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  • 182 Transcript.

    [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. 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.

    Welcome back, everybody. Glad to be back with you for the Testing Psychologist podcast. And I am really glad to have an old friend on the podcast today. Many of you have heard me talk about Joe Sanok, especially if you’ve been listening for a while. So Joe was my original business coach way back. He was the [00:01:00] individual who really motivated me to start the Testing Psychologist Podcast and the Testing Psychologist consulting business.

    So I have a lot to owe to Mr. Sanok. But over the years we have been fortunate enough to get to be really good friends as well. And that really came to the fore this fall, Joe and his family have been traveling around during the pandemic. And they stopped in our area for two months and we just got to hang with Joe and his family and kids played together and it was amazing.

    So yeah, I’m honored to have Joe back on the podcast for the first time in about four years since the podcast started, he was one of the original guests. And it’s really cool. It’s really cool to have a conversation now at this stage of our relationship. So we really run the gamut here. I mean, we talk about the business of course, [00:02:00] and Joe’s focus on helping people level up their practices. We talked about some of the new apps that are available to connect with others. So Clubhouse is one of the big ones that we talk about. We talk about differences in getting to $50,000 in the annual income versus $100,000 versus anything beyond a hundred. Gosh, what else do we get into?

    It’s a pretty wide-ranging conversation. So we talk a lot about relationships and the power of relationships in building your practice and the value of slowing down and taking breaks. So if you’re interested in any discussion around just lifestyle, big ideas, building your practice, this is a good one.

    Let me tell you just a little bit about Joe. So Joe is the host of the Practice of the Practice podcast, a TEDx speaker, and an author with a book coming out next fall. He sold his clinical practice in [00:03:00] 2019. And over the years has been awarded many awards, Podcasts of the year, consultant of the year, and best blog. His NextLevel Practice community is the most comprehensive membership community for psychologists and counselors in private practice trying to level up.

    So I hope you enjoy this conversation with Joe. Like I said, it was great to chat with an old friend and bring it into this context. So without any further delay, here is my discussion with Joe Sanok from Practice of the Practice. 

    Joe, welcome to the podcast, my friend.

    Joe: Oh, Jeremy, I’m so excited to be here.

    Dr. Sharp: Man, me too. I was thinking back, [00:04:00] and it has been almost four years on the dot from the very first testing psychologist podcast, which you played a huge role in helping me launch. So it feels fitting somehow that we’re circling back here after four years to have you back on. So I’m really interested.

    Joe: It’s crazy to see what you’ve done with this podcast and just all that it’s done for you. And just to be a small part of that is just so exciting.

    Dr. Sharp: Oh my gosh, man, you’re humble. You’re a huge part of it. I would never have thought to start a podcast if it wasn’t for your suggestion quite a few years ago. So don’t be humbled. You played a big role.

    Joe: Actually, I’m pretty awesome. I really got this thing going for you too. I should get all the credit. 

    Dr. Sharp: There we go. That’s more like it. That sounds good. No, it’s been great having you come on the podcast. I’ve really been thinking about and reflecting on the journey and where it has come. And you’re right. It’s a totally different animal these days than back at the beginning, which is really cool. It’s [00:05:00] everything that I hoped that it would be. So it’s nice to just share.

    Joe: Yeah, it’s crazy to see just like what a podcast does for one’s career, but then really how little it takes you to stand out in the podcasting industry.

    I was the other day looking at some numbers for one of my consulting clients who’s launching a podcast or has just launched a podcast. It’s After the First Marriage podcast. So she’s a therapist who helps people after they get divorced. And she just launched, I don’t know, she’s at episode 10 or 15 and we were looking at the numbers and she was hovering around 200 an episode.

    And she was kind of down on herself. And we were looking at the stats. And if you have 200 listeners per episode, you’re in the top 10% of all podcasts. So it’s just like what? And so it’s really to say, what’s it take to be successful in the podcasting world or to level up in these different ways that we often talk about. It often doesn’t take much, but it feels like such a big mountain when you don’t know how to launch a podcast, launch a practice, all those things that were never taught in grad school. But once you actually get into it and get the flow, and I don’t [00:06:00] know if you feel this way too, but when I get in the flow of podcasting, it’s just fun. I’m talking to all these interesting people and somehow I’m figuring out how to make money off of it. Like that’s pretty crazy. 

    Dr. Sharp: Yeah, it’s amazing. I always say it’s the coolest thing in the world. I get to just like call up experts in the field and say, can I ask you all these questions that I have? And they say, yes. And then a bunch of other people benefits from that. That’s incredible that that format exists to be able to share things like that.

    Joe: Well, and it’s like, you never know where those connections are going to go. I remember it was probably two years ago the Gottman Institute reached out to me to see if they could be a sponsor on the podcast. And we actually figured out some kind of in-kind different things where they were a sponsor on the podcast, and then I was featured on their blog and they emailed their list. They were like, “Can we please have Dr. Julie Schwartz Gottman on your podcast as part of this deal?”

    And I’m thinking.  Yeah, that’s funny that it’s on your side. You’re saying like, please give us this whereas, for me, I would be like, can that be part of the deal to have [00:07:00] one of the Gottman’s on my show? And then it’s like over time I’ve developed a connection with Julie and she wrote a kind of testimonial as to why I should get a book deal and she’s going to be one of our experts with NextLevel Practice. And just like that, it all happened because of a podcast and because of thinking differently about how we do this counseling and helping the world thing.

    Dr. Sharp: Yeah, you make such a good point and I’m excited to talk with you about a lot of this because I think this is really… like your wheelhouse in this world is figuring out how to help people take their ideas and turn them into something magical and really thinking big beyond the typical butt in the chair, hour-long service therapy or testing services, you know, really expanding the horizon. And there’s a lot of room for that in our field. So I’m glad

    Joe: I think that inside we want that too.  Sure maybe we want to keep doing counseling or doing testing or things like that, but we also probably have a million other [00:08:00] ideas that we think would help the world but oftentimes we don’t know how to do that. We aren’t surrounding ourselves with peers. You know, even just thinking about hanging out with you and Carrie and my wife, Christina, when we hang out, yes, e talk about family. Yes, we talk about big ideas, but we also talk about work stuff too. And just being around other people that are thinking differently. I imagine one of the reasons that Carrie started a podcast is she saw how much it helped you to start a podcast or just being around people like me or having a peer group. It’s really amazing when you think about it if you surround yourself with people that are thinking like yourself over where you want to head, just how much that just multiplies and magnifies things.

    Dr. Sharp: Yeah. It’s so true. Everything you said I totally agree with. But that’s also a problem I think for a lot of people in our field. I mean, I work in the testing realm, of course, and talk with a bunch of folks who are primarily doing testing. So I don’t know what you’re hearing on the counseling side, but I feel like at least [00:09:00] 75% of the calls I jump on for people who want consulting., they say I don’t have anybody else to talk to about this. People are so protective or people are competitive in my area, or I just don’t have anyone I can trust to talk through the business stuff. And that’s a big problem, at least in the testing world in a lot of geographical areas.

    Joe: Yeah, I hear that a lot in the counseling practice world too. And I think people tend to fall into different camps. I remember when we were moving back to Trevor city and I didn’t have a private practice at the time. We were moving back to our hometown that we want to be in and be close to family, close to the water and I emailed pipe 10 or 15 different therapists in private practice and just said, I’m wondering what the scene is for private practice and like, how would you describe it? And almost all of them were such Debbie downers. They were like, don’t move back. You’re never going to make it. This is a terrible place to open a practice and it was very competitive like we don’t need another therapist moving in to try to [00:10:00] steal our clients.

    And I think a lot of people think that way. But if you really ask yourself, of all the people in the world that need therapy and need testing, are they all getting served or are there may be a ton of people out there that don’t even realize that they could benefit from testing or therapy? And when you think that way, you say, okay, for every person that’s in therapy or getting tested, there’s at least another one or two people that don’t even recognize how valuable of a service that is.

    I think that’s a marketing and a mindset change to help society understand just how beneficial testing is, how beneficial private practice is, how beneficial going counseling can be. And then that competitive mindset when it’s like there are two to three times more clients out there easily than we all could handle. We actually do need more therapists. We do need testing psychologists because the reality is people are underserved in the mental health space. 

    Dr. Sharp: Yeah, that’s such a good point. I mean, just doing the math. I think about our local school district and even just the kids, there are 25,000 [00:11:00] kids in our school district and if each psychologist was seeing 20 of them each week,  that’s over a thousand psychologists I think, or therapists that we would need. And we don’t have that many people in our town. We don’t have that many therapists. So there’s plenty of people out there, but like you said, that mindset…

    Joe: what do you say to people when you’re on those pre consulting calls and they say they don’t have anyone else around them. How do you share with them the value of being in the community?

    Dr. Sharp: Well, I just first validate it and say, I hear that all the time, literally all the time. And then that’s a nice entry into just say like, Hey, that’s a big reason that I have these groups going on so that you can connect with people who know what you’re going through and will support you and hold you accountable and be there when you need it and answer those questions that you can’t get answered elsewhere.

    And you can just see people love that. They really need that connection [00:12:00] with other professionals and to feel safe. I think that’s the thing because when we get in those conversations with the Debbie downers like you said, or the scarcity mindset folks or whatever, then it poisons our own thought process about it and makes us feel bad if we’re in a different space or want something different. And it’s a whole ball of wax.

    Joe: And I think then you have people around you who would’ve guessed 2020 was going to be how it was. If you’re around a whole bunch of people that have big goals like you have, then they’re going to be thinking through tools and resources and mindsets and ways that they’re switching so that you can adapt way faster than if someone’s just on their own.

    Dr. Sharp: Yeah, absolutely. I think I’ve talked to you about this. We had to make a big pivot back in March to figure out ways to do an online assessment when we couldn’t see people in person. So, I think about the communities that were out there and thank goodness there were Listservs and Facebook groups and things like that where there were folks who were like, yeah, I’m [00:13:00] going to figure out a way to do this and get through it. And they were able to connect with some like-minded folks. But then some people said, I don’t want to do that. And that’s totally fine. But yeah, it’s all in the way that you look at it, right?

    Like there were a ton of opportunities this year. And if people wanted to take them and there were also plenty of opportunities to hunker down and take care of yourself but it’s all out there. That mindset piece is so important though. It’s what you make of it.

    Joe: Yeah.

    Dr. Sharp: So I’m curious, you know, we started talking about connecting with other people and I know that that’s something that you have really focused on with Practice of the Practice is bringing people together. Can you talk about the ways that you’ve got that happening within the Practice of the Practice umbrella?

    Joe: Yeah, we have a bunch of different ways we do that. And I think it all comes out of when we were doing live events when there wasn’t a pandemic. To see people come together and say, Oh my gosh, this is my tribe. These are my people. Where [00:14:00] have these like-minded professionals been my whole life?

    And whether it’s slowdown school or Killing It camp That is when I’m most invigorated. And so sitting on the beaches of Northern Michigan skipping stones and having a conversation with John Clark and Jeremy Sharp. That’s amazing. You have these connections with people that then you just can’t get online. And so I think it comes from just that we’re so much stronger as a community when we collaborate than if we ever try anything individually. And so a number of years ago, I  started brainstorming as a team. Like what would that look like? Because we had mastermind groups where we have hot seats and people connect and I think those are really good.

    But where we’ve seen people really accelerate is with our membership communities. And so we have NextLevel Practice, which is aimed at people that have a solo or growing group practice that are under $100,000. And there’s a bunch of things we can talk about in there. And then we also have Group Practice Boss, which is aimed at group practice owners that want to work together and share ideas.

    And we’ve got around 300, some people in Nextlevel [00:15:00] Practice. I think we’re about to 100 group practice owners and group practice boss and so just the idea is that I’m never going to be able to consult as well as a group will be able to. And so we have events called, What’s Working and we get together once a month and come together and might have a topic like marketing. So what’s working with marketing and we’ll break up into small groups of four or five people share all of our best tips around what’s working in marketing and then come back together as a large group. And people will popcorn share things that were really just game-changers for them. So it’s a way to quickly get information from a large group of people by breaking it up into small groups.

    And that’s one of many examples of how we build community. But we’ve seen people like their first thank you note, or their first piece of mail was from their accountability partner from NextLevel Practice, or when people are struggling the community coming together to really help somebody level up and get those new clients. And people moving into new communities. We all want to make money in our business, but it’s to have this community of people that just takes care of you [00:16:00] in a way that is very hard when you’re a private practice owner.

    Dr. Sharp: Yeah, sure is. It’s such a valuable asset. That makes it sound like a transactional thing, but it’s valuable to have people like close relationships. We talk about acceleration when you get together with people. And I think back to that original slowdown school experience where my roommate was a guy named John Clark, who I’d never met before. And I’m at Kelly Higdon during slowdown school and a bunch of other really cool clinicians and…

    Joe: Have you seen what Dana’s doing from slowdown school with her EMDR, Instagram?

    Dr. Sharp: Yeah.

    Joe: Dina Credit Stein. I mean, I forgot what her handle is, but Dina Credit Stein, she was there also. She is blowing up with the whole EMDR world, which is so cool to see those original people that were at slowdown school and what they’re doing.

    Dr. Sharp: Yeah. Well, and I think that a big part of that was just being in this group [00:17:00] and feeling so supported. And I know there’s a neurological, like biochemical stuff going on during those moments when you’re in the group and you’re pitching your ideas and people are supporting you and you’re connecting and there are emotions and it like really cements it in your brain and gives you some crazy motivation to move forward after that.

    And yeah, it’s been amazing. John and Kelly are two of my best friends now at this point. And I just think that everybody should have that opportunity and maybe give themselves that opportunity to connect with others and see where it goes. So I love that you’re doing that.

    Joe: Yeah. And I think it’s one of those things that if you… it’s hard to break in sometimes to say, “Well, how do I get into those communities? I want that but like, what does that even look like to become friends with Kelly Higdon or John Clark or Jeremy Sharp?” For me, not that it always has to be a paid event, but I do think that there’s something about saying I’m going to mutually [00:18:00] invest either with you or in you, and we’re going to jump into this together. You can totally start your own mastermind groups, your own small groups but there is something about knowing like slow down school, everyone invested to be here. They want to level up. There’s an energy of I’m taking time away from my practice for a week to fly into random Northern Michigan and get picked up in a big yellow school bus.

    Like, we’re all in this together. And let’s really like to make the most of this short period of time that we have together compared to just when I’ve been in volunteer mastermind groups where we all just opt-in and it’s like pulling teeth to get people to show up. And I’m just like, what the heck? There’s such a difference there between the groups that sometimes you pay for and the groups that are just organically formed. Not that those can’t happen, I think is a little bit harder.

    Dr. Sharp: No, I totally agree. I wanted to go back to something you started to talk about which is… this is supposed to be a business-focused episode. So I want to share what to give people, some things to take away rather than listening to us talk about our friends and [00:19:00] experiences over the past few years, which is cool. But with the crowd that’s like under $100,000, so what are some of the characteristics that you see that are both helping people to reach that $100,000 mark and then pushing even beyond that? Are you finding common characteristics from all the folks that you work with?

    Joe: Yeah, let’s first start with the things that we’re taught or believe that oftentimes are totally wrong because I think that we have to undo some of those negative mindsets or those unhelpful mindsets before we can move into the things that are most helpful for scaling up. And it’s the same side of the same coin or two different sides of the same coin. But I think that one thing that a lot of people think is that I have to take insurance to be successful.

    Now, there are times and communities to take insurance. There are definitely benefits to taking insurance. But I think what that does is you’re thinking, do I put my time into the systems such as all the billing or do I put my time into the marketing? And so [00:20:00] whether or not you take insurance, you have to have a mindset as if you don’t take insurance. That we’re going after customers, we’re having good marketing, that we need to have multiple ways to get leads to come to our practice.

