focusing on what is this, we can focus on well, I don’t believe it to be all these things. And I find that it helps sometimes but I still find myself running into these situations that are difficult.

Dr. Andres: I’m just thinking on the top of my head. Is there ever a situation where you could [01:15:00] possibly, I’m curious, like say you assess someone and everything is “normal”. There’s like nothing. I don’t know if that situation presented itself because they have to be experiencing some struggle before they come in. I don’t know what I’m trying to ask but I’m just thinking because a lot of clients’ worst fears like nothing’s wrong I’m just not working hard enough or something like that. And is that even a scenario that could have even happened?

Dr. Chris: It happens all the time. And the scenario I was referencing last week was that exact thing. IQ average to like a little bit above average. Nothing popped on the PAI. CPT was great. Connors, Stephie’s all that stuff was totally in the normal range. And I said, this is weird for me as a clinician because I have no data to support what you’re experiencing but I’m not doubting what you’re experiencing. And there was just a tremendous amount of [01:16:00] pushback.

I’m a firm believer that the feedback session is a super important part of the diagnostic process. So through that conversation, this person is able to put forth adequate effort and we do testing in a pretty sterile environment free from distractions. And so they’re able to do that but it depletes their energy so incredibly quickly, and this person was drained for a day and a half afterward, I put the report, of course.

And so the working hypothesis at that point was, you can probably look at normal quotation marks all over the place, but it takes a tremendous amount of energy to produce that degree of data or that normal data. And so that was that delicate walk in that feedback session. And even in the follow-up, that feedback session, because we had two of them. The data doesn’t produce what you’re saying but nonetheless, I’m not doubting that you’re experiencing it. Just not for these reasons.

Dr. Andres: There have been times when you and I approached in the feedback like our measures aren’t sensitive enough to detect everything and we don’t have labels for everything but I’m hearing that you’re [01:17:00] struggling still. Here’s what we do know and here are our evidence-based recommendations for how to manage some of the things you’re struggling with even though we might not have a label or a specific label. So maybe other specified or something I might go that way.

Dr. Stephanie: I think that’s where those therapy skills that you were talking about that are so important for assessment psychologists to have come in. We’ve all shared that we’ve had some burnout at some point in our careers. I’ve been struggling with that this year. If I went in for testing, I don’t think it’s going to show up on testing. It doesn’t mean I didn’t need support or understanding. We don’t really measure everything. We don’t measure everything sensitively. And a lot of the questions that our clients have are not the types that the D-KEFSs are going to tell you anything about.

So [01:18:00] that’s why testing should be one part of your assessment. Ideally, a small part. You also need all of the rest of that data about what Stephen calls the problems in living that the person is having. The problems of trying to get through life that aren’t often going to show up on our testing. So in my experience, it does happen a lot that there’s nothing wrong with the D-KEFS and yet the person is still struggling in some ways surprisingly.

Dr. Sharp: For those listening, Stephanie was doing air quotes.

Dr. Stephanie: Air quotes around the D-KEFS

Dr. Sharp: This is a good discussion. I feel like this is something that we all wrestle with a lot. I don’t know that there are any perfect answers but we’ve talked about the process a lot on this podcast. The content versus the process. And this was just another of those examples where you’re sitting in that feedback session and you can [01:19:00] tell someone is upset and it’s worth pulling out those therapeutic skills and like going down that path, like tell me about what this means to you? Why is this disappointing, or what were you hoping for? What was the worst I could have told you? All those process comments can get underneath and really touch into their experience beyond I wanted an autism diagnosis. Like, what does that mean? And where does this leave you? What are you afraid of now?

Dr. Chris: I have to admit that’s exactly what happened in that feedback session. I’m still processing it. It was pretty intense for me. But at that moment, I could tell something was up. There was a dismissal of comments, there’s a dynamic that was unfolding. I said, what’s going on right now between us. And I think we’re a little bit too far down the rabbit hole to really have that real conversation but it opened up an opportunity to revisit it down the road. And so much clarity came from it.

The perfect feedback session, at least in my opinion, is you go, [01:20:00] you produce the data, you have a conversation and you say, these are the limitations. These are what we’re going to do to help remedy them. These are all the strengths. Let’s double down on those. And everyone walks away great. We got some answers. The worst is what happened to me last week. And I was like, oh my God, it was so intense and so difficult for both of us, myself and the person here. But to pit that pump or pump the brakes rather than hit that speed bump just really slow down the train.

Dr. Stephanie: I would’ve gone the other way. That’s the best feedback. What an amazing opportunity to get more data about that person, to revisit it, to model for them a flexible way of holding on to truth lightly while still trying to grapple with it. And once you’ve had one of those feedbacks, I think it’s good for the client but also for yourself because then you start realizing like, wow, I need to do a lot more prep work upfront and be asking some of these questions in that intake so that every one of my feedbacks isn’t like [01:21:00] this. And once you’ve had one of those and it’s haunted you for a week, your practice becomes so much better because you’re bringing that to your next intake.

Dr. Chris: Yeah. Maybe I shouldn’t have used the word beautiful. I guess the easiest. Beautiful is fulfilling all those ones that go that well. I reflect on my feedback session last week, and clearly, I’ve talked about it a little bit this afternoon. It’s still with me but what a great opportunity for both of us, just as you’re alluding to.

Dr. Andres: Just thinking about the therapeutic assessment model where I think Stephanie talks about that the validity of your testing begins with the rapport you built. It’s not just on your test administration or the protocol or the standardization. It’s about the rapport, helping the client feel comfortable and safe with you. There are [01:22:00] no practical suggestions there but other than really weeding out those major concerns that might come up because people have so much access to data and information now through mediums like TikTok, bad information and good information. So being able to assess even in the interview or even in the initial phone call, like what do they know? What are they looking for? Yeah, those are huge.

Dr. Sharp: Yeah. I think one thing that is occurring to me as we talk about this is the dynamic that happens for most of us I think. When we are feeling attacked, we don’t get more flexible. We tend to get more rigid. And for me, being mindful of that over the years, and I’ve had so much practice with this in the business with client feedback or Google reviews or whatever.

[01:23:00] I’ve somehow cultivated this weird opposite knee jerk reaction. When I’d feel attacked or need to be defensive, it’s moving the other direction and just disengaging and like, okay, what am I missing here? What do I need to know? What could I be thinking about differently? That’s helped in smoothing over client issues. I wonder if that can come into play in feedback sessions as well for getting challenged and do you melt a little bit? Well, tell me about that. Help me understand that instead of, but that data, this standard score.

Dr. Stephanie: I agree. I think so often the characteristic defense that’s almost been trained into us is to get defensive, to get more rigid, to keep pointing to the data. And if you can instead [01:24:00] sit back a little bit and get curious, that can make what was a very difficult, challenging, interpersonal dynamic and crisis situation become a growth opportunity or a learning situation if you can do that. I need help from my colleagues to do that. That’s what I think the best thing about the Facebook group is. It’s like people can post things and be like, here’s why I’m right and the client is wrong. And everybody could say like, well, let’s step back and be curious about what might be happening here. When we step out of the system and can see it, what different perspectives or different options for moving forward might there be once we’re able to get out of that place.

Dr. Sharp: Yeah.

Dr. Andres: So jumping on the idea of crowdsourcing and technology. I think that was your question. What are [01:25:00] some of your thoughts about where our field needs to advance in the use of technology?

Dr. Sharp: I can’t remember if we talked about this before on these episodes, but there’s some information out there certainly about just moving some of our measures over to computers. I don’t know. That seems like a very broad term but I think you know what I mean. Easy through software.

Dr. Andres: Is there something that you do all the time when you’re evaluating someone or a client and you’re like, “This is so frustrating. I wish there were a fix for it.” I was just thinking about this the other day because someone mentioned that question. I think one of the popular questions that come up in the Facebook group is just like, I actually have it right here, like a timer, and it drives me a little bit nuts. With the timer, because sometimes [01:26:00] I’ll use my iPhone with a PAR app which is great, but then it doesn’t have physical buttons. So you miss the button and stuff like that. And then sometimes a physical timer is clunky and gets in the way. I’m just curious if like, there’s like a little quirk that you guys experienced. You’re like, oh, if we could fix this with some technology.

Dr. Sharp: For me, the fragmenting of publishing companies is maddening. And now, I don’t know that that’s going to be solved. I don’t know if there’s any software that can solve that but it seems like there are tools that can somehow crawl the internet for prices across all these different sites and then aggregate it somewhere. So I’m like, is there a way to crawl these publishers’ sites and somehow aggregate it and just let you like buy. I don’t know, that’s not even the same thing but you get the idea. The fact that I have to go to three different websites to send out questionnaires to people is maddening. And I don’t know how to fix that but that would be awesome.

[01:27:00] Dr. Stephanie: There are so many things that we have to do to make evaluations more accessible to people beyond just those who can afford a private pay evaluation. We need to be able to bring the service that we offer to people, somewhere in between those lucky people, I guess in some way, who have Medicaid and the lucky people who can pay for an evaluation, all the people in between so that they can get this. And it’s hard because this is a resource-intensive product that we offer.

Through cleaning out office, I was just struck by how much stuff I have in order to assess people. All of these different tests each of which come in their own designer bag, doing airquotes, again and all of these tools that we need to use to make the [01:28:00] assessment process go well. And all of the toys that we have and all of that but also just the resources that we come with and our expensive educations and all of the labor-intensive time we need to spend writing those reports. And if we don’t figure out ways to reduce some of the resource-intense heaviness of this product, it’s going to become something that is not available to a lot of people who could benefit from it.

Dr. Sharp: Great point.

Dr. Andres: I’m also thinking about how technology, just like with websites like Testing Mom. I just promoted it…

Dr. Sharp: I’m not going to put that in the show notes.

Dr. Andres: But performance-based tests that you, I don’t know, anything about test design. Maybe I’m just speaking out of turn here, but the idea that stuff you can’t practice for, [01:29:00] right? I like to see more of that stuff. And I think we’ve moved a little bit further away from that in the field. More questionnaires because of the prominent ecological validity. Manipulating blocks really translate to real-world situations, maybe, maybe not, but if there could be more research and test developed with that, that’d be really cool. I could imagine technology could really solve that if there could be some investment and time in it but that’s a tricky thing. In the grand scheme of things, we’re kind of a small field.

Dr. Stephanie: So we need an angel investor.

Dr. Sharp: Well, some people have angel investors. This is being worked on I think, but just not in my office. I forget who I was talking to though. Was this Melissa Brotman maybe from [01:30:00] NIMH? I can’t remember. But one of my recent podcast guests was talking about how they are working on developing momentary assessment via a phone app, like trying to build a, I forget the example, maybe like a very brief continuous performance test that someone would take at morning, noon, and night or something via their phone. I don’t know if that’s an exact example but you see where I’m going. Something like that that would prompt someone on their phone via an app. They would have to complete whatever task. And it’s like at the moment it’s again, ecologically valid, hopefully. It’s a little harder to crack or practice with. So I think there’s a lot to move in that direction. I don’t know how close we are necessarily, but that’s exciting.

Dr. Andres: Yeah. With the increasing popularity of Virtual reality and even augmented [01:31:00] reality, I think there could be a lot of potentials there for ecological validity.

Dr. Stephanie: And machine learning for language samples and writing samples, and things like that.

Dr. Sharp: So many things that we could be worth later. Maybe this is what we’ll do in 10 years.

Dr. Laura: There you go.

Dr. Sharp: We’re going to be working on that.

Dr. Laura: Have you guys come up with? Anything new that you’re using? Anything you guys are liking right now?

Dr. Sharp: I’m nodding like, Hey, that’s a great question. I’m thinking about that right now. Someone else would just…

Dr. Andres: Didn’t you release something recently, Jeremy?

Dr. Sharp: Did I? I forget what I say. I don’t know.

Dr. Andres: You released some…didn’t you launch some… did I make this up. Like some products, no, service. Am I making stuff up?

Dr. Chris: There’s a guy you had in your podcast.

Dr. Stephanie: [01:32:00] The Dock Health thing?

Dr. Sharp: Oh, yeah, sorry. That was more than two days ago. My apologies, everyone. I think a tool like that is super helpful for workflow management and prompting for our process has been super helpful. I love that. I was thinking about other applications within the report writing and stuff, but no, that’s been a great tool. I will put that in the show notes. So it’s a task management software that’s specifically for healthcare. That’s been cool.

Dr. Laura: I watched a podcast on the Said No School Psychologist Ever Facebook group. They copy-paste reports. It’s similar to a lot of other programs out there but [01:33:00] I liked the way that they wrote about all the different pieces of each sub-test. And it’s just another tool to clean up. I’m always trying to clean up my tables and make them all look nice, but also be effective, but also be understandable to other people. I hate tables. There is my nemesis. So something maybe I need to check out.

Dr. Sharp: Okay. Copy-paste report?

Dr. Laura: Yes.

Dr. Sharp: Interesting.

Dr. Andres: Nothing major really. This is the same stuff that we’ve talked about on the podcast but what is it? Google forms or IntakeQ or was it Job Form and into FormTool or Form Publisher. And we haven’t talked about this too much, but [01:34:00] FormToolPro, the paid version, if you are savvy and all, I just haven’t had time to do this, but you can basically automate your entire report but it takes a lot of work. And that would be a dream if I sat down and I did that, but the time it would take to do it, given that I don’t do as much assessment as most people at the time that I would invest in it just wouldn’t be worth it for me. I could just write the report.

Dr. Stephanie: That’s the hardest thing about business self-care is that it requires time in the present for future you. And if I had time in the present, I wouldn’t need business self-care. So it’s really hard to remember to take time to do something nice for future you.

Dr. Sharp: So true. I had that conversation with one of my consulting [01:35:00] clients this week and she was like, how am I going to even have the time to do these things? I know it will be helpful but I don’t know how to find the time.

Dr. Andres: I get it.

Dr. Stephanie: I recently got an app. It’s a paid subscription but it’s for textbooks. It’s called Perlego, which I think is Italian to read, or for reading. And it has a lot of textbooks. Basically, they have 600,000 titles, not all in psychology, but if for example, you’re cleaning out your office and you can’t have your beloved books anymore and you are worried about that, it’s a good option. It has the essential series, the common textbooks that we use that you could just easily access on your phone if you like to read textbooks for fun.

Dr. Sharp: Nice. Is that a subscription model?

Dr. Stephanie: It is. Yeah, but [01:36:00] it’s like the cost of one of those books.

Dr. Sharp: That’s awesome. I know people ask about accessing literature a lot. If you don’t have library privileges, it seems like this could be a solution for at least the textbook part. That’s really cool.

Hey, speaking of that, I’m going to try to make a segue to one of our other Facebook questions which is, how does Stephanie know everything in the world? So here’s the question, Stephanie. Are you just one of those blessed individuals where your mind is like a steel trap and you retain everything that you read, or do you have some crazy referencing system and citations or notes somewhere that you can pull up instantaneously somehow or some combination? People are very curious about this. This got the most likes out of all of our potential topics. How does [01:37:00] Stephanie know everything?

Dr. Stephanie: What’s weird is I get this question a lot. I do have a really good memory. I don’t want to suggest that I don’t. It’s how I got to go to college when that wasn’t really something in my family that was a part of our experience. So, I do have a really good memory. It doesn’t feel good to me because I’m constantly frustrated by how, like, I’ve read something once, why do I not remember it 100%

Apparently compared to the mean, I have a good memory, but mostly I think my system is just being really curious. I just Google stuff all of the time. And then I’m like, oh, this is the 9th time I’ve read this article. It starting to sink in. And now I remember.

The only other trick that I have is, on Sunday, I transfer what I’ve learned over into a commonplace book by hand and write it down with the idea that that will also [01:38:00] help reinforce my memory. So that’s the only trick that I use, but mostly I just am really curious and just Google things over and over and over again. I’m like, oh, what’s the prevalence of headbanging again? Let’s look that up. So I just look it up again.

Dr. Sharp: I’m so curious. How do you aggregate things over the course of the week to know what to write on Sunday?

Dr. Stephanie: I use WorkFlowy.  It’s an app on your phone. It’s just a note-taking app, but it lets me copy. So if I see something interesting in an article, I just copy it and just pop it over into there. And then I write it by hand in a commonplace book, just because I remember things better when I write by hand.

Dr. Sharp: Yeah. I got you. Okay.

Dr. Stephanie: But when I look at my commonplace books later, it’s like somebody else wrote them. I’m like, I don’t remember any of this stuff. And then I feel like I don’t remember anything but apparently, I do.

Dr. Sharp: Real-world said otherwise. [01:39:00] Okay, well, there you have. The mystery is solved. I’m so glad somebody asked that though. I’ve thought about it myself.

Dr. Stephanie: Have you?

Dr. Sharp: Yeah, because I think we all consume a lot of information but I do not remember a lot of that info.

Dr. Stephanie: Also, you guys have discovered that not every special interest equals autism and neuropsychology has a special interest for me. So you guys, for example, have suffered that I’m constantly sending you guys articles. I just spend a lot of time consuming this information as well.

Dr. Andres: Yeah. I can tell if it was coming up the top of your head or you are using EndNote or something like that, but apparently, it just comes off the top of your head.

Dr. Sharp: Yeah. I think that’s a great point though. You’ve said before neuropsychology is your hobby. This is what you love and you’re like reading about it a lot. And I think about that [01:40:00] in other contexts like Chris could probably talk to us about wine for hours. Laura could talk to us about singing, et cetera. We have these areas, but you are in an awesome situation where it just gets to shine all over the place and help other people in our field.

Dr. Stephanie: Yeah. Neuro-psychology and natural science. I have a friend who once introduced me as like, this is my friend, Stephanie. She knows everything about flora and fauna and then everyone else walked away. They were like, oh, that’s not a conversation I want to be part of.  Chris is not using and EndNote to remember things about wine. He’s just encountering wine because he’s curious about it. I don’t think Laura, that you use a special program to remember things about singing, right? Like it just is something you’re interested in and curious about.

Dr. Chris: I use EndNote for all my dad jokes. So getting closer and just getting [01:41:00] closer.

Dr. Sharp: Well, y’all, we’ve been talking for almost two hours. Anything else still floating out there? Any parting words before we wrap up for today? This has been good as always.

Dr. Laura: I don’t know if my microphone is working. This was random, but I wanted to share this. I ran across my first person who literally cannot recursive.

Dr. Stephanie: Wow.

Dr. Laura: They were not taught cursive. They don’t get it. They can’t read it.

Dr. Stephanie: It’s not wild. How old are they?

Dr. Laura: 20-ish.

Dr. Stephanie: Oh my gosh. Wow.

Dr. Sharp: Is that rare?

Dr. Andres: That’s pretty rare. I know more schools are not teaching it, right?

Dr. Laura: It made me feel really old. And then also I was like, I don’t understand how you don’t understand because I [01:42:00] never thought about it. That was just a random thought I had for you guys.

Dr. Stephanie: Yeah. Pretty soon assessment is just going to be, they submit their own TikTok videos, and that’s how they fill out the questionnaire.

Dr. Sharp: Right. Hey, related to that, I have a random thing too. I ran across a kid the other day who does mirror writing all the time, right to left, backward writing, that’s interesting. You’re nodding like you’ve seen that too.

Dr. Stephanie: Oh, it’s spontaneous in children who are 5 or 6 years old. If you’re interested in mirror writing, you have to check out Stanislas Dehaene’s book Reading in the Brain. It has a really good section on spontaneous mirror writing and how kids naturally do that when they run out of room and why that happens in the brain and why it gets eventually trained out of most of us. That’s fascinating [01:43:00] when you see it and it’s been still retained beyond that age.

Dr. Sharp: Yeah, that was the interesting thing that it was so consistent. It wasn’t just like running out of room, it was just like that was how they wrote. Fascinating.

Dr. Laura: This is why people are like, how do you do this? Because I’m sitting here like, what was the last book I read? I don’t know. But you just pulled that out. Well done.

Dr. Andres: Well, speaking of books, based on Stephanie’s recommendation, Revealing Minds by…

Dr. Stephanie: It’s so funny. I’ve recommended that book like 80 times, but for some reason, the last time I recommended it caused a rush on Amazon, I guess. I didn’t mean to.

Dr. Andres: Well, it’s a huge thing that we do not learn in our pro… Well, maybe you could talk about it. I just got it. So I have no idea. Just because you recommended it I bought it. That’s the only reason. I’ve no idea if I’m ever going to use it, but [01:44:00] maybe you can talk about it.

Dr. Stephanie: Well, I think you guys know, I’m like, I’m sorry, I’m super soap boxy today, but I’m like very passionate about accessible writing that people can actually read and that has, like you were talking about Andres, ecological validity. And most books about assessment writing give us models that are even at a higher grade level than most of us are naturally writing. So the average neuropsychologist or assessment psychologist is writing at about the 14th-grade level, 15th-grade level, and assessment textbooks are written at about the 17th-grade level. So unreadable to most people. And this is one of the few books out there that use real words to talk about kids and uses real-world examples.

It teaches you how to take subtests like block design, and say, okay, this kid had trouble with that. What does that actually mean for her real-life or which part of block [01:45:00] design did she actually have trouble with? Was it because it was the first sub-test? Was it because it’s spatial? Was it because it’s abstract? Was it because she has trouble matching to sample? Are there visual-motor problems, like actually do those task demands that we often don’t learn how to do from our standard assessment textbooks. So, I just like it for that. It has flaws like any book, so don’t blame me for everything that’s in there. But I just like that it’s actually written in the real-world language.

Dr. Andres: That’s huge because we learn reading these textbooks written in the 17th-grade level, whatever that is. And then we write a report based on those definitions, not knowing what we’re really writing if we’re being honest. Like when we talk about visual-spatial reasoning, most of us don’t really understand what that means. And then our client reads it and goes, okay, it’s big words. It must mean something.

I’ve had [01:46:00] therapy clients who go through a, like a full neuropsychological battery and they come back in and go, oh, I have some potential visual-spatial problems. What does that mean? But they just know like they’re lower in that score, but what does that mean to my real life? So, absolutely. It’s huge.

Dr. Stephanie: Did the kids you test ever ask what grade level you’re in? Do they ever ask, like what grade you went to in school?

Dr. Andres: I don’t know the answer to that.

Dr. Stephanie: I know. I’m always like, 29th, I guess.

Dr. Sharp: Well, I know that we didn’t get to talk a whole lot about conceptualization today, at least not directly. So we’ll at least have that for next time, but I feel like this is where we would transition if we had three hours, but we don’t. So thank you all for being here as always. It’s good to see your faces [01:47:00] and talk through some issues that are pretty important for a lot of us here. I appreciate you.

Dr. Andres: Good to see you guys.

Dr. Chris: Got it.