    The second thing that I see a lot of people do early on when you have time, there’s a tendency to say, I need to do everything. And that is appropriate when you’re trying to keep your costs low. So when you’re just getting started, sure. Maybe you put together your own website or you do your own Facebook ads, or you answer the phones and return calls and do the scheduling. All those things are very appropriate early on, but most people don’t recognize how quickly they need to start taking hats off in order to scale faster.

    And so I would say when you’re half as full as you want to be, so if you think 20 clients is full when you’re at 10 clients, that’s probably when you need to have a virtual assistant of some sort,  answering phones or returning emails, getting people scheduled because that’s one of the worst uses of a psychologist [00:21:00] time to be doing all those phone calls.

    And it also sets a barrier to entry that adds professionalism. I mean, you think about if you had primary care doctor or a surgeon and they were doing all their own scheduling and taking all the insurance information, you’d be like, ” Why is this surgeon taking my insurance card? Don’t they have somebody that they can pay to do that?”

    Dr. Sharp: Right.

    Joe: And then the third one I would say is really very quickly off of that second one, taking hats off. So outsourcing your bookkeeping. Making sure you have an attorney and accountant that you get those systems locked down early on so that you can scale later on because once you get past that $50,000 a year Mark, it really starts to accelerate quickly.

    The hardest is that $0 to $50,000. The next hardest is that $50,000 to $100,000 and then going from $100,000 to $200,000. It just starts to scale. It starts to double upon itself. I mean, it’s like in that book, the one thing where they talk about how a domino can push over a domino, that’s a third of the size larger than it.

    And if you just keep doing that, I think it’s within 11 Dominos. You go [00:22:00] from a regular-sized domino to like a two or three-story domino. It just that it starts to accelerate in a way that if you don’t have those systems down early on, it really can make it difficult to scale.

    Dr. Sharp: Yeah. What are some of the systems that you found people really need and were overlooked early on?

    Joe: Yeah. I think that we’re seeing a huge shift with millennials and people during the pandemic and COVID wanting to have clear automation to schedule. Overwhelmingly, millennials like talking on the phone less than Gen X or Baby Boomers. And so making sure that you have a very clear automated way that someone can schedule directly from your website without ever having to talk to somebody, that’s often overlooked. Because we want people to be able to say, okay, I want an appointment, when do I want it? Boom. I got an email confirmation, maybe even a text reminder. That’s obviously through a HIPAA compliant platform.

    So let’s say that… I would say having integration with your Telehealth into your [00:23:00] EHR.So yeah, if you have an electronic health record you probably don’t want to have multiple systems. So TherapyNotes, they’re a sponsor of my show, but I followed them very closely. They now offer Telehealth totally free as part of their EHR. And hopefully, other places will do that as well. And so I think it’s really important to make sure that those systems talk to each other really cleanly and follow HIPAA compliance.

    And then the last system is just understanding how do you sound like Joe? How do you sound like Jeremy? How do you sound like yourself, but not be the one that’s doing it?

    And so capturing your voice in your frequently asked questions, capturing your voice if you’re going to have someone return emails, capturing your voice throughout your website, you still want to have that heart within all of your systems. And so instead of having things sound super robotic, you may want to have a little bit of fun with it.

    And depending on what type of psychologist you are, if you are a pure testing psychologist by the numbers, make sure that’s reflected in how you’re talking, how you’re emailing, how your assistant is answering phones. Because when you have an assistant, [00:24:00] they’re not going to nail it the first time or the 20th time, they need that ongoing feedback.

    And I think people think that they’re going to hire someone they’re going to know how to do it. And then they’ll never have to give feedback. Feedback needs to be a part of the weekly conversation of what they did well, what they didn’t do well, and then how they’re going to improve.

    Dr. Sharp: Yeah. I think that’s such a good point. This whole process of setting these systems up and training someone else is really intimidating for a lot of clinicians. But for me, a big part of that is that we don’t spend a lot of time initially setting up our own systems or processes or values or scripts or whatever it might be.

    And then it makes it hard to train someone else because we’re not super clear on how that works in our own mind. I don’t know if you’ve seen this, but for me, one of the biggest challenges with myself and the people I work with is taking all the information out of your brain and putting it on paper. That can be really challenging for a lot of clinicians. Do you see [00:25:00] that?

    Joe:  I think that sometimes people think through like they have to write a whole policy and procedures manual, which depending on your state, you may legally have to but from a functional standpoint, I tend to say, let’s not just sit down for an afternoon and write all the policies and procedures out or how I’m going to do something.

    Instead, for example, when I brought Jess on as our director of details she handles email scheduling. She’s the catch-all. She texted me last night because I usually don’t work Thursdays and she’s like, just a reminder, Jeremy’s interviewing you tomorrow. And so she catches all the things I might screw up.

    And so training her as we go to me is more important than trying to capture all at the beginning. So the way that looked when she first took over my email, for example, was I had probably five or six different types of emails that were very common that I said, Jess, you should be replying on my behalf.

    So Hey, Jess here responding for Joe, here’s the script. Those were easy for me to say, here’s exactly what I want you to write. So that’s phase one, the easy stuff let’s hand that off. Phase two [00:26:00] was I would BCC her on any email that she had started for me that she thought I needed to answer that I actually thought she could have answered but she didn’t know-how. And so the idea is she’s constantly learning how to sell them like me more and building out that library rather than build it all at the beginning.

    The third step then is when there’s something new to have her come up with the system and then her document that, to me, that’s really important for a couple of reasons because first, it creates buy-in for her because she’s creating a system that she has to follow. So she might as well do it her way.  Second then if we have to bring someone on to offload things, which we’re actually doing right now for Jess, we just hired someone yesterday to offload some different things for her. She then can teach it better than if I had given it to her. Because otherwise, she’ll say, well, Joe said he wants it this way. I don’t really know why, but we do it this way. Versus here’s the exact reason why we do Pinterest this way, Instagram stories this way. And then you’re empowering that person to make changes as you go, because if they created the system then in our [00:27:00] conversation each week, which is only like a 15-minute check-in, she can say, you know what, initially the system I set up for Instagram stories is this, I realize this and just read this article and I just want to switch that around and give you a heads up. She just needs my approval and sign-off more than, Hey, Joe, will you read this whole article and create this whole new process because I don’t understand why I’m doing what I’m doing anyway.

    So I really think that when people overthink it, it’s that they’re taking more of that policies and procedures manual approach that honestly just sits on a shelf in most businesses compared to let’s have an actual function in a way that we do the process that empowers the staff to be the ones that make those changes and improvements to it.

    Dr. Sharp: Yeah, I forget who told me about this strategy, but someone shared. At one point when you’re trying to train someone to take over some of these activities for you, this would maybe be like step two or three in the process you just talked about is [00:28:00] to have them…Basically, if they’re sending you a question or an email or a thing to reply to, or address, they can of course ask your opinion, but have them put in the message. Here’s what I would do. And like take a guess at it. And the majority of the time it was probably going to be pretty close and over time you come to learn, you come to trust them and they come to trust themselves that they can handle whatever it is that gets thrown their way. So having them take a guess at it first before getting your opinion can be super helpful to too.

    Joe: Yeah. Rory Vaden has this thing called the focus funnel and he says to run pretty much any activity through it. And so first you look at, should I eliminate this and just not do the task? Second, could I automate it? Third, could I delegate it? And then fourth, should I procrastinate it? Because there are times when it goes through all that stuff. It still lands on my plate, but is this the best use of my time right now? Or should I intentionally procrastinate? He [00:29:00] calls it to procrastinate on purpose.

    And the idea is that you want to be putting your very best energy into the things that matter most. And so if you’re early in your practice, you’re just getting going. I mean, that’s going to be working on your marketing. That’s going to be doing Online, networking connections, virtual coffee dates, things like that, where you’re connecting with people that would likely refer to you.

    So if you see teen girls and that’s your main specialty areas doing psychological assessments with teen girls, maybe connect with another psychologist that focuses on teen boys or on parents. So our on custody evaluations, people that maybe aren’t going to see teen girls, but are also going to get referrals that they could send your way and say, Oh, I know this great psychologist that works with teen girls and in doing assessments.

    And so that’s the best use of your time to spend an hour or two dropping emails or calling places or, learning about people’s websites locally, writing blog posts, all of those things are going to have a higher return on investment for your time and money compared to answering the phones, [00:30:00] reading other emails, all those things that spend energy, but actually aren’t moving that needle forward for you.

    Dr. Sharp: I think what I’m hearing from what you’re saying is just being deliberate from the beginning, really and you say start really early when you’re half as full as you want to be. Just being deliberate about how you’re spending your time and whether it’s the right way to be spending your time, right? And if you’re getting the best return on investment for your time, or if somebody else can do those activities more cheaply.

    Joe: Yeah. And I think that each year I say to myself, what’s the big thing that if I had that done by the end of the year, it would just be a game-changer. And early on, when I was at my full-time job I think it was five full pay clients at $150 a session. I could almost be replacing my community college income off of that. And then I did that first year, and then it was if I can bring in two 1099 they can be bringing [00:31:00] in as much as my community college income that would be a game-changer for me. And I held onto that job probably two or three years longer than I should have. But I wanted health insurance. It was the sole income provider and my daughters had heart issues. So it’s like, yeah, I didn’t…

    I wanted to make sure that I was really making a good decision by leaving a very solid job. And then the next year it was if I can start to get consulting clients that are at least two to three times my private pay income like that’s a game-changer. And then it moved into if I can have a mastermind group where I have six people that are paying a certain amount.

    And so every year thinking about, wow, what would give me a ton of freedom if this happened? And so a year and a half ago, that was, Hey, if I get a traditionally published book through a big book company, that’s going to propel me differently than I just keep playing small. And so went through that process and have a book coming out in October through Harper Collins and all those things, then I’ll have to revision what is 2022 look like or 2023, and just keep saying, [00:32:00] what is that next big thing that’s going to make everything else easier.

    Dr. Sharp: Yeah. I love that. And that’s one of those things I was talking about at the beginning like big ideas have always been your bread and butter. It’s very inspiring to be able to talk with you and be friends. But the component here, I think that gets lost for a lot of folks is really that process of stepping back and saying, what do I want to be different or what could be better or what’s that North star. I think a lot of us really can get wrapped up in just day-to-day, trying to get clients or trying to keep on top of our reports or whatever it might be. And it’s really hard to step back and take that time for ourselves to do that visioning.

     But I’ve been saying, I don’t know it was very timely, but it’s been coming up in my mastermind groups where we talk a lot about, like, you need to be thinking at least six months ahead in your practice to take action now because it takes a while for momentum to build on things to actually [00:33:00] change. I think that’s a huge thing. How do you do that for yourself? Like, what’s your process for stepping back and being reflective and being deliberate with where you’re headed?

    Let’s take a quick break to hear from our featured partner. PAR has developed new tools to assist clinicians during the current pandemic, the RIAS-2 and the RIST-2 our trusted gold standard tests of intelligence and its major components. For clinicians using Tele Assessment, which is a lot of us right now, PAR now offers the RIAS-2 Remote, allowing you to remotely assess clients for intelligence, and the RIST-2 Remote, which lets you, screen clients remotely for general intelligence. For those assessing clients in office settings, PAR has developed in-person e-stimulus books for both the RIAS-2 and RIST-2. These are electronic versions of the original paper stim books. They’re an equivalent convenient and more hygienic alternative when administering these tests in person. Learn more at [00:34:00] parinc.com/rias-2_remote.

    Alright, let’s get back to the podcast.

    Joe: Yeah, I think it’s hard sometimes because you see people that are maybe like where I’ve landed, where I’m working a day a week and we’re living on the road. And it’s just so far from where maybe I initially started. But the process is the same. I think it starts with, well, Is my life, how is where I want it to be. And so for me right now, I could go on cruise control and I would be totally fine financially. I would enjoy it. And I’m in a very privileged position in that sense. And I also realized that I feel like I have ideas and expressions and things I want to give in to the world that is much bigger than how I’m playing right now. And so I think wherever someone’s at to just start with, am I at more of a cruise control right now or do I want to accelerate?

    So just yesterday talking to one of my consulting clients and you over the last nine months we’ve worked together. [00:35:00] He went from, I think, five clients a week and he’s now at 21 and he just wants to stay there. And so as he and I talked, it was he’s like, I don’t even know what to like, spend our last consulting sessions talking about, because I’ve achieved what I wanted to achieve so much faster than I expected. I’m making more money than I thought. And I said, well, First let’s just take a deep breath and say, you’ve worked really hard, like celebrate this. Maybe for a bit, we just relax within this. Not that we stopped doing things, but you have to have our essential list. Like instead of having two blog posts a week going out, we give ourselves permission to write a blog post every other week.

    And what we did is we created a what’s a maintenance list to just keep the cruise control going. What’s the, Ooh, there’s some danger ahead list. And so if you went from 21 clients, I asked him what number would you start to say, Oh, like, I need to do some things? If you knew three clients or five clients were going to discharge in the next month or two like, would that be a freakout or would that be like, Ooh, I think I can replace it? So you let me know if  I lost three clients, then I’d start to say, well, I got [00:36:00] to amp things up a bit. So then we made a list of what does that looks like?

    You start blogging, start reaching out to network more. And then we had the full freakout list. So if he lost five or six clients, I was like, Whoa, this is really going to slow down my work. And, that’s when maybe we’d start running some aggressive Facebook ad campaigns and some other things. And then we also look at do you think if over the next three months you expect to lose three people, do you think you’ll get three phone calls to replace that? He’s like, yes, well, I give you permission to be on cruise control. So then what happens in the brain is we say, okay, I’m safe. I can keep doing this. This feels secure, or even more secure than a full-time job. Now I can start to dream to get to that next level. And that’s where the people that really start to go after the big ideas and to accelerate, they’re the ones that start to really aggressively limit their time in two different ways.

    So one way is to have what I call hard boundaries and the second to have soft boundaries. And so hard boundaries are things like I’m never going to take a consulting client that wants to meet with [00:37:00] me on a Friday, Saturday, Sunday, or Monday. I don’t want to work on those days, so I will never take a client that says I can only see you on one of those days. So that’s a hard boundary.

    A soft boundary is I’m not going to work very much on Fridays, but I may check email for an hour, but I want something that’s flexible to do on those off days. And so when you start saying, okay, I’m only going to do clinical work on Tuesdays and Wednesdays, and that’s when I’m going to do all my testing. I’m going to have my intakes on the first Tuesday and the third Tuesday of the month and you really reign in that schedule and you try to fill it so that you just get into this flow state of boom, boom, boom. I’m getting so much done in this period of time. On Tuesday of this week, I remember it was 11:00 AM and I had already done a podcast interview. I’d done consulting. And then I had done two other podcast interviews and I was like, I feel like I’m done for the day and it’s only 11, Holy crap. I’m getting a lot done today.

    Like that’s what starts to happen when you just rack out these intense days. Then you can give yourself another day that’s more for that [00:38:00] creative effort. And so maybe it’s the Thursdays are your creative day and you explore big things or you read books or you listen to podcasts or you get on the clubhouse and you start to learn a lot through that app.

    Dr. Sharp: Joe, what is clubhouse? What is going on with the clubhouse? Why are people talking about it?

    Joe: I had the same question like a week and a half ago. The clubhouse is this new app you have to get invited in. So Jeremy, if you join the waitlist, let me know, and I can let you in. It’s a great marketing model because letting peers in. It’s just like when the g-mail rate started and they were like, you have five invites for Gmail and everyone was like, can I please have an invite? So if you view clubhouse as breakout sessions at a conference. So there are panel discussions, there are individuals talking, there are people listening, people raising their hands, people that want to contribute.

    The other day I hosted one and it was all on how to monetize a podcast. And I had Wendy pap, Roseanne, she and her husband, Jay.  Jay wrote the one thing and they have a whole amazing podcast network. Who else did I have in there? I had a few different people from interviews of [00:39:00] LA other podcasters that I know?

    We had this panel discussion and then a bunch of podcasters jumped in there and some raise their hand and they would contribute for a while. It was like an hour and 15-minute discussion that would have been one of the best discussions at any podcasting conference I go to bringing together people that are never in the same room together all sharing ideas around something.