Dr. Sharp: Thank you all so much for listening. I hope this was enjoyable for you. If you have not subscribed or followed the podcast, we’d love for you to do that. The listenership just keeps increasing which is awesome. It tells me that y’all are spreading the word about the podcast and making sure that anybody who’s interested in testing might be able to listen to the episodes and get this content. So, I really appreciate that.

I hope everyone is doing well. And I will be back on Thursday with another business episode. All right. Take care.

[01:48:00]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 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, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

The TSCC and TSCYC screening forms allow you to quickly screen children for symptoms of trauma. Both forms are now available through PARiConnect-PAR’s online assessment platform. Learn more at parinc.com.

Hello, and welcome back to the podcast, everyone. Hey, today’s episode is on a topic that many of you might be confused about, interested in, dismissive of, who knows. It’s relatively controversial in our field. We’re talking about central auditory processing disorder with Dr. Michael Wolf. Let me tell you a little bit about Mike, and [00:01:00] then I’ll tell you what’s happening in this episode.

Michael is a clinical psychologist and board-certified neuropsychologist. He is the co-founder of Behavioral Resources And Institute for Neuropsychological Services (BRAINS), a private practice in Michigan. Dr. Wolff specializes in medical and congenital conditions and how they influence cognitive and daily functioning. He works with children, adolescents, and adults with medical, neurodevelopmental, and psychological disorders. He has authored numerous articles in neuropsychology and published a text on the Complexity of Autism Spectrum Disorder. He is a professional speaker and volunteers his time with several nonprofits as well.

Mike is a very dynamic speaker. You may have heard him at conferences in the past, and I am very grateful to have him here today to talk about central auditory processing disorder.

[00:02:00] We talk about the definition of CAPD. So what it is. We talk about who can or should diagnose it especially in the context of psychologists diagnosing CAPD. We talk about how it may be similar or different to existing diagnoses, like ADHD, language disorders, and autism spectrum disorders among others. And we close with a discussion of available treatments for CAPD. The show notes have a number of resources if you’re interested in learning more.

And this is a good one. I, like I said, learned a lot and was surprised by some of the discussions and thoughts that came up during the episode. So really good one. I think it’ll make you think.

Before we transition to the episode, as always, I extend an open invitation to anyone who would like to enroll in one [00:03:00] of The Testing Psychologist Mastermind groups. These are accountability and coaching groups for folks at all stages of private practice. Whether you’re just starting out or you’re looking to hire your 10th employee, there’s a group for you. I facilitate all these groups and I love watching these groups go. It’s a cohort model. So people go through them together and grow over the course of 5 or 6 months toward their goals. If that’s interesting to you, you can get more information and schedule a pre-group call at thetestingpsychologist.com/consulting.

All right. I think that’s it for the intro. Let’s get to my conversation with Dr. Michael Wolf.

[00:04:00] Hey, Mike, welcome to the podcast.

Dr. Michael: Thank you.

Dr. Sharp: I am glad to have you here. I have seen some of your work over the years and heard about your work from a number of folks in the field that I really respect. And I feel like this interview or this topic at least has been a long time coming. So I’m thrilled to have you. I know we have a lot to jump into with CAPD.

Right off the bat, I always just like to ask people, why this? In the field of neuropsychology, why care about this and put the energy into learning about and teaching about this particular subject?

Dr. Michael:  Sure. I think as neuropsychologists, we often want to get caught up in the hospitals and want to get caught up in some of the hard medical factors that a lot of us do in our daily jobs, are epilepsy or tumor resections, different presurgical evaluations, or concussions and [00:05:00] TBI, but I think it’s easy to also forget that there are other conditions out there like CAPD that still warrant our attention. So warrant our research. And to know more about how these things come into fruition in terms of the evaluative process and in our role in considering and intervening in these types of conditions.

Dr. Sharp: I think that’s fair. We don’t specialize in it by any means, but it comes through our referral stream often. There are a lot of kids who either have had evaluations or want an evaluation for CAPD. And I know folks in the testing psychologist community have brought it up many, many times. So glad that you are focusing on it and can share some info with us.

Dr. Michael: Absolutely.

Dr. Sharp: Right off the bat, it’s a complicated topic. It’s a fraught topic in neuro-psychology maybe. There are [00:06:00] differences of opinion. I would love to start maybe with just some groundwork or background around some of this controversy or difference of opinion. There seem to be mixed opinions on the idea of sensory deficits in general and what that might mean. So, can you speak to that at all?

Dr. Michael: Absolutely. So let’s start out with just a general idea. I think a lot of times when you say sensory deficits like you just mentioned, I think half the neuropsychology world might cringe and go, “Oh gosh, here we go again.” The other half might go, “Yeah.” That’s where we’re going to get started in the sensory stuff. It is an everyday type of work.

When we look at sensory processing, it’s not necessarily always pathic pneumonic of anything specific. And I think that causes frustration in our field. If someone has a texture sensitivity, it’s like, “What part of the brain does that mean?” It doesn’t necessarily mean one [00:07:00] part of the brain, right? It’s a symptom that gives us a clue that something else might not be working right. And so, at the basic level, I think that part of the issue is that it doesn’t tell us something specific all the time.

But I think in reality, when you look at like a cranial nerve exam or something a neurologist is going to do, they’re essentially doing an evaluation to test stimuli or the perception of stimuli, and usually stimulate in motor movements, which then start to narrow down for them that process of understanding what might be occurring in the functioning of this individual and where do I start my investigation to then understand, is this a disease process? Is this deterioration? Is this developmental? Is this normal? Sensory stuff can be very normal for a lot of individuals. And when does it cross over into that world of pathology versus normality or developmental problems?

Dr. Sharp: Sure. I think that’s [00:08:00] something we all struggle with. When you say sensory issues in general, people get up in arms about that, right?

Dr. Michael: Yeah.

Dr. Sharp: There’s a lot to be concerned about. So, random question, you mentioned, there’s no part of the brain necessarily the maps directly to texture sensitivity. As far as we know, are there parts of the brain that map to other sensitivities: noise sensitivities, bright lights, food textures, anything like that? This term sensory processing is a tough one. I’ll just leave it at that.

Dr. Michael: Absolutely. All senses obviously come in through the environment. And I think the job of psychology and neurology and everything is to understand how the stimuli come in from the world because our job is to function in that world as best as we’re able to. But in doing that, we’re essentially functioning in response to [00:09:00] perception of stimuli or senses that are coming into us. Touch, taste, texture, sights, sounds, smells are those things that are coming at us. And then our response to those determines how well we perform in the world. And in neuropsychology, our job is to have a better functional outcome in order to improve or maximize everyone’s daily life activity as best as we can.

So are there specific regions that are mapped specifically to a particular type of sense? Well, some are. And we know more about some than others. We have that homunculus that maps over the motor and the somatosensory cortex neocortical. But that information doesn’t go directly from our hands, our lips, our eyes, our ears, right to this little guy sitting over the overfold of this amount of sensory in the primary motor cortex. It has to be filtered and come up through subcortical aspects of the neurological process before it gets to the higher-order levels.

And I think when we’re talking a sensory [00:10:00] basis older, like CAPD today, it’s what’s going on in that process or that evolution of perception of sound that then moves us toward the function in the world, whether it’s communication or reaction to, or sensitivity like kids who are afraid of loud sounds or TinEye is where there’s constant ear running. And we do know more about what might be relating to those types of things.

Dr. Sharp: Sure. I’m eager to dive into the specifics around CAPD. I know we’re going to get into that. I just want to talk a little bit more about the disagreement in the field, perhaps about these diagnoses. I was just looking over Pennington’s book, Diagnosing Learning Disorders, I forget the exact title. You’re shaking your head so you know what I’m talking about. So they include CAPD, [00:11:00] NVLD- nonverbal learning disorder, and sensory processing disorder in that chapter of, I think it’s less well-validated disorders.

And so, there’s been some back and forth about this. I’m curious. From your perspective, what do you think is so tough about this in our field? Why can we not figure this out? And why is there tension around these diagnoses?

Dr. Michael: I think there are two things that are occurring.

The first one, where are our boundaries? There’s neuro-psychology and then there’s the ASHA: American Speech-Language-Hearing Association. ASHA has typically taken that lead to say, both sound perception and sound process, which falls in the domain of both audiology, and that’s speech and language pathology. And if you follow some ASHA’s work, they’re saying, no one but an audiologist and or speech and language pathologists should really be diagnosing a central auditory [00:12:00] processing disorder.

So there is a boundary there that then takes neuro-psychology and saying, Hey, but we know how to assess and evaluate and look at a lot of this stuff too. And if we have covered all of our bases for making sure that there’s an individual’s past, a hearing test, and there are no other medical factors like tears and the tympanic membrane or Clessie OMAS or acoustic neuromas, or calcification of the ossicles, a lot of things that can change the conduction of sound initially coming in, and we’ve ruled out those mechanical processes already by medically evaluation, can neuropsychology come into that?

And then I think we also get neuro-psychology that starts to debate a little bit. Is auditory processing its own disorder, because it’s not obviously covered in the DSM? And is it its own entity because our supposedly diagnostic manual doesn’t include this as an option? And it can [00:13:00] be misdiagnosed very easily or included in, I guess, whichever way we want to look at it. Maybe this is an aspect of ADHD. Maybe this is an aspect of a semantic language type of disorder. Maybe this is a phonological articulation disorder. And is this an autism spectrum disorder?

And so we can lump aspects of CAPD into these other behavioral conditions, but I think a lot of us in neuropsychology recognize that the DSM is a behavioral math station or check-off list book that doesn’t really help us to understand and capably review other conditions that we now have tests and the sensitivity to look for that are actually more specific and more valid in many ways, in terms of symptom criteria to say, Hey, this isn’t actually ADHD. This is a specific subset of a condition that will mimic inattention problems but if you throw a psychostimulant at it, sure it might help.

A psychostimulant whether you have ADHD or not would probably help about [00:14:00] 95% of us at a low dose and whatnot. And that’s why it gets abused all over the place. But just because you get a response to that doesn’t mean it’s the right thing to do nor you’re treating the right condition. And for the developmental and then functional aspects of daily life, it still might not hit the mark. And we can be much more specific now than maybe we were 15, 20, some years.

Dr. Sharp: Yeah. I’m excited to figure out how we can do that. It’s good to know. There’s I think a lot of potential there and I hope this conversation will shed some light on that. I’m aware, maybe we should back up a little bit just in case somebody’s not aware of CAPD- central auditory processing disorder. If you had to do a 30 seconds definition or even a 15-second definition, what are we talking about here?

Dr. Michael: So a central auditory processing disorder is essentially a condition where an individual we’ve ruled out mechanical hearing issues, and so there’s no [00:15:00] conduction type of hearing issue, and we’ve ruled out any major sensory neural hearing loss- and so, we’ve ruled out again that mechanical factor, but then assuming a person has what would be considered to be normal hearing from a medical and an audiological sense, it then goes to the misperception of sound that then distorts the ultimate outcome of being able to function effectively in the world. Whether that’s because of the way that we talk and communicate and understand spoken language, or if that’s the way that we can’t ignore random background sounds and they start to really bother us and then we start to get edgy if someone is potentially chewing gum next to you, or swallowing a little bit louder, or making noises with their paper, pencil on the table in a way that then will disrupt our normal functioning.

Dr. Sharp: Yeah. I’m going to ask an off-script question right off the bat. When you talk about those things, [00:16:00] would you consider misophonia to be part of CAPD?