    So for a while, I’m going to on Tuesdays at two o’clock Pacific be hosting a clubhouse on a variety of different topics and just see who shows up. I mean, we had 50 or 60 people that were hanging out, which for any conference would be a decent breakout room.

    Dr. Sharp: Yeah, that’s crazy. I’ve heard stories of celebrities are on the clubhouse and we’ll just pop into these breakout rooms sometimes. That’s the thing that caught my attention. 

    Joe: Yeah, Amy Porterfield was hosting one the other day and I mean, there are like a thousand people in there listening about e-courses. I think it’s the first social media that I feel like I really enjoy. Instagram, Facebook, I’m on that for business. We share a lot of stuff on it. I do it because you have to have a presence, but this one, I find myself wanting to just go learn and learn and learn because there’s… so you can choose what topics you want to learn about. And so to just go like, Oh my gosh, Amy Porterfield’s talking about e-courses. I want to learn about e-courses from her. So you just go listen to the discussion as long as you want to and then pop out. Yeah, I like it a lot.

    Dr. Sharp: That’s wild. Okay. I just had to ask people who are talking about it.

    Joe: Oh yeah, text me when you’re on the waitlist and I’ll let you in.

    Dr. Sharp: Okay, it’s good to have a hookup. Thanks. So I totally interrupted you to ask about this clubhouse thing to make sure I’m getting hold of facts.

    Joe: No, that’s good, It’s a conversation. I was on my soliloquy there. I think the big idea is to make sure that you’re providing space for your brain to rest and be creative. Most of us when we enter the business, don’t have much business training. So then when things take off, we’re like, I can’t believe I’m successful. This is more money than I’ve ever made. Even if you do 20 clients a week at $150  a session, if you’re not even doing testing, that’s more money than most non-profits, most CMH, most government jobs. And so most of us are then shocked and like, Whoa, what do I do now? And so you just end up putting out fires whereas if we really start to then structure our days and our weeks, and then allow our brains to rest and allow our brains to be creative, that’s where I think we really start to notice the things that your potential audience is asking for.

    So as testing psychologists to say, okay, I’m noticing that a lot of my assessments for autistic people have the same five questions. What if I had an e-course about those five questions that I gave for free as part of my package? So it started like, okay, here’s your assessment, but here’s a parent’s guide to these results. And you’ve got maybe some videos in there and then maybe you sell it for $197 on teachable and you go on other people’s podcasts and you say, did you just get an assessment? You’re shocked that your kid is on the autism spectrum. You don’t know what to do. I’ve got this promo code where you can get my e-course for $97 and you do a handful of those. And that recording is out there for years and you may build [00:42:00] thousands of dollars a month in just passive income off of something like that.

    That’s just one example of how our testing psychologists could start to notice the questions their clients are asking and say, am I tapping into something that’s more global than just my local people here that are asking these questions? Is this something that my expertise could actually go way beyond my practice? But if you’re stressed out and maxed out and putting out fires, you’re not even going to think that way.

    Dr. Sharp: Yeah. I think I just want to put a fine point on that because I’ve talked so much on this podcast largely because of experiences like slow down school and other times of really stepping away and giving my brain time to rest and be creative. I think that’s so important for us to build that time into our schedule somehow. And even if it’s not during the workweek, like if we can’t do this every Friday or whatever, Tuesday afternoon, set aside some time on a Saturday morning, if you can to go walk your dog, but make sure to do voice memos on your phone if you have ideas. Like just have some dedicated space [00:43:00] to let your brain rest and record ideas. Building that muscle is super important.

    Joe: Well, I love how you actually get away for a retreat for yourself to work on your business to really make sure that you’re intentional about the neighborhood you’re in and where are you going to eat? And you plan it all out. I actually, after I interviewed you about that process, that made it in the final cut on the book as a great example of how to do retreats because you’ve eliminated all the barriers that will get in the way for you to have a great retreat. And so some people that work better for them to go away for a bit and work rather than to have it every week. I tend to be more of, I need to have every week I need to have that downtime and that rhythm.

    But you’re right. I mean, it’s more a matter of how does it work for you than it is to say, like, just do Joe’s or just do Jeremy’s method, but find a way to give yourself that space to just rest and then be able to kill it more later.

    Dr. Sharp: Let me ask you about your process. So when you’re doing this each week, [00:44:00] is this structured kind of thing? Are you sitting down with a notebook and note this and note that or is this just like, Hey, I’m gonna make sure to have two hours each week to go on a walk or think about stuff, or is it more structured, less structured? What’s that look like?

    Joe: Yeah, I would say it used to be way more structured because I was working three days a week. Every Thursday was my creative day. For a while, it was the day that I was writing my book but now because Tuesday’s my big Workday. Next month that’s switching to be a Tuesday on a Wednesday and then having a week off then a Tuesday and Wednesday. And so that’s a great schedule for anybody, but then on those off days, I’ve really tried to be intentional about if I’m even just doing the dishes that I’m listening to a book that pushes me forward in some way. So right now I’m listening to Think and Grow Rich. The Book from the 1930s. It seems like everybody’s listened to, except for me. Yeah, I’m listening to that.

    Dr. Sharp: I haven’t listened to it yet.

    Joe:  Okay. It’s free through the app Libby, which you can connect with your public library account. So I’m listening to it through that [00:45:00] app or even listening to a clubhouse while I’m doing dishes or doing something. So there’s that side of it where I’m just filling my brain with good information, but just as important, if not more is just have downtime that you’re not thinking about the business because walking with my daughters, hanging out with my wife, trying to learn to surf but failing miserably, those experiences are going to allow me to just be open to the world and to notice things that maybe I wouldn’t normally notice or bring into my business world.

    Dr. Sharp: Yeah. That’s fair. I think that’s one of the things I appreciate about your podcast is that you talk with people who are not in mental health? You’re always open to things outside of work. And I think there’s some good research around that.  It’s actually good for us to expand our experiences instead of zoning in and ultra specializing that actually puts blinders on us a little bit.

    Joe:  Yeah, I think that siloed approach sometimes, like when you look at whether it’s Steve [00:46:00] Jobs or Rob Bell, or there are all these creatives that when they talk about what helped them come up with really cool products or ideas, it’s almost always linking things together. Rob bell calls it tying clouds together.

    And so even looking at Steve jobs who took a calligraphy class in college and sat in on that. And he says that that was one of the biggest things that influenced his design of Mac and, or when you look at when Uber was created, it was people that were linking established ideas on-demand video, which was out when Uber came and smartphones, but nobody had then tied that to taxis.

    And so it’s really that downtime when our brain just freely roams and goes down rabbit trails. That’s when we have these ideas that we’re like, Oh my gosh, that would be amazing. That would be so helpful for my audience.

    Dr. Sharp: Yeah. For sure. I’ve heard some stuff I’m terrible at remembering where I get things from, but I know that I have heard some good research too around [00:47:00] top leaders, CEOs even athletes, basically top performers. If you really dig into their lives, they all have at least one separate hobby that is not related at all to what they’re famous for. So like,  I don’t know, I think this is an example, like Winston Churchill, amazing politician, whatever statistician or a strategist, he painted all the time. I don’t know, I’m just, I guess, reinforcing and agreeing with you that we got to make time to slow down to give ourselves hobbies outside of our work. And just give our brain space to do other things.

    Joe: Yeah, 100%. I mean, before the whole pandemic, I was regular into improv group and we continued it throughout the first half of the pandemic when everyone was stuck in their houses completely and it was such a creative outlet, but then I would always have applications for the business world that it wasn’t intentional. Like how can I do improv for my business but it helped. Even just the [00:48:00] idea of yes. And instead of killing someone else’s idea to say, how do I join them in that world? And what does that look like? And I mean, that’s such an important thing, even with my kids, like. Yes. And then the unicorn did this and we have a creative story that happens and it helps with parenting it’s helped me with business. So having those things that you can do I think are really important.

    Dr. Sharp: Yeah. For sure. I love that yea and idea. I mean of all concepts. That’s an amazing concept to hold onto in every aspect of life. Don’t shut it down immediately. Do a yes and try to build off of it and see where it goes. I think that’s very applicable to our businesses and our family and any number of things.

    Yeah. So, man, I feel like our conversation has run the gamut which they often do, it’s nice to have it in this format. And even though I miss seeing you in person but let me see, we talked a little bit about Nextlevel Practice. What else is going on with Practice of the Practice, either with Nextlevel [00:49:00] Practice or just projects y’all are working on, you always have cool stuff going on through Practice of the Practice.

    Joe: Yeah. We have a growing team which is really cool. So if we start with starting a practice, we still got our one-year practice plan which helps people to know what to do in their first year of practice. And then the next step up is Nextlevel Practice, which is our membership community where we bring in experts like pat Flynn, Dr. Julie Schwartz Gottman, other folks that we’re bringing in at that level, we have small groups accountability. We have several zoom calls a month to help people really grow their practice.

    The next step up from that is we have a six-month program that Alison Pidgeon and Whitney Owens are running around starting a group practice. And it’s a private Facebook group and calls for people that are solopreneurs that want to step up into a group practice. And then after that, it feeds into group practice boss, which is our membership community for group practice owners. And so we’ve got all that going as well.

    Alison Whitney and Latoya are all doing consulting with private practice owners. Then where I come in is I really focused on the people that are ready to either reduce their caseload or exit out of their practice. And that’s usually through some big idea wanting to be a public speaker, a published author. I hosted an event called the Art of Dreaming Big, back in November where I surprised the people that came to that event by having my writing coach and then my publisher, my agent talk about what they look for in published books. So helping people do podcasts everything from podcasts launch school, which is our e-course all about podcasting. And then we’ve got a bunch of new services we’re offering in regards to support for podcasters. And the podcast is people like therapists, coaches, people that they have some service-based business and they want to get to that next level by going national or international.

    And then helping to continue coach people by our done-for-you services. So if people are like, it’s just not worth my time to start a podcast for me to do all that backend tech, we have a whole sound engineering team. We now have six sound engineers. We’ve got a podcast producer. We’ve got all sorts of other things that can support people. So we’ve got a lot going on most of which isn’t me it’s a huge team now. I think we’re up to 12 or 13 people now supporting people in private practice and in the podcast world.

    Dr. Sharp: That’s fantastic. Yeah, it seems there’s something for everybody at every level of practice development. That’s the cool part.

    How do people find you or find any of those things that you just mentioned?

    Joe: Yeah, I think that if someone’s stuck, they can always go to Practice the Practice that comes in the bottom right and just has a chat with us button that you can say, Hey, I’m interested in this where can I get more information? So rather than list a million of those different links. I’d say if you’re stuck and you don’t know what to do, you can go there. If you want to apply to work with us, you just go to practice@thepractice.com/apply. Jess will do an interview and then connect you with whichever consultant would be best to do a free 30-minute pre consulting call.

    I think for most of your audience, they are testing psychologists that want to grow their practices. NextLevel Practice would probably be the best fit for them. So if they go over to practiceofthepractice.com/invite. We have a cohort opening in February. We only opened that up a couple of times a year. So if it’s between cohorts, you can be on the waitlist. But we’ve got our experts. We’ve got our small groups, we’ve got a lot of testing psychologists in there already, and it’s only $99 a month. I mean, if you get one client that comes one time, it pays for all of that. And we’ve got 30 plus eCourses and all things to really support you to get to that six-figure Mark.

    Dr. Sharp: That’s super cool. Yeah. It’s always good to chat with you and hear what you’ve got going on. And we were due for a good one. We haven’t seen y’all in two months, so it’s nice to sit down and have a conversation that maybe other people will benefit from as well. So, thanks for coming on. Always good to talk to you.

    Joe: This has been awesome. Thanks so much, Jeremy.

    Dr. Sharp: All right, [00:53:00] everybody. Thank you so much for tuning in to this episode with Joe Sanok. I had a great time talking to my friend here in this context and hope that you can take away a few things for your practice as well.

    Like we talked about there a ton of links in the show notes. So definitely check those out if you are interested. And stay tuned. I am hopefully going to be doing a little bit of a Practice of the Practice takeover, at least on the business side for the month of February. Next week, I have Whitney Owens talking about private pay tips. And beyond that, my hope is to be talking with someone about systems, diversity, and hiring.

    So stay tuned if you’re not subscribed to the podcast now it’s a great time to do that. It’s really easy in iTunes and Spotify. Those buttons are pretty prominent. And once you’re subscribed, you will make sure not to miss any episodes as they come out.

    So thank you as [00:54:00] always for listening and take care. We’ll see you next time.

    The information contained in this podcast and on the testing, psychologist’s 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 [00:55:00] 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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  • 181. Tools for Feedback Sessions with Kids w/ Dr. Liz Angoff

    181. Tools for Feedback Sessions with Kids w/ Dr. Liz Angoff

    Would you rather read the transcript? Click here.

    “This is not optional.”

    Anybody ever had a feedback session with a younger kid only to have the child walk away completely confused, upset, or bored to tears? This episode is for you! Dr. Liz Angoff is here talking through the evolution of her method of delivering feedback to children. Over the past several years, she has taken her own experiences and knowledge and turned them into a bona fide manual (masquerading as a children’s book) for delivering feedback to kids. Here are just a few things that we talk about:

    • Why feedback with kids is SO important
    • How to enroll kids in the assessment process from the beginning
    • Metaphors that resonate with kids

    Cool Things Mentioned

    Featured Resource

    I am honored to partner with PAR for the next few months to bring you featured items from their catalog! Listen to each episode for specific product recommendations and links. Learn more at www.parinc.com.   

    The Testing Psychologist podcast is approved for CEU’s!

    I’ve partnered with At Health to offer CE credits for podcast episodes! Visit this link to access current and past episodes available for CE credit. You can use code “TTP10” for a discount on ALL the course credits you purchase from At Health!

    About Dr. Liz Angoff

    Dr. Liz Angoff is a Licensed Educational Psychologist with a Diplomate in School Neuropsychology. She has been practicing for over 15 years, as both a school psychologist in the public schools, as well as in private practice. Dr. Angoff provides assessment and consultation services to families in the Bay Area, CA.

    About Dr. Jeremy Sharp

    I’m a licensed psychologist and Clinical Director at the Colorado Center for Assessment & Counseling, a private practice that I founded in 2009 and have grown to over 20 clinicians. I earned my undergraduate degree in Experimental Psychology from the University of South Carolina before getting my Master’s and PhD in Counseling Psychology from Colorado State University. These days, I specialize in psychological and neuropsychological evaluation with kids and adolescents.

    As the host of the Testing Psychologist Podcast, I provide private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. I live in Fort Collins, Colorado with my wife (also a therapist) and two young kids.

    Ready to grow your testing services? Click below to schedule a complimentary 30-minute pre-consulting call!

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  • 181 Transcript

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

    All right, welcome back y’all. As always, I’m so glad that you are here for another episode of the Testing Psychologist Podcast.

    Today’s episode is pretty remarkable. I am talking with Dr. Liz Angoff, about specific tools that you can use to enhance your feedback process specifically with kids, not with their parents but with kids in particular.

    And the cool thing about this is that Liz has developed a manual that is actually packaged as a kid-friendly book, a children’s book to walk through during the assessment process and help them get enrolled in their assessment and learn about themselves. So it is super cool. We spend a lot of our time talking about Liz’s experience with trying to do feedback, how that didn’t go so well, and then her journey to figure out better ways to do it. And like the title suggests you’re going to walk away, I think with some very specific tools on how to improve your feedback sessions with your kiddos. It was great.

    So, let me tell you a little bit about Liz, and then we will jump into it. Dr. Liz Angoff is a Licensed Educational Psychologist with a Diplomate in School Neuropsychology. She’s been practicing for over 15 years as both a school psychologist in public schools and in private practice. She provides assessment and consultation services to families in the Bay Area, California.

    So like I said, there’s a lot to take away here. I think you will enjoy this episode. And what’s unique about Liz is that she is really trying to launch this product and spread the word about this book. So you’ll see links in the show notes for how to access her book and get it through Kickstarter, which is where it is right now. So definitely check those out.

    Before we jump to the conversation, I want to invite any beginner practice owners out there to consider the upcoming Beginner Practice Mastermind. If you are thinking of launching your practice in 2021 or would like some support for a practice that you’re currently trying to launch or just post-launch, this could be for you.

    This is a group coaching experience with five or six other psychologists, myself as the facilitator. And we hold you accountable, help you set goals, and help walk you through that whole process of launching your practice. So this is only beginner practice owners all working through those initial stages of practice development. If that sounds interesting, you can check out thetestingpsychologists.com/beginner and schedule a pre-group call to see if it would be a good fit.

    All right. Without any further delay, here’s my conversation with Dr. Liz Angoff.

    Hey Liz, welcome to the podcast.

    Dr. Liz: Hey Jeremy, thank you for having me.

    Dr. Jeremy: Yes, I am happy to have you. Like I said before we started to record, I am totally thrilled to be talking through your thoughts on feedback sessions with kids because we haven’t really tackled this on the podcast before, but it is something that I think most of us are doing at least a couple of times a week, so probably pretty important. Thank you for being here. I’m excited.

    Dr. Liz: Yeah.

    Dr. Jeremy: Yeah. That’s what we’re doing. I mean, that’s a big part of our job. So, let’s just start as I usually start with guests. And I would love for you to talk through, of all things, why this? Why zone in on feedback with kids? Why is this important to you?

    Dr. Liz: Yeah, so of all the things. I think for me, the reason to focus on it is just that it did not come naturally to me at all. And then when I actually started to poke around and talk to other people, it turned out that a lot of people weren’t much more natural at it than I was. So it seemed to be something that was pretty challenging. A lot of people would go so far as to say, “I don’t do feedback with anybody younger than 12.”

    As I started my career as a school psychologist, and so I’m in school and there’s a principal who was like, “Oh, you just finished assessing Johnny. Can you talk to him about it as ADHD? I don’t think he really gets it.” And I was like, Oh, okay, that sounds like something that’s totally within my skill set. And I sat him down and said, this is what ADHD is and just watched him completely glaze over totally overwhelmed. He walked out in that zombie’s face. I was like, “Oh, that didn’t quite work the way that I imagined that it would.”

    And then I transitioned to private practice then and had a lot more of your time to really have these conversations with kids. And it was just really inconsistent. Some kids were totally ready to absorb the information. They were excited about it. And other kids still glazed over overwhelmed. One kid ran crying to his car. This is definitely something that we need to figure out how to do.

    And I think that the kicker for me is that in private practice, I started working with a lot of adults who had histories of learning disabilities and needed a re-up on their assessment for grad school or work or whatever it was. And I’d ask them, what were your challenges in school? And they would say things like, I don’t know, I was just dumb. I was really slow. I hated school. I was in a special class, but I’m not really sure why. And then we would do the assessment and start really unpacking how they process the world and do that demystification process in the context of the assessment. And it ended up completely rewriting the narrative of their childhood to the point of tears with some people.

    And it happened over and over again with adults and I realized that this is not optional. It is not an option that we need to talk to kids about how they learn, how they process the world, why things are hard so that they have a way of understanding that’s positive and empowering, even if it’s just a little piece of it. Because we have that power to really help them define the way that they are relating to the school and to other people and how they think about those relationships.

    Dr. Jeremy: Sure. That’s so powerful. I love that we’re just coming right out of the gate with that. I wrote that quote down. This is not optional. I haven’t thought of it that way before. I’ve thought of it as optional, but when you flip it around and look through the adult lens, that totally makes sense. Like we’re giving all this feedback, many of us, I think probably just to parents or in some abbreviated version to kids and then 10, 15, 20 years down the road, what are they going to remember from that whole process? And often it’s not great. They walk away with these narratives of failure or something being wrong with them. It’s not empowering or helpful at all.

    Dr. Liz: Right. I think most of us weren’t really trained on how to do it. I mean, there’s definitely a subset, but most of the people that I’ve talked to did not get training on how to do the feedback with kids, especially young kids. I think there’s a lot of ideas out there, but kind of hit the ground running, there was a kid looking at you, the training I haven’t heard a lot of.

    I think there’s a lot of nuance to it because we’re working with young kids. And it’s hard enough to break this language down. To translate a neuropsychology report to parents is hard enough, to school teams is hard enough, and then to go to the kid that’s even harder. So there’s just a number of things that get in the way that weren’t something I gave a lot of thought to before I started to fail at it so often.

    Dr. Jeremy: Well, yeah, that’s how it works a lot of the time. We get smacked in the face with blatant failure and turn that into learning. Oh my gosh. You’re so right. I wish we could do it somehow, like a show of hands right now just to see how many people actually got trained in how to do a feedback session with a kid versus parents during grad school or internship or wherever it might’ve been. I don’t think it’s that many. So, yeah, this is super important. I’m already getting really jazzed about our conversation here.

    So as we’re diving into this, my brain starts cranking on well. If nobody’s really learning it, I’m just making that assumption based on anecdotal experience, but if nobody’s really learning it, why aren’t people learning it? And then I go to, well, is there any research or are there any guidelines for how to do it? Is there anything out there that you know of as far a… I don’t want to say a manual to do it, but any information that we could have been taught at some point?

    Dr. Liz: I started to poke around and I have a background with collaborative proactive solutions, which is really about how to help kids talk about the things that are hardest for them. And that’s a huge influence and just shifting the way that I approach all my conversations with kids with things that are challenging. And so there are pieces in there. And then you had Karen Postal on your podcast with feedback that sticks and there are so many gems in there. And then of course the therapeutic assessment community, that’s where this is nailed. Like they have a process for working with kids. And it’s actually something I came into really late in my process, just really recently. And so I’m still learning a lot.

    My understanding is that the therapeutic assessment process, it’s looking at an intervention for the family system which is something that’s extremely important, obviously. I think I was coming at things from a slightly different angle and more the psychoeducation angle and helping kids develop a vocabulary and building a shared vocabulary within the family or the school team for self-advocacy.

    So obviously there’s a ton of overlap. And as I said, I’m still learning. I actually think that the approach that I’ve started to do over time, I have a lot of stuff from there I can integrate. I have not found the manual on child feedback sessions. I definitely have not found that. There’s a lot of stuff from Mel Levine on demystification.

    I think I have a lot of trouble taking theory, and putting it into what do I do right now with this kid in front of me? And so like for me, I needed some more concrete tools to really guide that process. And there’s a lot of things that weren’t so intuitive to me that I discovered over time just working with a lot of kids and like keep trying this out and trying something different. And having something systematized was really helpful for me.

    So I think that for me, there are pieces all over the place, but I needed a way for my brain to bring all that stuff together so that I had more of a routine to really help me through with each kid. A flexible routine so that with each kid I had an approach and then I had a starting point to go from there.

    Dr. Jeremy: Yeah, I like that. I think we all do best with a framework, even if we’d like to adapt it and then be flexible. It’s nice to have that mental or that concrete framework to fall back on so that we know what we’re doing. We’re going to hit the high points, but we can also be flexible within that. So I think this is a great segue to the meat of our conversation, which is really like what have you learned over the years and how have you distilled this into a framework of sorts? So we can take any direction that you would like. But yeah, I’d love to actually dive in and learn about the framework you’ve developed here.

    Dr. Liz: Sure. So definitely from trial and error, but there are four things that I’ve been keeping in mind. And so it’s the before, during, after, and beyond assessment for helping kids with feedback. The first thing, and this drove it home for me, there was that podcast that you did with Karen Postal forever ago that I think it was her that said “Feedback starts at intake.” Which is just a phrase that I love because of the idea of feedback as an ongoing process that no parent, no child, no anybody can process all of this stuff within one session. It doesn’t happen like that. So the idea that this is ongoing.

    But the first critical piece that I realized was that for kids feedback actually starts before intake. It starts before their first session because it starts with how parents talk to their kids about assessment before they ever come in. And so I developed a handout that’s on my blog. It’s very available.

    Dr. Sharp: I’ll put it in the show notes.

    Dr. Liz: Yeah, a little handout that just has the language that I use for talking to kids about learning about, developmental differences, about just different ways of being in the world and uses that growth mindset language. And it’s set up as here’s how you can introduce what we’re going to do to your kids. And here’s how you can talk to them about it. And what to do if they say, no, I don’t want to go.

    And it completely shifts how the kid walks into my office the first time because when kids have had these conversations with their parents and their parents are saying, Hey, we’re going to go discover something. We get to learn about how you learn. We’re going to discover your strengths and it’s going to be really cool. You get to learn about the brain. Oh, and also that thing that you’ve been complaining about how I’m always nagging you about homework, she’s going to help me with that too.

    So, we’re defining things in terms of the kids’ problems and putting it in their terms and putting it in discovery terms from the very beginning, which means I don’t have as much uphill work to do to get them there when they come in because they’re already like, “Okay, let’s do it.”

    Dr. Jeremy: Sorry, just to jump in. I mean, I like to be very practical with all this. You said this is happening in a handout. So are you like giving this handout to parents at the end of the intake but before testing or what?

    Dr. Liz: Either in my first call, when parents call to say hey, I want to figure out if I want to work with you. Often in that call, one of their questions is how do I tell my kid about this? They’re going to freak out. And so sometimes before they’ve even decided to do an assessment, I’ll send it to them just so they can see, but definitely at intake when it’s like, your child’s coming in the next week. Here are some tips on how to talk to them about it.

    And so it won’t just be sent home. I’ll verbally walk them through how I would introduce it. And then we can talk about some things that they might be concerned about for their own child and how we might approach it directly. But it’s nice to have that concrete language there, that bulleted sentence frames for parents that they can use so that they know what to say.

    Dr. Jeremy: Yeah, absolutely. I get that question I would say at least half the time. How do I talk to my kid about this? How do you suggest we bring this up? Because they’re always, Stephanie Nelson used that term secret question. The secret question is kids are going to… how do I make sure my kid doesn’t think there’s something wrong with them or how do I do this without making my kid feel bad? Something along those lines.

    Dr. Liz: And parents are on different pages too. I get this a lot like,  how do I convince my spouse that this is a good idea as well. And so just have it reframing it for everybody. And then the secret question piece is a lot of times, the parent or parents who are calling, they also have that secret question of maybe there’s something wrong with my child. And so reframing it for them from the get-go is really powerful because it starts the shift for parents and thinking. And so when parents come in, if we’re doing all this work and helping their kids develop this language for thinking about assessment and learning challenges, then we’re going to be shifting the way they think about it as well.

    Dr. Jeremy: Right. I love that parallel process. Yeah, I didn’t even think about that until the last few two minutes. But yeah, the underlying thing there is parents are pretty insecure as well and we got to help them too. Very cool.

    Dr. Liz: So the second thing is building that shared vocabulary with the child during the session. And there’s a couple of reasons for this. The idea of kids asking their own assessment questions is super powerful. I’ve since learned and I think that comes from the therapeutic assessment work as well for me for the younger kids because for older kids, middle school and beyond, a lot of times they were able to answer that. They had their frustrations. They had the things that they wanted to figure out.

    But for little kids, what I found is that a lot of kids either didn’t have the words to say or they weren’t aware. I mean, they just weren’t aware of any problems or it was really fascinating that with some kids, it happened enough to be a pattern that kids would get very defensive and say like, oh, I don’t have any problems. It used to be a problem. It’s not a problem anymore. I’m fine now. Everything’s fine.

    And so there’s the giving them the safe space to be able to talk about challenges and the words to talk about it, both of those things have to happen. And so the first piece, I love talking about the brain. And even at a very simple level, kids like it too. And I have a brain model like a lot of us do. And I have a little brain diagram that I draw on too. We look at just the lobes of the brain and general jobs that they have, and then think about something that they really like to do and how their brain is all working together to make that happen.

    The most recent kid, he loves to do legos. And so I was like, what part of your brain do you think you’re using when you’re building Legos? And he’s like, the part that tells me where things are. I was like, great. What else? Like, Oh, I have to see the Legos and I have to really make a plan. And there are so many instructions that I have to follow. And then I have to hear the click to make sure that they’re together. And so we look at it and I have to pick up little ones. And so we get to talk about how their brain is working in all these cool ways. And it gets them excited about the idea of discovering something about their brain through the tests that we do.

    And it also gets them starting to ask questions. And I actually, with any kid, I don’t care what question they ask. I just want them to ask a question. So like, why am I so good at rock climbing is a question I had recently. I’m like, great, let’s do that because we’re going to get into the fact that this particular young person has incredibly visual spatial skills and is really struggling with the language. And so like how we get to make those parallels. So any question.

    And then talking about how neurons are forming connections and we’re constantly building our brains. I like to use a construction metaphor. So neurons are connecting, making roads in your brain. There are highways and there are things that are under construction. We’re always building and always growing. And so let’s talk about your highways. What are some of the things you’d like to do? What comes easily to you? And then let’s talk about some construction that you’ve done over time. And this was key to shifting for younger kids. Like, what are some things that used to be hard that are now easier for you? What are you proud of building?

    And so these construction projects, the finished construction projects, a lot of kids are excited to tell me. And even if they don’t have something to say, kids who have been tutoring, they’re like, Oh my God, I’ve done so much better in reading. Most frequently, I’m building my Minecraft skills. I’m really good at it now but I used to not be so good.

    And so, I got to a new level in a video game. It’s all construction. Or we can just start with walking. Like you used to not be able to walk when you were a baby and every kid can connect to that. Like, Oh, okay. I guess I am building skills. And then we get to say, what do you want to build next? What’s next on your agenda? And now we can talk about the things that are hard. And it’s a way easier entry point because now they have some language for it. We’ve established that things are growing and changing. So whatever they say is something we’re going to work on, not something that we’re going to discover is broken.

    And it really changes the way. And so we’re building this vocabulary. I’m listening to the way that they talk about things, but because young kids don’t always have a way, I’m also building that vocabulary with them so we can jointly figure out a way to talk about their experiences both the positive and the tricky ones.

    Dr. Jeremy: Right. I just love that you’re that early in the process planting the seed and getting them acquainted with the idea of, it’s okay to not be so good at something because I have these experiences where it got better and then it’s priming them for whatever you might talk about from the assessment that’s not super strong. Well, now they know that they’ve worked on other things and made them better. Now this. Yeah, that’s great.

    So again, just very practically, when is this happening during the assessment? Is this clinical interview stuff or like throughout the testing day or what?

    Dr. Liz: It’s worth mentioning the way I do testing is over a couple of days. So kids come in. But I start with a brain diagram and drawing on the brain diagram with them. That’s how I introduce testing. And so depending on the kid, we might play a little game and then get into it or he might just drop right into it. But their first experience of coming into the room is I’m pulling out markers and I have a colorful book that we’re doing together, which we’ll talk about in a little bit, but it’s colorful, it’s engaging, it’s exciting, and it does not look like a test. So it’s very exciting.

    And then that sets us up for like, okay, let’s go see what we can discover. We’re going to be doing all things that make your brain work in different ways. And then that language of highways and construction zones, I’m using that throughout the testing. Like through a clinical interview, we find out that these are things that come easily to you. Do you think of those as your highways? Is that something that we could call your highways? Let’s write that down. Or it sounds like you’ve been working really hard, is that a construction zone that you have? Let’s write that down there.

    And then through the testing as well, if they knock something out of the park, and not for every test but for things where it’s like, wow, that was really fast. I think we found another highway. Or when they really struggle with something, now we have the vote. Instead of being demoralized by it, it’s like, Ooh, that must be a construction zone. I wonder what we’ll figure out about that. Can you tell me more about how you did that or what was hard? And since we have that vocabulary, I’m writing things down all throughout and documenting it in our book where we’re going to go back to later so that we’re creating this thing together.