Dr. Michael: Yeah, it’s a qualitative feature. It might be so specific that it’s going to just stay in a misophonic camp, but essentially that’s abnormal auditory figure-ground. And as a result of that, it distorts an individual’s means of being successful in navigating the social and environment around them that causes agitation or anxiety, or avoidance. But misophonia is probably even more debatable as an isolated condition more than CAPD, I think.

Dr. Sharp: Yeah. I’m debating whether we want to go down that rabbit hole. There’s so much discussion about it and of course, it’s personally interesting as well, to me.

Dr. Michael: Not just you. I’m right there with you.

Dr. Sharp: Right. I’m like, what is it about these particular sounds that are so disruptive to folks and why can’t we gate those appropriately?

Dr. Michael: Great question.

[00:17:00] Dr. Sharp: Yeah. You know what, let’s just do it. Do you know anything about that? Can you speak to that at all? Like where that’s coming from and why those particular noises are specifically activating for folks?

Dr. Michael: Yeah. So when we’re looking at that idea of misophonia, typically speaking, we’re going to see it maybe being disrupted as part of a couple of different core areas.

One might just be sensitivity in the cochlear nerve itself. The second that loud screeching sound, that chewing, that swallowing sound comes in, it already in that noisy environment is sending the brain the signal of like, I don’t like this and we become hypersensitive to it. Sometimes that auditory figure-ground perception of misophonia and not being able to ignore those random sounds also might come from the lemniscal pathway, the processing of the perception of electrical stimulation of sound coming up to be processed in the medial geniculate nucleus of the brain.

[00:18:00] And as a result of that, it’s also sending disrupting signals saying, Hey, we got to get away. We got to ignore this. And it’s kind of sending that fear-avoidance response that we’re usually going to get from the inferior colliculi conflicting with, now, we just got to ignore that because something’s being said, or I can’t get up and I can’t believe right now. In that conflict in neurological process between neighbors that should be working on similar types of clearing it up to get it to the higher-order processing or saying, no, we’re bailing, we’re getting out of here.

And so, as a result of that, now our emotions start to get provoked and our limbic system kicks into play. And in some way, even though it’s not puristic, it’s kind of that fight or flight, right? People who are really annoyed by certain specific stimuli of sound might have an outburst saying stop, or do you have to swallow louder? You’re annoying.

All of a sudden, we have this behavioral reaction because that whole [00:19:00] limbic system gears up as sensory perception, works its way up through what used to be believed in a very linear process. But now we know there can be conflict and there can be dual streams going simultaneously that will lead to conflict in the perception of sound.

Dr. Sharp: Yeah, I know there’s probably a lot to say about that. Maybe we could do a whole episode on misophonia, but that’s enough for me for now. I’m just very curious, and so, it’s something that I thought I might as well ask.

Dr. Michael: No problem.

Dr. Sharp: So as far as CAPD goes, you mentioned earlier that it often gets confused with ADHD. I’d say that’s probably the predominant question in our practice when we see it is, how do we separate those two? Can we separate those two? Is it worth separating those two? So are there other mental health diagnoses that we need to look out for that might masquerade as [00:20:00] CAPD or vice versa?

Dr. Michael: Yeah, we need to watch out. A lot of these kids can be easily misdiagnosed with an Autism Spectrum Disorder as well. They may misperceive the tone or the intent of language, not pair the non-verbal cue with the content of the language as effectively, we might also see them coming into language-based disorders, either receptive or expressive language disorder, which at its core is still a part of a central auditory processing issue.

But CAPD is going to be a little bit more encompassing of the functional aspects that will influence not only the perception of what’s being said, but the ability to have that auditory feedback loop keep up with what you’re saying to formulate your thoughts effectively to meaningfully engage interactively in conversation, which is why we have that social pragmatic language disorder, which added to the DSM in 2013, which could also be misdiagnosed or commonly diagnosed, potentially speaking [00:21:00] as CAPD. But I think ADHD is probably the most common misdiagnosed attribute of an auditory perceptual deficit. And yeah, I think it’s our responsibility to do as best as we can when we think it might be more specific to see and test the limits of that.

Dr. Sharp: Yeah, I don’t want to jump the gun too much and get into assessment, maybe that’s a nice segue. It’s hard to hold that back when it’s coming up right now.

My question is maybe a broad question in the diagnostic process. Let’s say we are evaluating for any of those things, autism or ADHD or social pragmatic, how do we know? That’s the question. How do we even know whether to consider CAPD as part of the picture or not, if the parents haven’t brought it up or the referral source hasn’t [00:22:00] brought it up because I don’t know that this is like automatically on people’s radars when these differential diagnoses pop up. Does that make sense?

Dr. Michael: Absolutely. I think the inquisitive nature of most neuropsychologists is where this all starts, right? So we start out with that clinical interview and when we’re working through that interview and we start to hear things that a lot of times it’s easy to ignore. My kid had chronic ear infections. They didn’t quite need tubes, maybe they did, but there’s always fluid there. There’s always wax there. And we know from that, that there still might be normal hearing especially once we treat those conditions, but when they’re in that fluid build-up, they’re hearing phonics and sound and speech at a very early age and this language develops very quickly for phonemic representation as though they’re hearing either underwater or there’s distortion from lax.

And so, I think as a neuropsychologist, I’m like, “Okay, that’s fine. It did make you sick. You [00:23:00] treated it. We’re good.” Or we hear there’s a chronic history of that should already set in motion to ask him a couple more questions about the pervasiveness of it. Was this just a couple of month interval of time or was this a couple of years? How long did they struggle with that? 

Then we go to the tubes. And when we hear tubes again, it’s something so easy to overlook. That’s not our job. It’s not a role. That’s a medical thing. But tubes might fall out, but that doesn’t always mean that the whole and tympanic membrane is going to close over the way it should. Sometimes there can be scarring or scar tissue. I think my record at this point in time as an individual is that 14 sets of tubes. We start to look at like, how often, how many, what was the recovery process, complications? Because all of those things eventually may still result in a child with a normal audiological review but could have fundamentally changed the way that sound was transitioning from sound wave to electrical stimulation and perception in [00:24:00] the way that we perceive and process sound.

So, we finally get through those areas and we move through making sure that an audiologist or they’ve passed our school hearing tests. And then we can start to go, okay, but they had a phonological issue. Is that dyslexia? And was that early phony misrepresentation, or was there a different factor that might’ve been acquired in this process to lead to that misperception? We’ll know that from the history medically, and being more inquisitive initially from asking those other questions.

But if we’ve ruled those out now, we’re coming in. It’s like, no, they just can never say their phonics. Now they can’t read phonics. Okay, maybe we have more of dyslexia, just phonetic pattern. That’s bright. But then when we start to say, okay but wait, they didn’t just have that. They always seem to be slower to respond. I’d ask them a question, they’d respond, but there’s like this leg. And it was always so frustrating. I thought they just didn’t want to answer. Maybe they’re being deceptive.

And so we started asking questions about how well did they start to [00:25:00] engage in language use and mimicking sounds and the speed of maybe learning to sing along with songs, especially children with singing along with Disney songs or something that might be kind of fun, are they always a step or two or three behind?

And so we started to pick up on, oh, so there is some lag here. So now we need to know, we need to add at least some more language tests. But now I can start to add some simple little things. Let’s do a WRAML attention measure. Right? We got visual figure-ground and auditory attention. I’m not going to go completely in testing here, but we can start to target. Quick little things to tell us, oh, something’s a little bit unique here.

But then as they get a little bit older, it’s like, okay, they learned to read, this is great. They still do some articulation stuff. That’s a little bit unique. But for some reason they can’t when we’re in a noisy environment, they never listen. When the coach yells at them on the field, they don’t hear it. When they’re in a work meeting, they’re taking notes and they’re trying to do this, but if I all of a sudden whisper next to them, they can’t pick me up. And now they’re getting a little bit of [00:26:00] trouble. They’re uncomfortable in group interactions. Something still is abnormal. They could do all this other stuff relatively well, but we can’t do meetings or groups, or we can’t ignore those misophonic sounds that are bothering us. They’re all triggering symptoms to tell us, oh, oh, this might be auditory processing adepts that I need to flush out a little bit further.

Dr. Sharp: Sure. I love these questions that you’re throwing out there. You’ve given us a decent list, but are there other things that we can be kind of looking for or asking during that clinical interview that can help at least tip us off that we might need to do some testing in this area. And I mean, if there’s anything that you didn’t already cover.

Dr. Michael: Yeah. So similar specific things that I would typically ask families when I am in my diagnostic interview is looking for, when you call their name, would they respond and would they acclimate their head [00:27:00] in the right direction? If you’re on the right side and you call their name and they look to the left, that’s an atypical response. They should be able to know, hey, they’re over here and I can shoot spatially locate. And so, we’ll have families telling us symptoms like that.

It’s also common for me to ask things to the family in terms of how long would they respond? And would the answer the question accurately? Which gives me a flavor of, is this a receptive language issue, which it well could be, but if they would pause, start to respond, and then respond to accurately, okay, well, they are receptive there, but for some reason, there’s a slowing in the perception of the process, which also gives me an indication of what’s going on.

And I think probably that one of the bigger tales that we have from families is they’ll tell us, like, even from infancy all the way through it, and sometimes we’re hearing this even from adults who are coming in from CAPD evaluations or at least questioning other’s processes, for some reason, at no point in my development [00:28:00] could I really engage in a conversation. There wasn’t a back and forth. And so if they’re of an age where a baby should coup and look and smile on cue back if they’re at an age where we should be going back and forth, but there’s always those lags. That’s also another sign of either language or an auditory processing deficit of some type.

And people are very annoyed by those because even if I do something unique to you and all of a sudden I took a three-second pause there on you, you’re going to think, oh, Mike just had a stroke. While, in fact, I didn’t, it was just that lag. And that’s very uncomfortable. And so, we can rule out language versus CAPD are our next steps moving toward the evaluatory process.

Dr. Sharp: Yeah, as we talk about this, it seems very hard to separate auditory processing issues from perceptive language issues. I’m [00:29:00] just being honest. So, I’m very curious how that might happen, but I’m going to save that for a little bit.

I’m curious about the order of operations, so to speak, and when or if you involve other allied health professionals. Let’s say you’re doing a diagnostic interview with a family and you get some of these signs. So you’re suspicious. What happens from there? Are you moving straight to testing or are you pulling in other people? What does that look like?

Dr. Michael: So we automatically start pulling in some other people or at least case history. So when we’re hearing some of those triggering things that might throw me into language versus CAPD or other diagnostics, I’ll ask them, have you ever been to an audiologist? Have they done a hearing test? Or if they’re an infant, did we do the BAER for brainstem auditory vote a response? Do we know that stuff [00:30:00] is getting into, through the brain stem to the brain to be processed?

And so if they say no, Hey, okay, I’m going to refer you to an audiologist to make sure that we at least have normal sound perception from an external mediated environment. If they’re saying, yes, we got that but we still have fluid buildup. Well, okay. Then I’m asking their doctor, can we get an ENT referral? Are we at a point now where maybe that canal is too small or maybe we need to open it up or do we need to do tubes? Is there something else going on that’s causing them to have glue ears? Is there something else that we can do to help mitigate the routine wax buildup? And so ENT consultation might be coming into play.

If those two things either have been done before or are managed and whatnot, then it’s coming into the next phases of going, okay, well, did you get it early on, and at least in Michigan, it’s called early enough. Did a speech pathologist consult with you regarding an early language screen, or if you’re in school, [00:31:00] has a speech and language pathologist met with you to look at your language aspects and had they said anything?