    Dr. Jeremy: Yeah. This is real-time feedback in a way. I mean, you’re talking through it as it’s happening.

    Dr. Liz: Exactly. Which leads to the next piece. And I think the biggest mistake I made during feedback sessions for a long time with parents also is, I’ve been thinking about it as surprises suck for all of us. And you never want to lay a surprise on somebody in a feedback session. There’s no big reveal of like, here’s what we got. And it doesn’t work with parents and it definitely doesn’t work with kids. And so by having a framework, and as I said, I need a framework and a structure. So having a structure to document all of this stuff in real-time with the kid means that when we get to the feedback session, we’re just completing something we already started and we’re just reviewing what we learned, which they already know, we wrote it down. The child watched me write it down.

    And if they’ve asked questions, they know that when they come in, we’re going to answer those questions. And so whether it’s why the kid who’s become staring at right now, why are some parts of math hard and some parts of math easy? And so he knows that when he comes back in, that’s the question we’re going to be answering. Or if it’s, why am I so awesome at rock climbing? We can answer that too.

    So one kid asked, why do I have lucid dreams? I was like, I’ll get on that. I’ll figure that out.  But a lot of times there is something about why is this hard and this easy, and those are our awesome questions. And then the kid knows that’s what we’re going to answer when we come back in. And we’re going to go right back to the same stuff we’ve already written down. And so now we don’t have surprises.

    And also I have their language or our shared language to define any diagnosis. And this is what I’ve been writing about most recently in my blog. How do we define these diagnoses for kids? And it sounds something like, we discovered that you have these strengths-these highways, and these challenges-these construction zones, and it turns out that this pattern is actually pretty common and you’re not alone and we have a name for it. And this is when it’s appropriate. Some kids it’s appropriate, some kids not. But when it’s appropriate, we have a name for this. We have some terms we can use.

    And so when we see this pattern of highways and construction zones, we call it ADHD. And it has to do with your whole profile. Not like you have trouble with attention, and that’s why we call you ADHD. That’s not how it works. We know what’s in the DSM. And then what we know about how different brains interact with the world are two totally different things. So really helping kids to understand their differences in terms of the whole picture and that this is everything together.

    And even I had a 6-year-old this morning who we didn’t diagnose with anything. But he’s at risk for a number of things. And we talked about how his brain is built to run super fast. He gets jokes really fast. He answers questions really fast. And he comes up with ideas really fast, but we got to work on his breaks. So, there’s the pause button. We got to construct his pause button. And he does a lot of Minecraft. He’s like, Oh, I could build it and I can do this. And so we’re just giving kids a way. We’re redefining things in a way that’s going to help them move forward and get them really engaged in whatever intervention is happening so they know why that’s happening. I never want a kid leaving my office, going into some intervention or therapy because their parents said so and they have to. Even a 6-year-old, I want him going in saying like, I’m here to work on my pause button.

    Dr. Jeremy: That’s great. I love the language. Just helping kids develop this vocabulary to describe their own experience is invaluable. They’re going to carry that. And it’s like you’re getting there first in a way before anybody else or anything else can give them a more negative vocabulary or a way to think about themselves. That was fantastic. I’m just thinking through all of these things and everything I’m not doing Liz. Construction zones.

    Dr. Liz: Yeah, definitely in my construction zone. I can’t say that I have this down like Pat. This is constant learning because every kid that comes into our office is a little different. And I think that’s what was really challenging about finding feedback tools and ways to talk because there’s a ton of stuff out there. I mean, there are metaphors for days but every kid seems to need something just slightly different. And on my part, I was spending hours and hours trying to find something for every kid. And what’s the metaphor that works for them? And it’s not quite there. And it’s not at their level or it’s not words that they’re going to understand or this video is too long?

    And so I need some way to do this. It was going to be flexible enough so that I could adapt feedback sessions to the kid in front of me without spending hours and hours trying to design something especially for them.  It is especially for them, but to do the hours and hours to do that?

    Dr. Jeremy: Well, sure. Yeah, aAnd that’s the thing that I love. I’m excited to talk through the… you mentioned this book that you use to go through this whole process. Before we dive into that, I think we still got the one component, right? Like the onward piece. And actually, I’m going to interrupt myself before I even do that. Tell me, what do your feedback sessions very literally look like? I mean, are kids and parents there at the same time? Are you separating them? How long are they? What’s the structure?

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    Dr. Liz:  If we could turn on the camera, I could show you the fallout on the podcast. And that’s probably going to fall out of the session I had this morning with the games all over. Talking specifically about elementary school-aged kids, I have the parents come in or at least one parent. And in COVID times, this looks like a highly ventilated room and everybody in masks. But we do meet outside. It’s the rainy season here but outside whenever we can. So that’s what it looked like.

    But we start with a game just to get everybody in the room. So we played family Jenga and just did a check-in. And then we talk about what the child remembers from what we did. And then we go over what we already talked about just reminding them about, you told me some of the things you really like to do or these things, remember we drew all over this brain. Do you remember how we talked about how your brain does Minecraft? And then for kids, I am giving them maybe 1 or 2 highways that we discovered in our process and 1 or 2 construction zones. And they have to be things that are aligned with things that are important to them. I’m not introducing anything new.

    And there’s a sentence frame in the workbook that I use. You should know that lots of people’s brains have highways and construction zones that are very similar to yours. In fact so many that there are special words to describe what’s going on. And then we introduce our special words.

    And for the child this morning who is 6 years old and does not have a formal diagnosis, and I don’t know that we would be ready to share any with him even if there was, his special word was perseverance for his highways because he has worked so hard. And he’s so proud of himself for the work that he does. And he’s really excited about catching his errors, so we use the word. So one of his special words was perseverance. And then for construction zones, it was building his pause button. So that his highways are like he can process things so quickly and he goes so fast, but he’s building his pause button. And he has perseverance. And so that’s how we described it.

    But for another child, I might actually write in like we learned that your brain is built in a way that comes up with ideas so quickly and so easily. And your hand is having a hard time keeping up. And we call that dysgraphia. So dysgraphia means that your hand is having a hard time keeping up with the thoughts in your head. And, of course, dysgraphia can cover a lot of ground. So just that as an example. It could mean different things for different kids. There’s a couple of ways that dysgraphia shows up, but for that kid that might be the way that it shows up. So we’re defining it in terms of their strengths and challenges. We’re just giving it a new name. And then I usually come up with one celebrity that has the same challenge.

    Dr. Jeremy: Always a good strategy.

    Dr. Liz: So Daniel Radcliffe who played Harry Potter had trouble with writing in school. So I like that one for little kids for a writing challenge. So we’re physically writing down that definition for parents to be able to go back to that definition so that they know. And then we’re writing down their construction crew and who are the people who are going to be helping them including if there’s going to be somebody new on their team. And then we’re writing down a couple of tools that they’re going to use. So things that will be helpful for them.

    Dr. Jeremy: Yeah, this is great. So are you talking primarily to the kid throughout this time or what?

    Dr. Liz:  Yeah, I’m talking to the kid. It takes about 20 minutes. It’s really quick. And then usually they go play and I talk to the parents to just review. Two minutes of just saying, here’s how you’re going to use this book going forward. Here’s how you’re going to use this language going forward to continue the conversation and to set the context. And this is the first bit of an ongoing conversation, but here’s the language that will help you moving forward.

    And that’s the ongoing piece. Is setting parents up to continue the conversation. So we’re coming full circle from the beginning that priming parents with a language to talk and teachers as well, but priming their parents to talk about it before kids come in and then helping them to use that same language to define the results of the assessment so that they can keep talking to their child in that positive growth mindset empowering way.

    Dr. Jeremy: Yes. So important.

    Dr. Liz: Yeah. In PS, often a lot of parents there’s a lot of like light bulbs that go off in the feedback session with a kid because like, Oh, that’s what you meant. So it’s a nice way to present things in a very visual way for parents as well.

    Dr. Jeremy: Yeah, that’s amazing. So then how long is the entire feedback session then?

    Dr. Liz: Less than an hour. I mean, this is the kids. I do it separately then the parents. So the parents come in first for their feedback session. I do a session with the parents to review the report. And then on a separate date, sorry that wasn’t clear, on a separate date, the kid comes in for a short session with their parents to finish the book so that their parents can hear how we’re talking about it. And then they take the book home with them.

    Dr. Jeremy: Okay, very cool. And then speak just a little bit to that ongoing component. Is there more to that in terms of follow-up that you do or, is it all housed within this workbook that you’re using? What’s the after and beyond?

    Dr. Liz: Part of my assessment process is meeting with the school team and following up with other professionals who are working with the child. And so whatever language we come up with in the child’s feedback session, I’m communicating that to either the school team when we meet or the other professionals that I talked to so that the language is consistent.

    And then just the way that I run assessments, I always do a check-in three months after our last session. And so that’s a moment in time too. But I think because it’s such a moment in time, the assessment process is just like a snapshot, we come in, we do our thing and we’re gone, and realizing that one of the things that makes feedback with kids so hard is that it’s just a moment in time and that’s not how it works. That’s not how kids work.

    The way that they’re processing differences that are going to come up at different points in their developmental trajectory is going to require a new framing. And also like to expect the child to understand it in one session, that’s ridiculous. That’s not going to happen. We’re trying to jumpstart things. And so,  one of the key reasons for having something concrete that families can take home is so that they have my language and my voice and the collective words that we came up with to continue the conversation because otherwise, parents are overwhelmed in this process as well. And it’s really hard to remember all the details and how he did that.

    So that concrete nature, something they can go back and revisit with the child is interesting to look at. I think it is really helpful in continuing that conversation. And that’s the feedback I’ve gotten from families. They’re like, yeah, we look at all the pages we did and all the drawings you did. And in the early days, this was like a clip art printout. And so then I would write on, which is like another way to do it. And I have kids who still have them posted on their walls and stuff. I have the drawing of our brain on my wall. And so that those physical pieces and the visual piece are just so critical for making sure that that conversation keeps going.

    Dr. Jeremy: Right. I think that’s a nice transition to actually talk about the book because it has been quite an evolution from what I understand. So talk through how this even came to be? We haven’t really shone a spotlight on this very much so far in this conversation, but you sent me one of these books and it’s a legitimate book. This is not just a thrown-together binder kind of thing. This is a real book that you’re writing in and creating with these kids. So tell me, how did this even develop from the clip art to where you’re at?

    Dr. Liz: I went into private practice. I was having trouble explaining brains to kids. And so I went back to school and did this additional neuropsychology training. After that training, I actually got more confidence skills, knowledge to be able to actually start drawing out the brain for parents during feedback sessions. And so I would bring out my markers. Parents would come in ready for the 30-page report and I’d bring out one page and markers. And the experience was like, you could just see everybody relaxed, like, “Oh, well, if she has crayons and markers, this can’t be too dire.”

    And then parents started asking me to do that with their children. That evolved into just a PowerPoint presentation that I would personalize for each kid. And that was really helping with the feedback sessions when I had that personalized thing. But what really changed things is when I printed the thing out. And we had a physical book that we could look through together. I thought it was going to be way more interesting to kids on the screen and flipping through things and animations and all this stuff, and it was not as fascinating. It just was not.

    But when I printed it out and they could point to things and draw on things and we could do that, then that was way more effective. And then this concept of surprises sucks, I was just realizing that if we did it all, it was too much for just the feedback session. So I started introducing pieces of it at the beginning of the session, and just for me because it was so much time to make a personalized PowerPoint presentation for every kid, I had a template, but I was trying to find images that were personal to the kid. And it was just so much.

    So, I ended up with something that was more generic and a lot more white space so that we could draw our own stuff in. And that was a game-changer because then we started it at the first session in introducing little pieces along the way. And then that made it so that the feedback sessions were not so overwhelming. And that little clip art printout once that got stable enough that it was the metaphor, the construction metaphor was working with all of the kids that were coming in, it was pretty versatile.

    Dr. Jeremy: Can I ask a question about that?

    Dr. Liz: Oh yeah. Sure.

    Dr. Jeremy: Sorry to interrupt you. But that occurred to me earlier and I’m glad that it came back up. With the construction metaphor, I was curious, do you find that the majority of kids resonate with that? It seems very traditionally masculine to me. That’s the question. Do most kids get on board with that or have you seen some results?

    Dr. Liz: It’s so funny that you asked that. Somebody else asked me that. And it’s funny because that’s the metaphor that resonated with me the most. It was just about my personality. And that’s something that I could talk about and relate to. But it has never been something that any of my kiddos have shied away from. And there’s always a relationship because most kids are either Legos or Minecraft or Roadblocks, like the video games are very much doing these things. And even for kids who aren’t into that, it’s very easy to understand.

    And we’re talking a lot about neurons making connections and higher brains working together. And so depending on the sophistication of the kid, I might put my emphasis in different places. For the 6-year-old that was in this morning, we talked a lot about Minecraft and building things and all of that. And for another kid, we might use a different aspect of the metaphor. But I have not seen a difference in the girls and boys that have come in. Maybe it’s how I talk about it because I’m really into it. It’s not a new metaphor. I want to be really clear. I did not make this up. It was the most versatile and the one that was easiest for me to talk about.

    Dr. Jeremy: That makes sense.

    Dr. Liz: And it has proven true over 2 years with dozens of kinds. And so that’s been really useful.

    Dr. Jeremy: Nice. Yeah,  I just had to ask that. It got to me a couple of times. So thanks for talking through that. So then you really made it come alive with these strong metaphors?

    Dr. Liz: Yeah. So, when we all went into lockdown, I hired an illustrator.

    Dr. Jeremy: When we’re bored. Yeah.

    Dr. Liz: It had actually been something that I was thinking about for a long time because the clip art was a little lame. And so the clip art definitely did not resonate. That was a little harder to find the right images than the other. I was fortunate enough to work with an illustrator and a close colleague who is a scientist and a phenomenal artist. And so he helped me to bring my image of the metaphor to life. And then we had a digital artist make the images and the book. I’m super proud of the book. It looks really cool. It’s super engaging. Kids are responding really well to it. And it’s really colorful. It’s different than your traditional workbook.

    Dr. Jeremy: I know. It looks great. It yeah. Like I said, I was fortunate enough to get to peek at it as we were prepping for this. And yeah, it was super impressive. When you said, Hey, I’ll send you a copy of this book that I put together, honestly, my expectations were low. Nothing to do with you, but we can create any number, everybody’s creating something. So, it was a pleasant surprise. It really is pretty awesome.

    Dr. Liz: Thank you.

    Dr. Jeremy: The important piece here is you’re trying to maybe get this thing in the hands of more clinicians who could use it, is that right?

    Dr. Liz: Right. So this has been a super helpful tool to me and a couple of colleagues who are really excited to use it. And then it grew from there. And so I’ve talked to enough practitioners at this point to know that child feedback sessions are a problem for a lot of us. There’s a lot of us who want to get better at it. We see the need. There’s both a lot of stuff out there and not enough stuff out there to really help get this targeted about what we do in the office on the ground.

    And so the hope is that this workbook, it’s called The Brain Building book in line with the metaphor, and the goal is to bring all these pieces together. So to have a structure for building that shared vocabulary with the kid, for having something you can do along the way, and then to have a final product at the feedback session that makes the feedback session more predictable. It makes kids excited about what they’ve learned and it gives parents the language to continue that conversation with them without taking up a ton of my time in preparation. Something that’s a little easier to put together and still be exciting and impressive.

    And so this has definitely solved this problem for me in my practice. It’s been super fun to use. And now the question is this going to solve the problem for more people? And I think there are two pieces to it. So there’s a Kickstarter campaign that is designed to see if enough people are interested to really make this thing possible.

    Printing them one by one for my own practice is totally worth it but expensive. And so, to make it affordable to people to be able to use, we would have to do a bulk print, which means that I need to know that there are 200 people interested enough to be able to do that bulk print and make it really affordable. And so the Kickstarter campaign that’s going on right now is a way to do that. So people can pre-order the book. And then if we meet our goal, they’ll get printed and shipped. And if we don’t meet our goal, then everybody gets their money back and we try a different way to solve the problem. Try something else. So there’s that piece of  just, is this the thing? Knowing that it’s definitely a problem that people are interested in solving, is this a thing that’s going to solve it?