Often with CAPD, we’ll find kids being able to pass through core language testing, whether it’s a cell for other measures, that the mechanics of basic language use and perception and receptive language are there, but there still seems to be something a little bit atypical. But often they have a speech and language pathologist are involved is very important. And then sometimes, but not always in the early phase of CAPD, an occupational therapist who might specialize in things like listening programs or whatnot could become involved at some level if they have toolkits that also look at various sounds.

So let’s say those are your biggest ones, your audiologists, your ENT, your speech and language pathologist should be working alongside us at some level or have already done as we move into the journey.

Dr. Sharp: Yeah, I’m just thinking [00:32:00] logistically. I might be getting too granular here, but I’m a concrete thinker. So, how do you handle something like this when there are such waitlists for a lot of these services? I mean, just like procedurally, you do an interview and then you refer to X person audiologist, or maybe try to pull in or get some records which can take forever and then get them back in for testing. I don’t know if you have any thoughts on how to manage, just coordinating all these pieces when it can possibly get drawn out over so much time.

Dr. Michael: So in my view, neuro-psychology can still keep moving forward with their evaluation even as you wait for the other pieces. Sometimes, we can simply ask, have they pass our hearing screen at school and we know that all kids have to do that every couple of years, especially in their early academics, not once they get into late elementary and beyond. We can ask if doctors that were taking tuning forms.

[00:33:00] As a neuropsychologist, we should also be able to do basic sound perception testing: walking behind an individual and putting their hands up next to their ears and having them raise their hand when you’re just gently rubbing your fingers together to see can they perceive some of those early sounds just from the finger rubbing in the ears and how loud do you have to rub? You have to start snapping them. That’ll give us a sign like, oh, this actually seems to be a hearing issue not even a perception of audition and beyond that. And so now, I’m going to wait. But if they’re passing through those screens, if they’re oriented in their head, if they’re in your office, and even an infant who hears someone walk by loudly might be startled and look like, “What was that?”

And so, we can always use our observations. We should all be able to do some of the basics of cranial nerve exams in my opinion. I have been trained on those, sometimes in-depth, and then also have all tool kits that we can use for sound or sound disruption [00:34:00] to at least rule out the basics of, they’re definitely hearing, so I can already rule that in. Now, what’s next?

At the end of our reports, we might say things like, I’m pretty confident this is X but we’re still waiting for similar findings first. And when those come in, we may change our final diagnoses and recommendations, or these will be consistent with them. We’re already moving forward into the next steps.

Dr. Sharp: Sure. Yeah, that’s good to know. So then let’s talk about the evaluation process and what that might look like. So feel free to dive in. I’m curious about specific measures and what we might be looking for, but you’re welcome to take that in whatever direction you might want to. How do you approach the evaluation process?

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

[00:36:00] Dr. Michael: So approaching evaluation, here in our company, BRAINS, we always look at the balance of, what do we need to do and not what do we all want to do because neuropsychological evaluations could be 15 to 20 hours. But at that point in time, it’s almost cruel and unusual punishment for anyone to go through that much testing. And so, it’s picking and choosing enough to give us information and then starting to chase a little bit of, is this just a Mulligan or is this in fact clustering as a dataset to say this as a concern?

So as we start out with the basics, if we know there’s a possible CAPD question, I am going to do the basics. I’m going to do a basic phonic test. That might be as simple as a pseudoword decoding on a WIAT. I might look at pulling out that WRAML attention index. I can get a quick split between visual working memory and auditory working memory. It’s so easy to [00:37:00] pull a WISC out and look at auditory retention in terms of digital banner reversal or resequencing information.

I’ll do some simple sentence tests. To add, I’m just going to say something, repeat it after me. And I might not even use a formal test, but I’m just going to do simply like an MMSE, no ifs, and, or buts, or John, cross the road to go look at and I’ll make some things up to see, can they just mimic my language? And if they’re younger and we’re not quite to fully talking, can I get them mimicking the sounds that I might be making? And are they the right sounds?

But it’s not just the right sounds, when you’re working with an individual, you got to be observers, right. We’re neuropsychologists. Did their mouth move in the way it should or am I looking at an oral motor issue that caused him to distort what they just said? Or am I looking at no, it looks like the mechanisms of everything I’m saying, it might not be perfect yet, but look right? But boy, that still wasn’t what I [00:38:00] said or that wasn’t the sound that I made.  So we can do those types of things.

From there, if they’re still concerned, we use the SCAN here. And in the SCAN has both a pediatric and adult test to it. And that will start to break out for us. Auditory filtered words, auditory figure-ground, binaural hearing as well as selective auditory attention or dichotic listening. And so, that gives us a pretty good sense of what might be going on. And as a general baseline for me, if I see an auditory filtered word that isn’t performing well, that does raise more questions for me about, do they have a hearing issue? Because that’s just someone mumbling a little bit and you got to hear it and then clarify it a little bit more.

So if they don’t pass that one, I might say, okay, if you haven’t had a hearing test, I’m going to send you your hearing test. But if they pass out with flying colors or at least average or above, I pretty much [00:39:00] know, if I send you an audiologist, you’re going to pass an audiological exam. You’re picking these things up.

We like to use the IVA- the integrated visual and auditory continuous performance test. Even though I know there are debates about the validity of that one and a lot of people have their preferences for CPTs, it’s simultaneously tasked visual and auditory attention, and it’s amazing with CAPD individuals where you can easily see this huge split where visual attention is like solid and right on an auditory is doodling, if not pretty significantly impaired.

And I’ll ask him, how did it go? I think I did great. Well, great, you did in one area, now we have to watch out for the video game kids that are really attuned to paying attention, visually gear screens, and then maybe not as much auditory, but that’s there. We also have the sound perceptions from the tops. We have the test of auditory processing (TAPS).

And then if it does seem to be more language, then we can [00:40:00] start to bridge into broader language tests, our castle and the SLDT and many other phonic tests that we can break into to just say, this might be dyslexia. This might be phonics only. This might be […] only. And then that opens up a huge fund of tests once we get to those higher-order processing types of things.

Dr. Sharp: Sure. As you list all these measures, one, just honoring that process of being able to think on your feet and be flexible as you go and add when you need to add and stop when you need to stop, know what you’re looking for. But another thought that occurred to me was just stepping into the others’ realms potentially. I wonder if you’ve ever gotten pushback from a speech-language pathologist or audiologist? We touched on this at the beginning, but I’m curious to bring it to [00:41:00] the real world a little bit and just ask if people ever are like, “Hey, you can’t do that. That’s our realm. Why are you giving those tests?” Whatever it might be.

Dr. Michael: Yeah, it’s interesting that you ask that. During the pandemic, all of our typical audiology clinics closed. They stopped seeing patients. But I continued to see individuals who needed evaluations to delineate, so essential patients, but sometimes that became part of the question. And I actually had a conversation back and forth with ASHA. I emailed them specifically, and then they sent me to their ideological department and we had some conversations back and forth.

I think that they had put that provision of saying, we’re the ones who diagnose CAPD. If anyone can do it, no one else. And when I pushed them, it’s like, “Okay, you’re right. As a neuropsychologist, you actually are doing tests that we actually don’t know that should maybe be [00:42:00] considered in this process as well. Cognitive testing, memory testing, different types of exposures and how do prenatal alcohol or drug exposure or trauma, or concussions and these things also affect what might be misperceived as CAPD.

And I think at the end of our conversation, it came down to, well, as long as an audiologist has ruled in normal auditory function, then yeah, neuro-psychology actually does do a lot of these things.

In our office, I’m privileged to have speech and language pathologists that work right alongside us. And we work together all the time. They can do a lot of the tests that I can do, but they’ve even said to their training along with speech and language pathology, they weren’t trained on a lot of what’s needed to look at a CAPD  evaluation.

So we’ve worked alongside and now they do some of it. I do the rest of it. And we come together for a consensus opinion of what is this looking like, and what do we think before we make that final diagnosis. So it’s [00:43:00] really nice to work alongside allied professionals. And they really haven’t had too much kickback. ASHA did initially. When I pointed out some of the pitfalls of a standard CAPD evaluation from an ASHA side, they hadn’t considered the other factors themselves either, which could also, again, result in them misdiagnosing something that should be looked at in a different way.

Dr. Sharp: Right. If I remember right, that is one of the primary criticisms of ASHA and their perspective is that initially the criteria maybe still the criteria for CAPD is only based on tests that they can administer. And that seemed a little bit limited in scope and less well-defined than maybe we would like.

Dr. Michael: Yes, that’s correct.

Dr. Sharp: So let’s think about, how does this all come together? This could just be me, it takes me a while sometimes. So I’m curious if you can delineate a little bit more [00:44:00] how you might separate “attention issues” from a CAPD? A lot of those measures you mentioned: auditory attention, visual attention, auditory memory, visual memory. I’m just curious, like, if you can even give any more specifics about what you might be looking for, differences in those profiles that might help us make that distinction.

Dr. Michael: So in our trying to distinguish between CAPD and ADHD is a good example here. ADHD is a mutual opportunity attention pathology. And so it should affect most aspects of attentional regulation, not select aspects. In some rare cases, we can argue, okay, well, you can make an ADHD diagnosis if only one potential area of attention is influenced, but in our opinion, ADHD should influence some executive functioning skills. Maybe they can get through a working memory task, but divided attention testing or distractibility is going to be off, sustaining [00:45:00] simple attention should be off, and we’re going to see that difficulty shifting focus. So, we should be able to see ADHD influencing these multiple domains.

We can do Go/No-go tasks. We can do a Stroop test. We can do the Decafs colored inference, and we’re looking at that disinhibition and disinhibition switching. We’re probably going to see some vulnerability in an ADHD individual whereas in a CAPD individual, those tests are probably going to be absolutely fine. And they’re not going to show that dis-inhibited quality.

We’re also going to be looking at the Trails, quick down and dirty, easy, right? ADHD, might have trouble with trails B and shifting their focus. CAPD, that should be a rare finding if at all of a deficit therein. And with ADHD, often when we’re testing other components of language perception like on the SCAN, they’re going to pass the SCAN all right, at least low average or average or above. CAPD individuals, they’re going to be pulling out the headphones. They’re going to be looking at you like, [00:46:00] “It’s not talking.” It’s fine. I got it on my headphones here too. It’s right where it needs to be. And they’re going to start to tell you things that aren’t there or when we’re looking at binaural hearing, an ADHD kid might not correctly get the word or because you’re supposed to say you right ear first, then your left ear, your left your first and your right ear. So I might mix that up, but they’re going to get the words. A CAPD individual might completely suppress a right ear, left ear, and get everything right in one ear, but they can’t listen to both simultaneously. And so we’re going to see that process.

Obviously, on the IVA, we already mentioned that split of visual-auditory performance. That’s not a classic ADHD profile. ADHD should have both suppressing and looking very troublesome and showing scatter, and we’re not going to see that. And of course, with ADHD, communication and talking, and back and forth, sometimes they’re going to go really fast and they’re just boom, boom, boom and right there with it clicking fast, while that individual with an auditory [00:47:00] processing, it might be like, “Oh, give me a minute.” And you can feel like you’re overwhelming them by going too much.

So those are some things that we’ll look at both in profile testing as well as then functional probation and outcome.

Dr. Sharp: I like that. I appreciate that. I like how you articulated that. And for anyone who doesn’t know, I did want to ask, myself included, you mentioned the SCAN two times. What is that acronym and what does that test?

Dr. Michael: That was an unfair question.

Dr. Sharp: Well, I don’t know. Why?