    And then the second piece is that getting a bunch of people using this means that I can get a lot of feedback on how it’s working and anything that needs to be tweaked or what else could be useful. I’ve had people asking like, can we do a different version that’s specific for rehab, or can we do one version that’s for dyslexia and one version that’s for autism and one version that’s for ADHD or different aspects of it. And so getting all of that feedback, I think would help evolve this tool into something that really could solve this problem. And that’s super exciting for me that it could up all of our game. Because as I said, I’m very passionate about solving this problem because I really think that it changes a kid’s trajectory in a major way to be able to have a way to talk about their experiences. And so, it’s important to me to get something out there that could really help.

    Dr. Jeremy: Yeah. Absolutely. Well, it’s just cool. I wish people could see your face because you’re just beaming and so energetic. I can tell that this means so much to you. And that goes such a long way. When we started talking about this, it immediately resonated. Yeah, this is something that I think a lot of us could use. It just seems so helpful in this process. And so the business consultant part of me is kicking in. And I’m like, you should do training, Liz. Like somebody gets the book and you train them how to use it. It’s this whole process and everything.

    Dr. Liz: It will come with a manual. So, if the Kickstarter is successful and we do end up producing this thing, it will come with a manual. And I will do a training on how to use the book that everybody will have access to. And the hope is to also bring together just everything that I’ve been learning about child feedback in general to get some of those concepts out because they’ve been just game-changing for me. I mean, just  completely mind-opening and things that just weren’t intuitive to me. So, it’s neat to talk about those things in general also.

    Dr. Jeremy: Well, yeah, definitely. And those connections with the community I’m sure are like a snowball rolling downhill. It’s going to help. Just keep feeding itself. It’s really cool. Of course, we’ll have the links to the Kickstarter campaign and everything that we have mentioned here in the show notes. Just to say a little bit more about it. This seems very appropriate for elementary-aged kids. How do you apply this thing to older kids if you do, or do you not, what’s the age range here?

    Dr. Liz: So this particular book that’s on Kickstarter right now. It is definitely kind of the K5 or elementary school. Here, elementary school is K5. So that’s the age range I have in mind. I actually have developed one for middle school that is called Brain Building 101. We’re going to try this one first. If this brain-building book is successful, that one will be coming out soon. The middle-school version will be coming out soon.

    So I personally have a slightly different book that uses a little more sophisticated language. But the process is exactly the same. The metaphor is the same. It just talks a little more about emotional regulation and that’s a big deal in adolescents in a positive way although both books address it. So it just uses a little more sophisticated vocabulary and pictures are designed for the older group.

    So this book is for the younger kids, but conceptually how the framework has developed,  I’ve found it applies to all kids of all ages. So just thinking about how parents are talking to them about the process, introducing brain language at the beginning has been really helpful for me because for the older kids, it just takes on a different level of sophistication. And the conversation, especially with my teenagers, is often asking me questions I don’t know the answer to, which is very exciting. It’s like, “Okay, I forget. I need to go look that up. Check back with me in the next session.”

    But that concept of introducing some language to help talk about things has actually been really helpful for all ages, and having the conversation ongoing. I think when I was first trained to do an assessment, it was more like you give the tests and standardization says, can’t talk to him, you know.

    The first rule about testing is, do not talk about testing.  But I think making the process a lot more transparent, what was that like for you? And there’s actually a lot of theory about opening up the testing process and really examining, like, what was that like for you? Let’s go back and revisit some things. And putting that into the metaphor of highways and construction zones even for teenagers it’s just a really helpful way to be able to talk about things. And then the tools that we use might be a little bit different.

    Dr. Jeremy: Right. That makes sense. I have taken so much away from this conversation. My wheels are spinning. I love that kids are co-creating this whole thing. They’re active participants and it’s not just you sharing the information with them or with their parents telling them what’s going on. They’re taking an active role in the whole process and have this physical representation to take away and look at. There’s going to be some pride there for kids I would imagine. So there are just so many layers to this that I love.

    So closing, I suppose, thank you so much for coming on and talking through your process and this approach with putting this workbook together. If people do want to reach out and get a hold of you or ask questions or anything like that, what’s the best way to find you?

    Dr. Liz: For more stuff about the book, brainbuildingbook.com is the place to go. And then for me, I’m at dr.lizangoff.com Please reach out, email me, let me know it’s on your mind. I’m definitely in a space where I’m collecting experiences and the challenges that practitioners are facing around this because if these tools are going to solve a problem, it needs to be based on what people are experiencing in their real lives with their real kids.

    Dr. Jeremy: Exactly. Right. I cringe to think about my work as a child psychologist before I actually had kids, thinking back like what in the world was I telling parents? It’s so ridiculous.

    Dr. Liz: I have a two-year-old. So I’m at the beginning of the humble pie eating process.

    Dr. Jeremy: Yeah, we get two layers of that. And there’s the layer of actually being humbled by your child and your parenting skills, but then there’s a second layer of thinking back to all the things you told parents when you didn’t have kids of your own.

    Dr. Liz: I think the biggest thing for me, when I had my son, I remember picking my pediatrician and the people that were on our team, those people who could tell me what to say and do.  I just needed somebody to say, “Here are your guidelines.” And I’m really good at saying no, I’m not going to do that, but I need the framework.

    And so I think knowing that’s something that I need as a parent to have some language and have some approaches that give that piece of parents, not just theory of, “Well you need to talk about their strengths and really be supportive.” I think it has been really helpful for parents to have something concrete. And those words “here’s something that you can use, here’s a tool” have been really helpful. And I know it’s helpful for me. So maybe that’s part of how this thing evolved to something I would want.

    Dr. Jeremy: Yes. I think that’s a nice note to close on. So thank you again. All the links that we talked about will be in the show notes. And of course, best of luck with this whole process.

    Dr. Liz: Thank you. This has been amazing. It’s been really fun talking to you.

    Dr. Jeremy: All right, y’all. I really appreciate you checking out this episode with Dr. Liz. I hope that you found it helpful. This is definitely one of those where I took away quite a few things and we’ll be putting it into practice pretty quickly. And like I said on the podcast this is no joke. Liz sent me an advanced copy of her book and it was really cool. It was pretty impressive, to be honest. So definitely check out the links in the show notes to get the book or back the Kickstarter. And there are plenty of other links to help you in your practice as well based on things that we talked about.

    Like I said, at the beginning of the episode, if you are interested in the Beginner Practice Mastermind, if you need a group to help you stay accountable and reach those goals of launching your practice in 2021, we would love to help. Spots are filling up for this group. It starts March 11th, I believe is going to be the date. And it could be a great fit if you are looking for an accountability group and some group coaching. You can get more information at thetestingpsychologists.com/beginner and schedule a pre-group call.

    Okay, y’all, it’s always good to be with you. Thanks for listening. Let’s see. What’s coming up next? I think we’re going to be in the middle of a Practice of the Practice Takeover of my business episodes. So, check it out. This upcoming Thursday, I think Joe Sanok is going to be on the podcast talking about getting your practice to the next level. So I hope everyone’s doing well. And I will catch you next time.

    The information contained in this podcast and on The Testing Psychologist’s 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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  • 180. EHR’s for Testing Psychologists: Jane (Basics)

    180. EHR’s for Testing Psychologists: Jane (Basics)

    Would you rather read the transcript? Click here.

    Hey everyone! Given all the questions about EHR’s (electronic health records) in the Facebook Community and among my coaching clients, I wanted to take a few episodes to dive into some of the major players in the EHR space. Each of these reviews will focus primarily on the testing-specific aspects of each EHR, though I’ll also do an overview of non-testing features that are important. 

    For the FULL review experience, check out the accompanying video on the Testing Psychologist YouTube channel. Enjoy!

    Jane is the star EHR for today. Here’s how the review broke down:

    Pros:

    • Great pricing for larger practices
    • Lots of features for larger practices w/ multiple locations
    • Customizable note templates
    • Nice layout
    • Lots of reporting features
    • Little qualities like choosing the color of appointments, uploading a bio and pic of practitioners, uploading practitioner signatures, etc.
    • Database of codes for billing and diagnosis

    Cons:

    • Could not figure out how to write a note for the appointment
    • Not obvious how to submit an insurance claim
    • Features could be overwhelming for a solo practitioner
    • Expensive for just one practitioner

    Verdict: Definitely keep this one in consideration, especially if you’re a larger (or multidisciplinary) practice!

    Cool Things Mentioned

    Featured Resource

    I am honored to partner with PAR for 2021 to bring you featured items from their catalog! Listen to each episode for specific product recommendations and links. Learn more at www.parinc.com.

    The Testing Psychologist podcast is approved for CEU’s!

    I’ve partnered with At Health to offer CE credits for podcast episodes! Visit this link to access current and past episodes available for CE credit. You can use code “TTP10” for a discount on ALL the course credits you purchase from At Health!

    About Dr. Jeremy Sharp

    I’m a licensed psychologist and Clinical Director at the Colorado Center for Assessment & Counseling, a private practice that I founded in 2009 and have grown to over 20 clinicians. I earned my undergraduate degree in Experimental Psychology from the University of South Carolina before getting my Master’s and PhD in Counseling Psychology from Colorado State University. These days, I specialize in psychological and neuropsychological evaluation with kids and adolescents.

    As the host of the Testing Psychologist Podcast, I provide private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. I live in Fort Collins, Colorado with my wife (also a therapist) and two young kids.

    Ready to grow your testing services? Click below to schedule a complimentary 30-minute pre-consulting call!

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  • 180 Transcript

    [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 has a number of remote testing tools that will help you stay safe during social distancing times. Measures include the RIST 2, the RAIT™, the TOGRA™, the IGT™2, and the WCST™-Wisconsin Card Sort  Test®. Learn more at parinc.com\remote.

    Welcome back to the podcast, everybody. And welcome to the final installment in the EHR review series. Today was an interesting one. I included an EHR called Jane in the review series because I’ve heard [00:01:00] really good things about it from different folks in the mental health space, but it’s not one of those really well-known EHRs. It’s definitely not one of the top five that people think of when it comes to mental health. So I wanted to give it a shot and see what came of it. And I’m glad I did.

    A short story is that I think it is certainly worth considering. And I will go into great detail about that in the accompanying YouTube video for this podcast.

    So as with all the previous EHR reviews, you can go to the YouTube channel, The Testing Psychologist, and there’s a playlist called EHR reviews for testing psychologists. And this will be in there as well. So the video is again about 30 to 40 minutes long, and it’s just me diving in, messing around with the system, and doing all of those things that we tend to do as psychologists to see how the system works [00:02:00] for us.

    Before I jump into the podcast where I do a brief summary of my review of Jane, I wanted to invite any beginner practice owners out there to consider the beginner practice mastermind group as a way to get support and accountability as you launch your practice in 2021. So this is a group of other psychologists who are launching testing practices. I’m the facilitator. And like I said, the intent is to give you all the guidance and support you might need, and some accountability to get those things done so that you can launch or help your practice continue to grow if you have already launched. You can find out more information at thetestingpsychologists.com/beginner and you can apply for a pre-group call there as well.

    All right, let’s jump to my discussion about Jane, an EHR for testing psychologists.

    [00:03:00] Okay, let’s dig into it, everybody. I am excited to talk with you about Jane as an EHR for testing psychologists. Right off the bat, I have no idea where the name Jane came from, but it kind of follows in the trend of what’s hot right now with sort of cute one-word app names. But naming aside spoiler, I think Jane was pretty good. It was pretty good. I could see it as a contender for testing psychologists. Two things that I did not really get into were, inputting patient info because they have a demo account with tons of patients already put into the system. So I did not do that. And the other thing that [00:04:00] I didn’t really look at was sending paperwork through the online portal. It certainly appears that they have pretty robust functionality for doing so.

    Okay, so let’s jump into Jane. As usual, this is going to be a relatively brief review and the YouTube video which is linked in the show notes or on the YouTube channel, The Testing Psychologist, will have that in-depth review. So definitely check that out.

    As far as good things about Jane, there is a lot to like. So, Jane, just right off the bat, I can tell you about the pricing. So pricing is $74 for a solo practitioner not billing insurance. $99 for a solo practitioner who would like to bill insurance and have all those features included. But where things get interesting are at what they call the corporate level, which is 10 practitioners for $369. So you can see the price drops [00:05:00] dramatically if you have a larger practice. So that’s my first pro for Jane is that there is really very competitive pricing for larger practices. Either way, there’s going to be a $25…it’s either a $20, $25, or $30 fee for additional practitioners above and beyond the base level for each of those tiers. So keep that in mind. But yeah, if you have a bigger practice, that’s very competitive pricing.

    Along those lines, Jane, I think, is really built well for larger practices. So as you’ll see in the YouTube video, there are lots of options for bigger practices. It’s clearly set up the handle multiple locations, and a room scheduling many, many practitioners, multi-disciplinary clinics. I think it would be great if you have a multidisciplinary clinic because Jane is [00:06:00] not specific to mental health practitioners. It includes templates and information for Chiropractors, acupuncture, massage, nutritionists, that sort of thing. So if you have a larger multidisciplinary practice, it could be a nice option for you.

    Another thing, more testing specific is that Jane did offer customizable note templates. I think it is pretty robust in terms of the note builder. Maybe not quite as user-friendly as something like IntakeQ, for example, but it did have customizable note templates where you can build a testing note that makes sense for us where you can have checkboxes for the tests that you administer and then corresponding note boxes where you can type in the time, and any notes about the test that you gave. So the note templates are pretty customizable and relatively easy to assign [00:07:00] to specific practitioners or specific services.

    Overall, I think the layout of Jane was really nice. I mean, the colors are attractive, but you can also pick the colors and you can upload your logo and branding and all of that, which is nice.

    There are a ton of reporting features in Jane. So, I’m talking about like income reports, activity reports, patient reports. There are a ton of reports that you can run. So if you’re a data person and you really like to track a bunch of numbers, this could be a good one for you.

    They have a number of really interesting little features that I really liked. You can choose the color of your appointments. You can upload a bio and a pic of your practitioners. You can upload practitioners’ signatures too to sign notes and documents and so forth. There are also integrations. There’s an [00:08:00] integration with MailChimp. So if your patients opt into your email list from the intake process or intake paperwork, you can automatically import them to MailChimp which I thought was really cool. I haven’t seen an EHR do that. It’s an easy way to build an email list. They have some other integrations as well, like with Google analytics.

    So, I think it was pretty thorough thinking through of all the nuances that a practitioner might want, particularly on the business side. I haven’t seen a lot of EHR pay that much attention to businessy kinds of reports.

    Another feature, if you have a larger practice, it’s really easy to track income for employees. You can set different percentages for different employees and that sort of thing.

    So that was cool.

    It also comes with a built-in database of codes for both billing codes and diagnostic codes. So that was pretty easy to [00:09:00] set up testing-specific appointments. And I found it pretty easy to create an add-on code or assign multiple codes to the same date of service and choose the units. All of those things were pretty easy. So, yeah, there are a number of things to like about Jane.

    As far as things that were less attractive. Here are the things that I did not like.

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

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

    The biggest thing, and again, keep in mind, this is a beginner review. I didn’t do any work with the software before I jumped in.

    So this is just really a gauge of how user-friendly it is right off the bat. But I could not figure out how to write a note for the appointment, like a process note or a progress note rather. I kind of poked around and you’ll see on the video, I spent a fair amount of time trying to figure this out, and I just couldn’t find the place where I’m supposed to write the [00:11:00] note. Easily could be an oversight on my part. Lord knows I make oversights in many, many situations. So I may have just missed it, but I couldn’t find it.

    Related to that, it was not super obvious how I might submit an insurance claim. So for insurance-based practices, keep that in mind. It was really easy to see the claims that needed to be submitted and you could Mark them as submitted. I’m just not totally sure how to actually submit them. Now, that may be a feature that’s not available in the demo and I just couldn’t access it, but it did stand out.

    One thing to keep in mind is that if you are a solo practitioner, I think Jane might be a little overwhelming. There are a lot of features and, it might be kind of a little bit of overkill for a solo practitioner. That’s up for you to decide, but that’s [00:12:00] one thing that I picked up on. It is very robust for a larger practice. I’m not sure if solo practitioners need everything that it provides.

    And related to that, it is more expensive for a solo practitioner compared to some of the other options out there that tend to kind of hover around that like $40 to $50 a month range. So starting at $74 without insurance billing, and then going up to $99 with insurance billing for a solo practitioner is on the high side. But again, it has a number of positive qualities and integrations. So that’s up for you to decide.

    Overall, in terms of the verdict for Jane, I would keep it on the list as an EHR to consider.

    I would absolutely consider it if you have a larger practice. And if you have a multidisciplinary practice, that’s even better. I could see it being really, [00:13:00] really helpful. So, yeah, generally thumbs up. Definitely, some things that could be different, but there weren’t any deal breakers. And a lot of the cons are just things that maybe I couldn’t figure out during my beginner status in the EHR.

    So there you have it. That’s my brief review of Jane. Like I said, go to the YouTube channel and check out the YouTube video review for the full deal where I dive in for 30 or 40 minutes and just explore.

    Thank you as always for listening. If you are a beginner practice owner trying to launch your testing practice in 2021, or if you just launched, you know, if you’re maybe 6 to 12 months out from launching and you feel like you would need some support and guidance, this could be the group for you. So you can get more info at thetestingpsychologists.com/beginner. And let’s see, we have two spots left. And I would love to see you there. [00:14:00] So you can book a pre-group call. We’ll talk about it, see if it’s a good fit, and possibly get you into that group and get you where you want to go with launching your practice.

    Okay. I will be back on Monday and I hope everyone is doing well. Staying warm, getting their vaccines.

    All right. Take care y’all.

    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, [00:15:00] 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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  • 179 Transcript

    [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 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. You can learn more at parinc.com.

    Hello, and welcome back to another episode, everybody.

    Today is part two of the trauma-informed assessment with Dr. Julia Strait. If you did not catch part one last week, I would strongly encourage you to go back and listen to that episode first. We really set the stage last week for this episode. [00:01:00] Last time we talked through the basics of trauma, definitions of trauma, what we consider trauma. And like I said, really lay the groundwork for everything that we’re going to talk about in this episode.  So, if you haven’t listened to part one, I would strongly encourage you to go back and check that out before diving into this one. But this is part two of trauma-informed assessment.

    I’ll tell you a little bit about Julia. I’m not going to do a full introduction because I did so in the last episode and it’s in the show notes as well. If you are curious, definitely go check those out. But Julia is a licensed psychologist, of course. She’s in private practice. She has a long history, extensive training in trauma-informed care. She’s done training across the country for schools and other [00:02:00] professionals on trauma-informed care. And you can tell that she is incredibly passionate about this topic. She is quite accomplished and has been doing this work for years and years. I’m so thrilled to have her back on the show here and talking through these important topics.

    Today’s episode is really aimed at the assessment side of trauma-informed assessment. If you think of the two episodes, last week was the trauma-informed. What is trauma? Defining it, that sort of thing. And now we’re really digging into the assessment process. We talk about everything from the beginning. What does the intake look like? What does testing look like in terms of appropriate measures and a room set up and interacting with kids and parents where [00:03:00] trauma might be a factor. We talk about the feedback report and any number of other things related to trauma-informed assessment.

    We do, of course, talk about separating trauma from other diagnoses or not. That’s a little teaser. And talk through how trauma comes into play for so many kids’ lives and how we consider that from a diagnostic perspective. This is another kind of action-packed episode. There’s so much information here and I think you’ll want to listen to this one a couple of times, or at least have a pen and paper handy to take some notes. There are extensive show notes for this episode and for the first part. So you can always go back and check out those resources as well.

    Before I jump to the conversation with Julia, I would invite any beginner practice owners who are [00:04:00] launching a practice in 2021, or just launched perhaps in late 2020 to come and check out the beginner practice mastermind group. This is a group coaching experience that provides group accountability and coaching of course, and support to help make sure that you are launching your practice in a way that will work for your life instead of the other way around. You can get more information at testingpsychologists.com/beginner and schedule a pre-group call to see if it would be a good fit.

    So without any further delay, let’s jump into this discussion on trauma-informed assessment with Dr. Julia Strait.

    [00:05:00] Dr. Sharp: Thank you so much for talking through all of the background and sort of the definitions of trauma, but I would love to transition to the assessment process. So, you tell me, Julia, where do we start in this whole assessment process?

    Dr. Julia: So, how I usually conceptualized the kind of nuts and bolts piece is what that stands for definition. So I mentioned the event, the experience, the effects. And I think there are ways to assess all of those things. So, I can go through that for you. But I think this is maybe a good place to put this before we start. You had asked me before about when the child or person, I’m talking about adults too, comes into the office or on Telehealth now, but you had asked me before, like, are there different things you would do or different ways to approach that person that’s more “trauma-informed or trauma-sensitive”? So [00:06:00] maybe this is a good place to talk about that when you meet the person and before you even jump into the nuts and bolts part.

    Dr. Sharp: Yeah. I love that.

    Dr. Julia: Okay. I think I joked with you before. I do a lot of yoga and I take some training on trauma-informed yoga. I got my psychologist judgy mind. I’m always in there like, oh no, no, that’s a little…, I just want to put out there first, there’s so much pseudoscience about this. So there’s so much. I was in a yoga thing the other day and the lady was saying when you teach yoga students you have to avoid saying any personal stories or anecdotes because you could be talking about your kid and then it could traumatize someone.

    And I just thought that is a good example of what we were just talking about with the concept, right? I think that you’re treating people a little too, like they’re not going to break, right? Like, there’s this concept, kids are kids, and adults like anti-fragile. Like, we actually need some [00:07:00] stress, not that they need trauma, but like, it’s actually good too in therapy, like we would talk about the trauma. And not that you should do that every time, but I think that there’s a big fear of like, oh my God, this kid’s coming to my office. They have trauma. I have to tiptoe and I have to serve them sooner.

    I don’t know, like, there’s this whole other thing because that buds were like trauma-sensitive, right, which I don’t remember. I do think it’s super important to be sensitive to things and to open your mind to like, oh I hadn’t thought about that before. So just to give an example, like in the yoga world, there’s this big controversy over being touched, right?

    So like, do you touch someone when you’re trying to adjust them or whatever? And I think in therapy too, do you hug someone that’s had trauma? And I think that, again, just like the answer at the beginning where we talked about the philosophy of what is trauma and you know like, it totally depends. Obviously right now during COVID, it makes it a little easier to answer the physical touch question because we’re not going to do that. But I know a lot of people to say like, Oh, should I [00:08:00] maintain a distance? I don’t know that those things are as important as just the general approach that you take.

    For example, of course, I want to make sure they know it’s a safe space, it’s welcoming.  But I think that I’m doing that more through my actions, in my words than letting incense or whatever. It’s definitely easier I think to make people feel at ease when you have a real genuine relationship or a genuine wish to help and they can see that rather than trying to be some bubbly, soft-hearted large necklace wearing therapy idol who… I’m like, I’m just coming to these stereotypes of like, we don’t all have to be that kind of person to be trauma-sensitive. And so I think whatever your personality is, that genuine relationship particularly kids like they are so used to being lied to and manipulated themselves. 00:09:00] My number one rule is always I’m super transparent, especially with my trauma kids, right?

    Like, “Hey, did anyone tell you why you’re here today?” And you’d be surprised. Very often, they’re like, “No, I have no idea.” So talking to them about that, like, why are you here?  We want to help you. We want to figure out how to help you. And I’m sure everyone has their steel for that, but I think that’s super important because they’re sitting there. Like if you put yourself in their shoes, they’re just sitting there staring at this “professional” who in Memphis, kids used to say, we had this one kid who was like, we said, “What are you nervous about? Are you okay?” He wouldn’t come into the office and he said, “Hookies”. And he thought, because we were doctors, we’re going to give him a shot.

    Dr. Sharp: Yeah.

    Dr. Julia: So, like he had no idea or like some of the parents would think that we were part of DCS and we were going to take their kids away.

    Dr. Sharp:  Sure.

    Dr. Julia: They’ll just like clarify like, which depending on your setting but just clarify, hey, this is why you’re here today. This is our goal. And then I loved a couple of weeks or, well, probably a few months now, but like that therapeutic assessment series that you all [00:10:00] did. I actually went and got some training in that afterward because I thought it was such a great collaborative approach, but not that you have to do this full model with them, but like, involving them in the questions of the assessment, like, what do you want to know about yourself? Is there anything I can help you with?

    I’ve had lots of kids who are very insightful, right? Like some of them will be like, well, I want to know my IQ. Like, okay, well I can answer that? Or like, I want to know why my mom’s crazy. Well, we talk about that later, but involving them in that process, like where is it going?

    I give kids who I know have a trauma history, a lot more autonomy and choice in what we’re going to do and structure and routine. I might do this for a lot of kids, but especially, I just make sure to be on my game about like, Hey, I’m going to give you a poster that has the 10 things we’re going to do today. Like, to some extent, do you want to start on the iPad or do you want to start on the computer? Do you want to play with toys first? So that they feel like they’re in it. And then another way of doing that is with older kids, like I said, I’ve been incorporating more personality types of assessments because I think the [00:11:00] self-reports are so nice.

    Like., hey, you have a voice, tell us what you think so that we’re not just sitting here saying, well, I think she’s depressed I think that… and so what I’ll usually do is actually give them like that voice through the report measure. But then, and this is getting into methods a little bit, but then later I follow up as suggested in therapeutic assessment with an extended inquiry of like, Hey, let’s talk about this report because very often it’ll come up with things like manipulative, whatever, and like, hey, what, what really actually makes sense for you? And can you explain some of these answers rather than just… sometimes like in the school setting, we were forced to work so quickly that there was no following up? It was just like, well, you put this on the basket. So you must be having hallucinations. I’m like, “Tons of people put that.”

    Dr. Sharp: So many kids to answer that question.

    Dr. Julia: Yeah and so many kids are like no, I just like saw my grandpa’s ghost or whatever it is.

    So yeah, so we’ve, I do a lot more follow-up with them, a lot more qualitative information. I think that having them have more of a voice, [00:12:00] being transparent, being structured, like telling them when they’re going to get a break, saying if you need to use a bathroom like just sounds silly, but the more control I think they have the better. They’re probably so used to going to, well, maybe not quite, but a lot of them are used to going and just doing whatever their parents say or whatever. And even the adults too, like we all think about this like therapy settings, but that might be the first time I’ve ever interacted with a mental health professional or they might’ve had like some “little t trauma” from previous interactions with like residential settings or other settings where they’re expecting you to be like really negative and ask them to just go on and tell me about all your terrible things right now, kind of a longer runway. Maybe not the first day you meet them talking about all that, but a longer runway.

    So all those things, I think that’s a little scattered, but those are the things I think about when I’m seeing one of those. All people of course, but like, just make sure to [00:13:00] be on my, A-game when I’m testing kids and young adults who have histories of trauma.

    Dr. Sharp: Sure.

    Dr. Julia: And comforting their parents. Sorry.

    Dr. Sharp: Well actually, yeah, I’ll differ back to you. Did you say comforting their parents?

    Dr. Julia: Yeah. Well, in private practice, we see a lot of adoptive parents or foster parents. And talkie again, it goes back to that shift of like are they manipulative or can we like shift the context and help you understand?

    I think that the therapeutic assessment model has a lot of potential for those parents because of the family intervention. I haven’t fully implemented that yet. So I’ll let you know. I’m sure there are people who are doing it. In fact, I think there’s a clinic in California that does it. But yeah, talking to them about realistic expectations from the evaluation as well. Like we’re not going to be able to tell you, yes, her mom was crazy and did drugs when she was pregnant.

    And so [00:14:00] I feel like the adoptive mom, and of course, like you consider they’re feeling really protective and they’re feeling like they want to save this kid. Like that’s often a dynamic that you see. And that is so laudable, but how can we also have perspective and talk to them about what’s realistic.

    Well, that’s a realistic question to answer in the assessment. I’m like, am I really going to be able to say like, yeah, if his mom hadn’t done drugs, he would be 10 points higher. No, I can’t say that. So I don’t know, that’s really, really hard and I’ve still not figured out a great way to do it, but you just often get adoptive and foster parents who mean so well. And they just so feel so strongly about the bio parents or that they give a really, really negative view. And I don’t know. I also make sure I separate so that we’re not talking about that in front of the child because of course, that’s not good. You don’t want them listening to this tirade about their mom, right?

    So that’s [00:15:00] just a sidebar, but yeah, parents often, or just parents in general who may be their kid like went through something and it is their biological child, but maybe they just found out that like their brother abused their daughter. We’d often get cases in Memphis where it was like fresh like this just happened.

    Dr. Sharp: Wow.

    Dr. Julia: And so just be a little more mindful of how we speak and how we act and how quickly we kind of move through our clinical process. Like checklists, we’ve got to get this done. That might be something that I’ve had to teach myself to slow down. I don’t have to get it all done right now.

    I might have to call you back later. You might have to come back again. Like that’s okay. Because we’re getting really good information. We’re making you feel comfortable. And at the end of the day, it is going to be more efficient because if you’re making everybody feel more comfortable and open and you’re going to get better information and it’ll probably be easier to do the feedback than if you just decide on your own that you have this disorder and here’s what I’m going to push on you.

    Dr. Sharp: Of [00:16:00] course. Is there anything to say about the timing of a trauma assessment since you brought up that idea of something being fresh or not? Does the timing make any difference in how you approach it?

    Dr. Julia: Yeah, well, I think there are separate maybe questions like what is… more of a diagnostic question of like, how much is this impact? And of course, like there’s the timeline like one month, six months, whatever. But maybe an underlying issue or question is, okay, so maybe an ethical one like, I, for example, will not evaluate someone who has not finished their CPS investigation. So if something just happened and you are still in an ongoing investigation, I will not see that child for an assessment because I do not want to mess up what they’re telling the person. And I also don’t want to get called to court because I’m not a CPS investigator.

    Dr. Sharp: Right.

    Dr. Julia: So I think that’s like a huge thing. If you have kids that are… I often get calls from former students or student is in the schools and they’re like, well, I think this kid [00:17:00] was abused, but like, okay, well here’s the thing. You’re not a CPS investigator. So if you really have enough suspicion that you are concerned then you have to report that, right? But if you’re just digging and almost in a gossipy way, we’re not going to search. I’m not going to press. Most of the kids I’m talking about today that I assessed, there’s already a known history and everybody knows that, right?

    Dr. Sharp: Yes.

    Dr. Julia: I’m not going to go digging. And again, if it rises to the level where I actually do suspect abuse that hasn’t been reported, of course, I report that. I’m mandated to report. But I’m not going to go do some five-hour shot to try to get at some repressed memory that they don’t have. So I think that’s important too.

    We’re not assessing “trauma” in the sense of we’re digging for something that happened.  We are saying, given that we already know something happened, what are the effects? That’s a really important distinction, I think is, I don’t know.

    Dr. Sharp: Yeah, it is. [00:18:00] Yeah. Thank you for making that explicit. I wasn’t even thinking about that difference. No, but that’s an important distinction. Yeah. I mean, it’s not like we’re trying to dig in there like you said.

    Dr. Julia: Yeah. Well, I think at first it’s almost really intriguing. I could figure out if that and especially with adults, like, Oh, is there something here? Well, I keep quoting this therapeutic assessment because I just want that training, but like if that’s not a door that they have opened, I’m not going to barge in there.