Dr. Michael: Let me say it. I’m going to Google that one quickly. I don’t know what the SCAN stands for.

Dr. Sharp: It’s so funny how we live by these acronyms. I’ve gotten caught in this very situation many times in the past by supervises. “What’s that? I don’t know. Let me think about it for a second.”

Dr. Michael: Yeah, I don’t know if Pearson actually spells out what the SCAN stands for.

Dr. Sharp: Oh, okay.

[00:48:00] Dr. Michael: Yeah. Just a SCAN- test of auditory processing disorders for children, but the acronym SCAN doesn’t break into its own specific words.

Dr. Sharp: Okay. Fair enough. Well, that really was an unfair question then.

Dr. Michael: Yeah, that was a tricky question.

Dr. Sharp: An unintentional trick question.

Dr. Michael: Yeah.

Dr. Sharp: So can you describe that test for us in a little bit more?

Dr. Michael: So you asked about the SCAN. It’s a test where you both have headphones on. It’s this prerecorded CD. This test has four different subsets of auditory perception to it. It’s got auditory filtered words where it sounds like you’re listening to a muted sound, almost as though you’re having a conversation across the gym, or if you both have hats on and they’re trying to have a conversation. So the language isn’t pronounced very clearly, but the brain can easily pick up the sound patterns to make it into a word very easily.

Then [00:49:00] it goes through the auditory figure-ground. And this is the one where it seems like you’re in an airport or subway or something like that. There are random extraneous sounds going on around you, not language sounds, but people walking by, little noises that might throw an individual off, and the job of the individual is to listen. It might say, “Say the word big,” but all those random sounds are going on around you. And can you ignore those sounds and still pay attention to the words that you’re hearing?

Then it goes into a dichotic listening task competing for words. In competing words, it gives you two different words simultaneously in each ear, and your job is to say both words, but for half a test, you say a right ear first and your left ear and then the other half of the test to say your left ear first and then your right ear. So you can accurately delineate between and on which side is, is functioning. And the test does a pretty decent job at letting you know, was there a strong ear dominance, left ear or right ear dominance? And most of us are going to be right ear dominant because left hemispheres [00:50:00] predominantly, are for our language perception of at least core language itself, not the tones and sounds and other appreciable qualities, which are more right, but it does go contralaterally.

And then there’s competing sentences where you get two different sentences simultaneously in each ear and your job, it’ll say, Hey, for the next 10, ignore your right year or for the next 10, ignore your left ear.

And then there are different subtests within the SCAN that go through different Hertz of listening, different Hertz of sound that you can go through, but I also like the one at the end that’s time-compressed language. Now, the SCAN is giving words very quickly, or not words but even sentences. So it might say very quickly, […] Can the individual hear that when someone might be talking quickly and accurately understand what sentence was said, and then repeat that back to you?

So, we get both receptive language. We get sound environments. We get dichotic [00:51:00] listening. We get the ability to perceive sound when it has a muffled or muted quality. And then you can do different decibels or Hertz that are going to come into, is there a particular one that seems to be harder for an individual than not if you do the full test? A lot of times we’ll do the core foreign time-compressed and see what that’s looking like.

Dr. Sharp: Very nice. Thank you. It sounds like a cool test. I’m going to go look that up after we’re done. I feel like I should take that test.

Dr. Michael: Caution. If you have a possible auditory perception issue, some people have come away from that going, Oh, Oh! I have 2 colleagues here that are like, “So just because I have it,” but now they won’t administer the test anymore because to administer, you have the headset on to make sure that it’s not skipping, but then they can’t score the test because they can’t do or process the test.

Dr. Sharp: Oh, that’s interesting. Well, so let’s think about treatment. So assuming that [00:52:00] results are pointing in this direction, you’ve gotten all the data, the history, everything you need. Well, first of all, are we the ones that are recommending treatment for this or? Okay. You’re shaking your head. Yes. So, okay, I’ll take that.

Dr. Michael: In my opinion, neuropsychology for identifying areas of vulnerability, it’s also for us to give specificity of care, to know some of the treatments that are out there even if they’re not the best research, as long as they’re: 1, not detrimental, 2) not cost-prohibitive. Our job is not to sell miracle cures for other people to go and spend exorbitant amounts of money. If we have a solid foundation and what we’re recommending and enough knowledge to suggest that it makes sense and it meets a litmus test, then yeah, we do make recommendations for these areas.

Dr. Sharp: Okay. The next question, of course, is what are the valid treatments that you would consider for something like this? And are there [00:53:00] multiple treatments?

Dr. Michael: There are multiple treatments. I think validity becomes a problem. And I think that’s true. So many things are in our treatment environment. These aren’t pharmacological companies that are inventing these treatments for so many things in our field. And so they don’t have the financial leverage to do really solid controlled studies. Some of the things are pretty easy though.

In my opinion, if we have an individual that has difficulty with phonic sound representation, which usually is going to sit either subcortically coming up through the alumnus skull pathway or from the medial geniculate nucleus to the primary auditory cortex, and through the insula, we’ve got to make sure that we’re hearing those sounds accurately.

So lots of times when I work with speech pathologists, if I think it’s more of a sound perception versus an articulation or motor movement, I’ll tell him, “Look, I don’t want the […] necessarily because it’s not a motor or a motor apparatus issue. I want you to say the sounds and I want you to [00:54:00] record the sounds for them so they can hear the accurate phonic as best as they can. We know that hearing is not a part of this. We don’t need some amplification or anything like that, but I don’t want them representing the sounds as much as hearing the sounds accurately and saying I’m slower, slow on our cadence of speech. Make sure that we’re not overwhelming them because we want them to make sure that they can participate in what’s happening.”

So for speech and language pathologists, we might slow down on Orton-Gillingham Approach. We might target a little bit differently. So it’s not a dyslexic type of intervention, but it’s an auditory processing phonological recognition type of task. And we might do a lot more of saying the sound and have them point to the sound. And eventually, then they say the phonics that they’re seeing on the page, and then we can start to blend that into. So it’s a little bit different than a traditional Orton-Gillingham.

I think the most debatable aspect in making recommendations is, do therapeutic listening [00:55:00] programs work? That’s where a lot of money can be spent. You got Berard who’s the most popular in terms of integrated listening types of things. And then here we will sometimes recommend Integrated Listening Systems (ILS). They’re similar. Usually, it’s listening to classical music and that classical music, when we have normal hearing, but if we know their suppression of the right ear, left ear, we can’t do the binaural hearing. You can choose soundtracks that might do specific sound representation in the right ear for a while or the left ear for a while, or bring it together where if they don’t hear both simultaneously, the music will be a little bit more kickoff.

And then, in Integrated Listening (ILS), we also feel stuff. And so, the ILS system and its headset also have a bone conduction type of play that allows that feeling of what it’s like to have that vibration. It’s subtle. It’s not like we’re putting them through some sort of vibrant vibrating rock tumbler, [00:56:00] but it is subtle, but sound waves can startle by feel just as much as I can by sound. And so letting them feel what that’s like when things are amplifying or diminishing. So we don’t have unusual soccer responses.

There are things like neuro tone and lays, which are additional auditory acoustic sounds for people who might have Misophonia, like you mentioned, or Tinnitus for sound blending and matching of those types of things. So we know that lipo-flavonoids has come out in some of the scientific literature to suggest this might be healthy for the auditory acoustic nerve in the perception of sound and reducing particular tinnitus, but maybe it has something more to do with. And so sometimes recommending a lipo-flavonoid. It’s not well validated for CAPD, but we do know it’s working for another area of missed sound representation or excess excitation of sound in tinnitus.

And then there’s [00:57:00] also things that we can do, like a cadence of speech, duration of the speech. I’m starting to work with them on memory. You’re using context memory, like story memories versus rope memory where you just memorize words. And we’re trying to then challenge the system to function better function longer, to move into a more normal type of representation of auditory perception.

Dr. Sharp: Thank you. You went a totally different direction with that than I thought you were going to. So that’s super helpful.

Dr. Michael: Which direction did you think I was going to go?

Dr. Sharp: Well, so when you started to say, and the most controversial, I thought we were headed down the route of filters, like in-ear filters because that…

Dr. Michael: Oh, I can talk about those too.

Dr. Sharp: Okay. Yeah, I’d love to touch on that because we see a fair number of kids who have had filters or have filters or are considering them. So I’m curious what the research says about filters and how they work and are they helpful?

Dr. Michael: Yeah. I’m glad you brought that up [00:58:00] and I forgot to mention. So, there are two sound filters. DUBS is one, or I think they’re called one DUBS and there’s a couple of others out there on the market.

Original research started out at the University of San Francisco, at least that I know of, and that was probably about a decade ago. And they’re trying to compare that with smart technology to say, hey, if we implant these filters, which are smart filters, can we then on your phone say, hey, there’s a screaming individual next to me? Can I control my phone, these filters to screen out that individual screaming next to me?

And what they were finding is there is that possibility to in fact do that. And so, they, I think the University of San Francisco had relinquished some of the research and it sold the concept off is my understanding, but I’m not exactly sure how that happened, but so there are earbuds out there that do suggest they can sync with our technology to pick up what is going on in a complex sound environment. [00:59:00] And you can effectively look at your smart technology and move your bars to minimize some of those other extraneous sounds in those.

Now, sound blocking in and of itself, usually that’s going to be more of an autism spectrum disorder thing. That’s your headsets. So, that’s just putting something in your ear to suppress all sounds so that they’re not as acute coming in at the same time. Those ones probably aren’t going to be as helpful, unless there’s just very sound sensitive, but they probably won’t do much else.

And then there are now some computer programs and interfaces that do suggest that they can introduce sound filters to then desensitize your system. And again, particularly for misophonia, to desensitize particular sounds that you seem to be hypersensitive to by the introduction of them through a controlled sound environment, which does make sense. I mean, that’s kind of like deconditioning or flooding almost for an obsessive-compulsive germaphobe type of thing or whatnot, but we’re doing it to a [01:00:00] different modality.

And so I think we’ll find some good outcomes as these things are published or as the technology comes online, or even if it’s not Bible technology, but it’s using clinics that they can take some of these sounds that are bothersome and in fact, decondition them to some extent, but will we ever get good controlled studies? It’ll be a long time coming is my guess because again, funding source for them is limited. So families might be putting financial risk out there for some of these things that are newly hitting the market and we don’t know enough about them to know if they work.

Dr. Sharp: That’s fair. I feel like you have shared a wealth of information with us today. This interview really flew by. What did we not cover? What’s still hanging out there? Anything that you want to share or clarify or even resources if people want to learn more?

Dr. Michael: Yeah. So, I’ll try to send you some resources. I was actually [01:01:00] testing when I was emailing today. So if I had patients back to back, but sometimes when a patient’s doing a bordering tests, I can email.

Dr. Sharp: I love it. Multitasking.

Dr. Michael: Multitasking at its best. The only thing I would, it goes way back to the beginning of our discussion here, in my opinion, neuropsychologists, our job is to understand not only medical complexity in what’s happening medically neurodevelopmentally and in terms of circumstance, but it’s also to translate all these different conditions and all these different types of ways that the body can perceive senses, and then they transitioning to function in order to optimize the outcome of life.

I think if we’re too dogmatic to say, “Nope, that doesn’t exist. Nope, that’s not in the DSM,” it puts us at risk of missing the complexity of the human condition to some extent. I think a lot of times we end up in arguments that say, is this valid or not valid, but then when we’re saying [01:02:00] it’s not valid, okay, that’s great. But what other option is there? Wait and see? And will that come around in 5 years, 10 years, 15 years? Will people just ignore it because it’s not polarizing enough to get energy?

And so now we just leave patients with something that we know is problematic or saying good luck with that. And that does bother me sometimes. So I think we need to be more diligent in our own field to recognize that we are responsible to understand and to move forward, not to necessarily stagnate cluster and then minimize some of these challenges that our patients do have.

Dr. Sharp: Well said. Yeah, I think that happens in many cases in our field. We do like to get dogmatic and maybe self-righteous occasionally.

Dr. Michael: Every now and again. I see that daily.

Dr. Sharp: Well I appreciate this. I really do. It’s funny when we were way back [01:03:00] trying to schedule this interview, I think I phrased it in email. I was like, “Are you in the camp of, this is a thing, or this is not a thing?” And you thankfully wrote back with a very nuanced response and I think presented a pretty compelling case that this was something worth looking into and something that we could potentially help with and distinguish from some of these other disorders that get mixed up in the picture.

Dr. Michael: Absolutely.

Dr. Sharp: Yeah, I really appreciate it. This is fun, Mike.

Dr. Michael: I appreciate it. If there’s anything else you ever need, I’m a wealth of some prevalence knowledge. Hopefully, you found someone for lifespan neuropsychology because you had asked me about that initially too. And there’s a lot of us out there in the field, but I know that that’s probably if you haven’t found someone yet, that’s worth finding someone for because I think in neuropsychology it’s like you can’t do lifespan, right?

It’s too [01:04:00] complex. You got to know your pediatric, your Mirabelle, your geriatric. It’s not feasible to really do it all well, but there are certainly people doing it well or even the neuropsychologists at blend clinical practice with forensic practice and they can have free or renals or a couple of big wigs out there explaining how did you mitigate that in your career? So there are some more really interesting things there to keep people not reified in their own profession.

Dr. Sharp: I like that. Well, and thanks for providing a little teaser for some future episodes here. These are all good things that I want to talk about. So yeah. Grateful for you. Thanks. I hope our paths cross again soon.

Dr. Michael: I look forward to it. Take care of, Doc.

Dr. Sharp: All right, y’all, thank you so much for tuning in as always. I really appreciate you. I appreciate all of the new subscribers that I’m seeing showing up in the numbers. It’s great to see the word [01:05:00] spread for testing and neuropsychology. There’s a number of resources in the show notes today. So check those out as always.

And like I said at the beginning, if you are interested in a group coaching experience, you can get more information at thetestingpsychologist.com/consulting.

Okay. Hope you all are doing well. And I’ll look forward to talking to you on Thursday with another business episode. Take care.

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 [01:06:00] 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, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This episode is brought to you by PAR. The Feifer Assessment of Writing examines why students may struggle with writing. The FAW and the FAW screening form are available on PARiConnect-PAR’s online assessment platform. Learn more at parinc.com\faw.

Hey everyone. I am back with another episode around hiring and employee stuff and how to take care of your folks. Today, I’m talking about ways to offer benefits to your employees. I get a lot of questions about benefits. And honestly, a lot of [00:01:00] misconceptions are out there about who we can offer benefits to, how to do it, what it looks like. So I thought I’ll do a quick episode to dive into benefits and what those might look like in your practice.

If you’re a practice owner who is looking to grow or expand or even start a practice, I am continually enrolling folks in Testing Psychologist Mastermind cohorts. There’s a beginner, an intermediate, and an advanced group. They are getting started as soon as the next cohort fills. So you don’t really even have to wait that long. If you are interested, you can schedule a pre consulting call or pre-group call at thetestingpsychologist.com/consulting, and we’ll figure out which group might be a good fit for you.

All right. Let’s jump into [00:02:00] this discussion around benefits.

Okay, getting right down to it. This is going to be a pretty quick episode, I think. But the intent is just to dispel any myths about benefits and give you some quick ideas about how to get started offering benefits in your practice if you would like.

As we get started, I want to say that I will generally be talking about how to offer benefits to W2 employees. It is possible to offer benefits to 1099 Independent contractors. It gets a little trickier but it is doable. So, that’s the most I’m going to say about [00:03:00] offering health care or health benefits to contractors, but there are a number of resources out there that could be helpful if you’re thinking about going that direction, but there are some implications as far as conditions that have to be met and tax implications and so forth. So for today, we’re going to mainly be talking about employee benefits and how to do that.

One of the first misconceptions that I run into is folks who assume that they have to offer benefits to all of their employees or any of their employees. So that’s the first thing. You do not have to offer benefits to your employees. If your business is a small business with less than 50 employees, you are not mandated to offer health insurance or any other kind of benefits to your employees. [00:04:00] Just know that right off the bat.

The second misconception that I run into a fair bit is that if you do offer health insurance, that you have to cover the entire premium for each of your employees. This is also not true. So you can enroll in a small business health insurance plan and offer it to your employees without the guarantee of covering their premiums.

Now, most employers do cover at least a portion of the employee premiums. So let’s say you have an employee who enrolls in your small business health insurance plan and their premium is $400 a month, you could opt to cover $100, $200, $300, or you can cover the whole premium if you’d like. So there are options for how much you would cover your employees premium. And like I said, you don’t have to cover any [00:05:00] necessarily. You can also structure it where you cover more of the premium for different types of employees. So, full-time employees versus part-time employees and things like that.

So there’s actually a good deal of flexibility. If you decide that you do want to offer benefits through a small business health insurance plan, there’s a good bit of flexibility about how to do that and how much you might have to pay for that.

Now the second piece is whether you want to actually offer a small business health insurance plan or not. You do not have to. There are other options aside from just doing an employer-sponsored health insurance group plan that you could consider. And this is another misconception that I see [00:06:00] relatively often.

So, there were basically three options for small businesses to offer health insurance or health benefits. One is, I think the most traditional model that you’re probably used to, if you’ve ever worked at a job full time as an employee, you were likely offered health benefits through the employer. That’s certainly doable. You can look on the exchange, the healthcare.gov exchange, and find small business plans. I included a link to that in the show notes. So you can check that out. It’ll ask you to give your location and then it will point you in the right direction to figure out some plan options that are available. So these are traditionally plans that are administered through the major employers. It might be Anthem, Optum, Aetna, Cigna, and so forth, Kaiser in some areas. [00:07:00] So you can check that out and see if any of those plans fit your practice.

If you choose to go that route, you would likely get in touch with an insurance broker who could help bridge the gap and serve as a liaison for your practice as you set up your health benefits for your employees. That’s the option that we have gone with. So at this point, we are offering a number of different health insurance plans, and people are allowed to opt-in and the practice covers a varying degree of their premium depending on their work status or employee status here.

But if you don’t want to go that traditional route, which is totally fine, there are other options that you might consider. So one of those options that you can consider is called a QSEHRA. It stands for [00:08:00] Qualified Small Employer Health Reimbursement Arrangement. And this option is actually very similar to the other option, which is an Individual Coverage Health Reimbursement Arrangement, or ICHRA. I can’t think of a clever way to blend those letters. So, ICHRA or a QSEHRA.

And these are very similar. So these are both plans that are not formal insurance plans. They’re reimbursement plans. So, these are options for you as the employer to reimburse your employees for health insurance or health coverage expenses that they take on. So in both of these plans, you can set a monthly allowance that gives you the maximum amount that your [00:09:00] organization will pay into their account. In each of these plans, the employees themselves purchase healthcare. They would likely go out on the exchange and find whatever plan suits them the best. So you’re not, again providing the health care plan. They have to submit reimbursement requests. You have to review those and then generally, you can reimburse them tax-free. So, it’s still a tax-free reimbursement, which is great. It’s similar to paying their premiums for a formal health insurance plan in that it’s it is tax-free. So that’s fantastic. It does not count as income. And that is a plus.

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Differences are kind of hard to navigate or hard to nail down, to be honest. I mean, there are some small differences between the two. I think the biggest one is [00:11:00] that the size of the organization comes into play. So if you have fewer than 50 full-time employees and you cannot offer a group insurance policy, then you are limited to a QSEHRA.

The second option, the ICHRA is open to employers of all sizes. And you can also offer a group health insurance policy to some of your employees and the ICHRA to others as long as you have those different classes of employees well-defined.

Let’s see. As far as employee eligibility, all full-time employees with the QSEHRA and their families are eligible. [00:12:00] You can also extend it to part-time employees. That’s what a lot of practices will do. With the ICHRA though, it’s a little more nuanced in that you can choose the “class of employees” that you offer it to, which is also dependent on the size of your organization. Like I said earlier, if you want to integrate a group health insurance plan, you have to do an ICHRA.

That’s about it. Those are the major differences. There are some other little nuances that you might want to consider, but the main takeaway here is that there are definitely options for providing health insurance or benefits or just reimbursement for healthcare [00:13:00] expenses to your employees. So, if you’re a growing practice owner or you’re just starting out and you’ve got a good handle on your numbers and you know that you would like to offer some kind of benefit for health insurance to your employees, these are great things to consider.

You don’t have to go the whole hog. Is that a thing people say? That’s my Southern upbringing coming out. You don’t have to go all-in or whole hog and offer a full-blown health benefits plan where you pay the entire premium. So just know there are options. And I think in this day and age when we in private practice are really having to compete with other mental health services, the BetterHelp, the Talkspaces, hospitals, other entities, any little advantage that we can gain or any perk that we can offer to [00:14:00] sweeten the deal is going to be invaluable in our hiring process.

So I hope this was helpful for you. I will include a couple of good resources and places where I got a lot of this information in the show notes so that you can read for yourself and decide what might fit you.

Thanks as always for listening. And like I said at the beginning, I am really doing my best to get people together into these accountability and coaching groups rather than individual consulting. I see so much power in the group. The way that people go through these cohorts together, it’s really pretty amazing that people support one another and grow together.

So, if you are looking for a group coaching experience, I’m the facilitator of all these groups and you can connect with other testing psychologists at [00:15:00] the same level of practice as yourself, then, reach out, let’s do a pre-group call and see which group might be a good fit for you. You can get more info at thetestingpsychologist.com/consulting.

Okay, that’s it for today. I will be back on Monday with more clinical content. Y’all take care.

The information contained in this podcast and on The Testing Psychologists 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 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] Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

The BRIEF-2 ADHD form uses BRIEF-2 scores to predict the likelihood of ADHD. It is available on PARiConnect- PAR’s online assessment platform. Learn more at parinc.com.

Okay, y’all. Hey, welcome back to another business episode. Today, I’m talking all about hiring. So if you are lucky enough to have found candidates for your open position, this is the episode for you. I have made, I would say a number of mistakes in hiring over the years, and would like to share about some of those mistakes and offer a few tips for [00:01:00] interviewing, how to conduct a good interview, and some additional strategies outside of interviewing to make sure that you are finding the best folks for your open positions.

Before we get to the episode, as you know, I am really moving toward more of a group coaching model and would love to chat with any of you who are interested in some accountability and group coaching as you build your practice. You can get more information at thetestingpsychologist.com/consulting, schedule a pre-group call and figure out which group might be right for you. There’s a beginner group, an advanced group, and an intermediate group. So there should be a group for just about everyone out there if you are looking for some support.

All right, let’s jump to this conversation about hiring and interviewing.

Okay, everyone, here we are. Like I said, we are going to be talking about hiring and interviewing today. As I mentioned, I’ve had a few situations where hiring did not go well. And the difficulty with these situations is that I didn’t know that they weren’t going well in the beginning because the interview process went very well as far as I could tell. But here’s the thing. There is a good deal of research out there to suggest that interviewing is not an effective means of gauging job performance for a number of [00:03:00] reasons.

One, we tend to conduct unstructured interviews. Unstructured interviews are generally easier for the interviewer, the employer, but you probably aren’t getting the best information that you can about your candidate because unstructured interviews lean heavily on first impressions and charisma, and impression management, to be honest.

Some of those things might be helpful as you consider your candidates. In fact, I think some of those things are helpful actually in our field. But if you rely solely on an unstructured interview, by which I mean, you ask questions, maybe you start with a predetermined set of questions but then you sort of riff on those or go off script and ask different [00:04:00] candidates different questions, and you tend to ask questions that don’t actually get at job performance, then what is really happening is you’re just sort of having a conversation with someone and that quickly leads to just figuring out whether you’d like the person or not.  And that’s important but it does not really do anything to predict actual job performance.

So, let’s talk about ways to structure interviews, ways to have a better interviewing process overall. And I’m going to talk about some ways to introduce some processes into your interviewing or hiring sequence that you may not have thought of or may not be implementing regularly.

So, as I said, interviews are [00:05:00] fraught. I think we know this. Trusting our gut or gut feeling is not actually a helpful thing in many cases because people can engage in impression management and put forth a good face during an interview without that relating to their job performance.

Now, I do want to start with some pros, some things that can actually be helpful about interviewing. I don’t want to throw out every aspect of interviewing because, in our field, first impressions are actually really important. They can be really important. Especially with testing, we have a limited number of appointments by which to connect with someone. So, I think an interview can offer a good sense of first impressions and how that may translate to the client relationship. [00:06:00] So I think that’s one pro.

I think that an interview is also just a great qualitative assessment of how responsive someone is to email when you’re trying to schedule the interview, whether they arrive on time, whether they seem prepared, and so forth. So you can get some decent qualitative information from an interview.

Like I said, the way that you connect with someone and sort of your gut feeling with someone could be a good indicator of how well they connect with others. Now that assumption is reliant on another assumption that you have a good sense of other people. So, if you know that you don’t tend to be a good judge of character or you tend to react to people differently than the majority of your friends or family, then that is not going to be as valuable.

[00:07:00] I think it’s helpful too. I mean, an interview can be helpful because the role that we play can be fairly scripted, by which I mean that, we deliver similar information day in and day out. So, if a person can deliver relatively scripted information and present a positive demeanor, then that could translate to the job. That doesn’t say anything about their clinical skill, of course, but it at least says something about the way that they might connect with other people.

Now, what are some downsides to interviews? You may know these things, but I’m going to go over them just in case because a lot of these are cognitive biases that it’s hard to be aware of because they just seem to fly in the face of everything that we feel.

So the first is just [00:08:00] generally speaking that interviews are a biased process. We tend to pick or hire the people that we liked the most. And we tend to like the people the most that tend to be similar to ourselves. So, just in that process, you’re already biased, not toward the best candidate necessarily but the candidate that appears to be most similar to you. Just know that right from the beginning that we are going to be biased in our selection process and we almost can’t help it.

So implicit bias is rampant in the interviewing process. So we start with whatever implicit biases we may have that we are aware of them or not, and then our brains do these really [00:09:00] tricky contortions by which we then bend our impressions after the initial impression to fit the initial impression. So once we decide that we like someone, we look for evidence that confirms that impression. Whether it’s there or not, we bend the evidence to support that impression. And we have a really hard time changing our minds. So that is not helpful. You’re, I’m sure drawing this conclusion. Like if someone presents a really good first impression, that can go a long way towards sealing the deal to being hired. Again, not unimportant, but we just have to be aware that these processes are taking place.

If you’re interested in reading more, I’m sure a lot of you have read Thinking, Fast and Slow by Kahneman. [00:10:00] That book details a lot of these cognitive biases and ways that our brains trick us into thinking all sorts of things, but there is a section in that book on interviewing as well.

So interviews are biased. We don’t do a good job of changing our minds when we need to. We decide if we like someone pretty quickly. That’s based on a gut feeling. That doesn’t really predict their job performance. So a simple unstructured interview on a single occasion is about the worst way to hire someone.

You’re probably saying, “Well, what do we do about that?” Here are some things that I have found to have been super helpful over the years as we’ve continued to refine our hiring process. And this information is also taken from different sources out there [00:11:00] research-wise in the business world.

The first one that I have found that is super helpful and often overlooked part of the process is to check references. Now that might seem simple. I’m sure some of you are saying, “Well, of course, we’re going to check references. That’s a simple part of hiring.” Well, easier said than done. In my experience, it takes some time to track down references and get people to respond. I tend to like to do things over email and it’s really hard to do things over email or get the true sense of a reference over email. So it requires a phone call a lot of the time and that it was some extra effort.  So you got to do it though.

Any of the times when I have been burned with hiring decisions, I did not check [00:12:00] references. Now, when you do check references, I think the way that you do it is important as well. A lot of the time, we might just approach these phone calls and say, “What’s your relationship like? What do you like about this person? Any red flags?” And that’s that. So I would encourage you to be a little bit more detailed and not be afraid to ask explicit questions about the areas that are most important for testing, but also most important for your practice.

We’ve talked a lot about practice values over the course of the podcast. Practice values have to make their way into this conversation as well. So I would ask references about testing specific things like their clinical judgment, their case conceptualization, their ability to write reports and get reports done in [00:13:00] time, their interaction with clients, their writing skills, all of these things are important and specific to testing. So, I definitely want to ask those questions.

But I also know that a major value in our practice is having fun. So I will ask what is this person like on your team? Does this person get along with the other folks in your practice? Do you have any concerns about this person’s personality? Sometimes I’ll be very direct and just say, “Hey, we have a practice where literally everyone gets along and literally everyone likes each other. We like to hang out. We have zero drama. Is this person going to disrupt that in any form or fashion?”

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And in my experience, you can get some pretty valid answers. That’s not the right word. You can get some very illuminating answers [00:15:00] if you ask direct questions like that. I know that there is some confusion out there about what you can or cannot ask. I have chosen to go the route of asking whatever questions you want and then it is on the reference to choose how to answer that question. Occasionally, you will find references who will say, “I can’t really answer those questions. I can only say if this person is eligible for rehire or not.” And that’s totally fine, but like I said, I want to encourage you to really drill down and think about those questions that you find most important that will get at the information that you really need for your practice.

It may be different. I mean, you’re going to have different values than our practice, but you can craft some questions around those values so that you are really digging in and getting to the nitty-gritty of this person’s presentation.

Now, another way to combat some of these [00:16:00] interview pitfalls is to do multiple interviews with multiple members of your team to see how somebody presents in different situations. Now, if you’re a solo practitioner, you at least should do multiple interviews on different days with this individual. This has been so helpful for us because I perceive individuals differently than my assistant director perceives people than our admin team perceives people. And we’ve had a number of situations where somewhat we disagreed and we had to talk through that and it was very helpful.

So as much as you can, do multiple interviews with multiple members of the team. I also recommend a practice that we just started implementing over the last probably six months that’s been super helpful, which is giving the interviewee the chance to [00:17:00] connect with existing team members.

Now, this is informal. It’s not supervised. I don’t give our team members specific questions or anything like that. It’s really structured or presented in a way such that the candidate is able to talk with existing team members informally to get the answers to any of those questions they might be afraid to ask me or the rest of the leadership team. And that way, your other team members get a chance to connect with the candidate. They of course can provide impressions about what that was like, and if they liked that person or got a good sense or whatever it may be. And on the flip side, the candidate gets to sort of get a peek under the hood and connect with some of your staff and get some of those questions answered that may be tougher to ask in an interview. You’ll also get a little bit of a sense of how they come across in a more informal [00:18:00] setting.

Another way that we can combat these interview dangers is to do a more structured interview with questions that actually relate to the job or the role that they’ll be filling. When I say structured interview, I mean, ask every candidate the same questions, first of all. But second of all, really try to devise questions that get at the job roles that there’ll be fulfilling. An example of that might be something like, “How would you handle it if you promise a report by a certain date and discovered that you were not going to be able to meet that deadline?” And see how people answer. So, you can craft questions that actually relate to the job.

That really flows into the last [00:19:00] suggestion which is doing a skills-based interview. If any of you have engineers or computer programmers in your family, you may have heard of skills-based interviewing. These are very popular in other fields, again like engineering and coding, where they will go in and actually have a problem to solve to get a sense of how they do with job-related tasks.

Now, in our situation, that is hard because it’s not like we can parade a client into the interview and see how people interact with them. But what we can do is present case examples. So you can present a vignette and ask how the person might respond and have them do a kind of on the fly case conceptualization just to see if they’re in the ballpark. You can have them devise a battery to test [00:20:00] whatever the referral questions might be. So there are a number of ways to do a case example.

One thing that you should absolutely be doing that’s related to skills-based interviewing is getting a report sample. I always like to make sure, especially if you’re you’re hiring early-career folks to say, please send me a report that was not edited by anyone else. Send me a report that you wrote. I always ask for two examples. I try to get different types of reports, different presenting concerns. I always get report samples as early in the process as possible. So, make sure that they send those to you along with any other introductory materials like a CV or cover letter.

Another example of a skills-based task that you can do [00:21:00] is something simple like just have them send an email to address a specific client question. And this for me, I know that sounds very simple, but we do a lot of communication over email, especially around scheduling and logistics and things like that. And I love to see just how people craft a quick email that needs to be concise and to the point yet also take the client’s feelings into account and be kind and warm and that sort of thing.

So those are just a few examples of skills-based interviewing that you may be able to do. I would love to hear if others have additional ideas for skills-based interviewing, but these are some things that we found helpful.

So again, just to recap, the last thing that you want to do is a single [00:22:00] unstructured interview before you hire someone. Beyond that, you have all sorts of options to increase the efficacy or the predictive value of your interview to see how this person is going to do in the job. So don’t be afraid to put the time and effort into it. Don’t be afraid to ask hard questions of references, and don’t be afraid to say no to people.

That’s one thing that I have to mention is that especially these days hiring is so tough. And I know that myself included, we can get really excited when we find candidates and already start to build a picture of who this person is before we’ve even met them. And then it can be really hard to go back on those expectations or impressions if the person turns out to not be a good fit.

So all that to say, [00:23:00] don’t be afraid to say no, don’t be afraid to turn down candidates if they’re not a great fit for your organization. Don’t be afraid to say no to people and keep on looking and just be patient. I know that’s easier said than done sometimes, but it’s so much more work if you bring someone on board who is not a good fit for your organization and have to backtrack and figure out how to not to let them go.

So hopefully, you’ve taken away some helpful information about interviewing. There’s so much research out there. If you want to dive into it, you certainly can. There are a number of books and other resources to help you become a good interviewer. But the takeaway, I think is just don’t trust your gut. Let other people interview this person and don’t be afraid to [00:24:00] give them some applied case examples and so forth to really test their job skills.

Like I said at the beginning, if you are a practice owner who’s looking for group coaching and accountability, I would love to chat with you about the possibility of joining one of The Testing Psychologist mastermind groups. These are all groups that I facilitate and have a small cohort of other psychologists to go through the process with so you can have support and like I said, accountability as you build your practice. You can get more information at thetestingpsychologist.com/consulting, and I hope to talk to you if you are interested.

All right. That’s it for today. I will be back with you on Monday with a clinical episode. Until then, take care.

[00:25:00] The information contained in this podcast and on The Testing Psychologists 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 [00:26:00] with expertise that fits your needs.

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