    Dr. Sharp: Yeah. I love that model. Yeah. I did want to ask just a little as we were talking about the sort of approach and ways you might do assessment differently. Anything around just like physical proximity or the way you set up the room or doors being open or not just little things like that, is that different with you?

    Dr. Julia: I try to think of [00:19:00] it, like all kids because they’re all squirrely, so it really is individual, but of course there are some principles. I always just go back to autonomy and choice. Like if I’m not sure, I ask them, Like do you prefer… I always tell them to pick a spot. That’s part of my thing.

    Right now during COVID, we have these long six-foot tables and I’m always like, okay, there’s a cheer on either side. Which one do you want to sit in? But I do know there are people who don’t like to sleep on the side of the bed, that’s by the door, or don’t like to sit in the chair that’s backed up to the door.

    And I think that can be true. But if in doubt I’ll ask them. And if it’s a small child, I guess I’ll just default to… you can see the door. In our clinic right now it’d be hard to have everyone’s door open, but we do have white noise machines and stuff if they’re really uncomfortable. And sometimes I’m really big about like, Hey, your mom’s right here. Let me show you the room she’s going to be in. She’s going to be [00:20:00] right here at any time you want you can go and talk to her. So yeah, the physical. It’s weird right now because of COVID because like I said, we default to six feet and a mask. So it’s a little easier.

    Dr. Sharp: Yeah.

    Dr. Julia:  Because it’s everybody.

    Dr. Sharp: That is true.

    Dr. Julia:  So I think that’s awesome to be mindful of all those levels, right? Like conversationally, physically your body language. I try to talk to them like a person and not like a clinician. I mean, I try not to be too doctory.

    Dr. Sharp: Yeah, a little more informal. Certainly.

    Dr. Julia: Yeah, we used to train… in Memphis we had a couple of interns that would come and they would wear these giant diamond rings and we’d be it’s up to you but the population you’re working with, you really got to think about do they trust you and think of all the people they’ve encountered that have really nice suits and high heels. Not that’s bad. You’re totally welcome to do it but just think about obviously the SES level and their comfort level with you. And if you’re with kids, like, I [00:21:00] wear like jeans I get on the floor, you know? I think it depends definitely or if I have like a super educated family just adopted I’ll put on my blazer that day or what, so the parents feel more comfortable. But it’s a case by case, I think that’s the take-home with trauma, especially. There’s no blanket recommendation. It’s just being very aware of all levels of communication.

    Dr. Sharp: Yeah. Well, I think that’s important. We talked in our chat a little bit earlier just about being flexible and a lot of these cases. And I think that’s a good rule anytime when you’re working with kids or adults for that matter. But just being flexible and willing to adapt if you need to and reading the room and not coming in with sort of a rote approach.

    Dr. Julia: Yeah. Like I said, I can’t have a standard. I mean, I have my go-to which we’ll get to that hopefully, people listening for like, come on, tell me the tests. [00:22:00] But it’s really hard to have a standard battery, right? Like it’s constantly evolving and we’re also just getting new research about this stuff all the time. So it’s hard to keep up with.

    Dr. Sharp: Right. Well, let’s talk more nuts and bolts. I think people are probably interested in that. So just right from the beginning, are you interviewing the parents first or the kid first? Are they together or are they separate?

    Dr. Julia: I didn’t even know this was a thing until, so when I was in academia for about four years before I went into private practice we were part of a clinical school combined doc program. And it was so interesting because we have an on-campus clinic where we serve the community. And I learned so much about like, this is how I was trained to do this. For example, in school, psych, we were always trying to interview the parents separately first, and then we would do the kid, but clinical, they’re like, oh no, we always see the family together so I think people have preferences.

    When there’s a history of trauma, particularly if it’s a younger child, I definitely at least want to talk to the parent first to [00:23:00] see what is the trauma? What’s the deal? Of course, you can get records. I know when I worked in Memphis or in the schools, I think it’s really important to get a ton of records because you may not have the accessibility that I have more in private practice to actually talk to the parents. In a school it’s like, well, I don’t know. They’re not going to come up here during work hours. So maybe I need to get more records to support my stuff. But yeah, I’m usually interviewing the parent first right now on Telehealth. I know that you guys say all the time, you do two-hour interviews and I’m working like. I don’t know how to fit that into my schedule yet, but I usually have to break it up where I’m going to talk to the parent for about an hour. I might have to call you back at some point this week.

    And I usually interview the kid in person if I can wait. Right now during COVID we basically do an interview on Telehealth. I have them fill out a ton of background stuff like forms. I tell them before we even talk, I want you to send me all your records. Like anything that you have. And so I try really hard to [00:24:00] have a really good idea before I even interviewed them. Like what the records say.

    Dr. Sharp: Yeah. And what are you asking on those forms? Is it really digging into details around this family?

    Dr. Julia: No, no, no. Usually, the… well, I guess I can’t say usually because it’s a case by case, but if the trauma is a big question it’ll be on their intake. Like we have SimplePractice, so we have people intake what…, and I’ve put in there the TA, what questions do you want to answer? And so trauma is a big piece of that usually, I’ll see that pop-up. Every now and then it’s slipped in. And we actually have one question on her intake that says, has your child ever experienced any trauma? We give a few examples, like abuse, neglect, shootings, violent incidents. And some people will leave at Blank, which is usually okay, I’m going to follow up on that. Or they’ll just write something really quick. Like sexually abused by grandpa, like, well, what?  And other people will write like three pages.

    But [00:25:00] I do like to have that question in there just to see what I’m looking for because I shouldn’t say a lot of the cases that I see now, especially in private practice, like they’re not coming in for “trauma” right? Like it’s just like a by the way, also this happened. So yeah, we get some information.

    There was a time in our clinic at the university where we were screening everyone for ACEs because, at some point that was the guidance, I think maybe five years ago. I stopped doing that because now there’s some information saying I don’t know if you’ve heard the mammograms, you’re over screening and you’re sending a lot of people through a lot of testing that they don’t need.

    And so we were over screening and I think so we don’t do that anymore. I just asked very vaguely, is this a question? And then in the interview, I don’t start with that. Right. We go through the developmental history as we go through all the kind of normal stuff that you would ask anyway.

    And then the trauma thing I leave for the middle-end if that makes sense. If they’ve already felt a little more comfortable with me. [00:26:00] If we haven’t gotten to it, but I think it’s important and I’ll say. Hey, would you come in? Would you mind if you and I talked a little bit before I tease Jimmy or whatever? Sometimes they’re more comfortable.

    I’ve had adults lean over on Telehealth and be like, I don’t want to say right now because my parents are home, but I’ll talk to you when I get there. I also always tell like older kids and adults, Hey, I’m going to be interviewing today. Just so you know, confidentiality is different from an assessment.

    I do write things down on the report. If there’s ever anything you’re talking about that you do not want me to write down, please tell me. And I was afraid to do that at first because I thought, well, what if there’s a really important, whatever. But actually, it hasn’t been a problem like people… Like, I had one girl recently who like, doesn’t mind about the actual trauma stuff.

    She just didn’t want me to write down her opinions of how her mom handled it, which is fine. Right. Like that’s not that doesn’t need to be in there. Like she was really unhappy with her mom’s [00:27:00] view of it. And so I’m not going to put that in there, but should I just make them aware, like I’m writing this down and so they know.

    Dr. Sharp: Yeah. Again, that full disclosure, just making sure that they know what to expect.

    Dr. Julia: yeah, when I’m writing a report.  Can I imagine this girl who’s eight now reading it when she’s 18, is she going to be like, wait, what? So try to make it a little sensitive.

    Dr. Sharp: That makes sense.

    Dr. Julia: Like what you need to know about it. What’s it called? You need to know the basics. Yeah. Like if it’s not something that’s absolutely necessary, I try not to put too much Interpretation in there.

    Dr. Sharp: Yeah, sure. I think that’s something that I personally forget and have to constantly remind myself that these kids are going to grow up and even though they’re seven now when they’re 18 or 20, they might look back.

    Dr. Julia: Yeah, I know me too. I’m always like I’ve gone in and rewritten pull reports right [00:28:00] before feedback cause I’m like, Oh my God. Sometimes I just get that I wrote in my template, whatever I’m feeling super awesome about all the amazing things I’m saying. And then the next day, like, oh my God I don’t need to say all that.

    I just need to say, this is why they need the criteria. And then I’ll talk to them verbally about some other things. I might have some side notes, but it’s hard to remember your audience when you’re sitting in front of a computer at 3:00 AM or whatever.

    Dr. Sharp: Right. Yeah, I’m sure there’s nobody out there that can identify them. Right. So how about the battery? What does that look like?

    Dr. Julia: This is something really exciting to me. So when I was in academia, one of my specialties was measurement, so I get really excited about the section.

    Dr. Sharp: Oh, you’re one of those kinds of people?

    Dr. Julia: Yeah, I know, right? So like I said, that was the alluring part of grad school was like, Oh, measurement.

    I remember one of my first assignments, my advisor Scott Decker at USC was like they want us to update this IQ test called the WJ. And like, would you help us with the questions? And I was like, [00:29:00] wow you’re you want me to help you with like IQ test questions? So I always get a little excited. Isn’t that cool? It turns out I was just an RA, low level. It wasn’t as exciting as you think, but anyway, just to say this exciting and I’m also a collector of scales. So I like to recommend a bunch. But I’m going to break it down by the event, the experience, and the effect.

    I usually start backward with effect because I always say, this is the stuff you’re collecting anyway, like the functional impairment, the stuff you get from the interviews. In schools, we were taught like RIOT- So record review, interview, observation, testing, not that that’s the order, but like you should be getting something from all those categories.

    Within each of the Es’ the event, the exposure, the effect, try to get RIOT data for each of those things. So for effect, if I’m looking at records, right? [00:30:00] Like for a kid is the impact on their grades? Is their family fighting? Are there arguments at home? Socially, how are they doing with friends? And then interviews will tell you the same thing.

    Observation, how are they with me? And then there’s testing, the stuff we already do, like IQ testing, achievement some of the personality tests, what are the… even I think comorbid stuff kind of goes in this thing too, like in the effect category because maybe they have depression, anxiety on top of some of the other things they’re dealing with. So that’s first because that’s what we already know. And I guess that doesn’t mean like chronologically first, but necessary. So it’s just something I think about first because I’m already collecting this data anyway. So there’s nothing different I’m doing for any of that really.

    The two pieces that are pretty specific are the event and the experience. So I think of that as the event, being an exposure, that criteria A, what is this event? Tell me more about [00:31:00] it. And that like you said, it’s mostly like the interview. I as a rule as well in a setting I’m in now, when I was in a setting where we were contracted with DSP, I would go into more detail because we were privy to it because we had the DPS, whatever your state calls it, the department of children’s services.

    We had those records, but now I don’t get any more detailed than I need to know you have experienced something that was really scary, right? And this was the general nature of it. This isn’t therapy. So I’m not going to make you sit here and process your entire trauma. I think that’s important, but there’s a couple of standardized ways you can get at that too.

    Dr. Sharp: Yeah., can I ask a question about that that you might be ready to answer or about to answer? How do you balance that sort of general discussion of the event with sort of need to document it [00:32:00] in enough detail to either reach a diagnostic threshold or inform intervention?

    Dr. Julia: Yeah, if it’s the parent or a collateral source, I honestly let them tell me as much as they would like. And if it’s very brief or they’re avoiding it… That’s actually rare than I would think when I started. But I try not to pry, but I will say at a bare minimum, I just need to know what happened with whom not the names, but was it someone related?

    And the reason is that I’m guided by that research that says, which we haven’t gotten into, but these mediators, right? So if a child or a person experiences a potentially traumatic event, there are certain factors we know that will make it more or less likely that they are having PTSD symptoms. And some of those are like being a girl. Yes, be a girl already having an existing mental health condition, having household dysfunction. [00:33:00] There are some pretty specific ones for like physical abuse if it was chronic. And then for a sexual abuse trigger warning, but if there was penetration or someone they trusted and loved and knew that typically leads to worse outcomes.

    Those are the things I’m trying to get at just to evaluate the risk level. How far do I need to go? And then definitely how old were they or when it started and stopped, just so I can see developmentally what the timeline is. I think the general things you look forward of it, onset duration, all that stuff.

    But, yeah, that’s usually about as far as I go. I do not put other people’s names in the report. Again, I’m not the CPS person. I document Barey Hep so special when we were in Memphis, we learned document very heavily where I got each piece of information according to records, according to mom, because very often, let’s say like foster mom gives you a story that you’re not sure if you know, well, mom used to crack and have it. I’m not sure if that’s true. So I’ll just say, according to mom, [00:34:00] there was drug use during pregnancy. And then I just stopped. I’ve learned to like, just period. There’s like this inclination to like, explain that, but it’s just like, period. Okay. She said that I’m not arguing with it. That’s what she said.

    Dr. Sharp: Yes.

    Dr. Julia:  So, yeah, that’s about as far as I’ll go. And then we have some exposure measures, so there is a variety. I’m a big fan of using free things. There’s this great article and I forget the author, but it’s called free, brief, and validated. And it’s a big modern analysis of all these freely available measures for everything for youth and adults, for anxiety, depression, but trauma also. So I try to like pick from there as much as possible, not as much in private practice where you have resources, but my people in schools and forensics, or wherever else, it’s nice to have those. So there are some that are valid. 

    The best two places to go to get measures in general for this stuff for adults is the PTSD [00:35:00] center site and they have all the different life events scale that talks about exposure and they also have symptom measures. For children, it’s NCTSN- the national child traumatic stress network. They have in-depth reviews of all the measures like how many items, is it appropriate for or do you have to pay for it? So those two. The ones I usually use with kids used to be the Northshore. It’s got a really long name. It’s like the Northshore New Jersey health systems… but it’s basically a big yes-no thing. And it’s worded like a checklist. Like you could just hand it to someone, but I use it as an interview. So I just say. Hey, a lot of times scary things happen to people. I’m going to ask you these questions.

    And I’ll do this, even if I know, or the parent told me what the event is just because I want to see what the kid says. Because they’ll often be like, Oh, well, I was bit by a snake and they’ll report all these things. So at the end of exposure measures you want to… before we [00:36:00] go to the symptoms, you have to pick an index traumatic event.

    So like, when you’re asking questions about symptoms like flashbacks, or you talked about being in the hospital, right? What is the index event? And for a lot of complex trauma, it’s like, I don’t know, my whole childhood. But it’s funny. They’ll usually say like the snake bite or whatever, because to them all the other stuff was normal because it was happening all the time, but that’s a long way to say you’re getting at the exposure even if you already know, just to see like what the person themselves feels is the most… because that’s the experience piece. How did they experience it? How did the people around them react? Which we know is a big predictor for kids. Like when your kid falls down and they wait to cry until they look at you and then they’re like, how is she seeing this? Oh, okay. Must not be a big deal. That’s huge like. Did people believe you when you first said it? Did you have to go downtown and do 50 investigation interviews? That can be really… So all those events are on this little form.

    [00:37:00] So the North Shore and then there’s another, well, there’s a bunch that I’ll send to you, but there’s a bunch of exposure measures you can use. And some of them are connected to the symptom measures. The CPSS is another one, the child post-traumatic stress syndrome scale, and that one has the exposure and the symptoms and it’s free. I don’t know of any exposure ones that are actually standardized and paid for because I think that’s the more subjective piece.

    So exposure, check, we got that. All right. We know you’ve been exposed to potentially traumatic events. You’ve met this criterion which we talked about, like philosophically in the report. I’m very brief. And I put it in the measure section. This person was administered this measure, they endorsed being bitten by the snake, blah, blah, blah. And I try to word it as clinically and being inexperienced for physical abuse from ages three to five from their father or whatever. And then I just leave it at that. Then the next section I say, because of this reporter exposure, [00:38:00] we did some symptom measures and there are also free ones that have kind of cut scores like the CPSS.

    And it’ll give you an overall cut score for… and this is for PTSD, but it also is really nice to score qualitatively to see, even if they don’t meet criteria or whatever, I don’t meet the cutoff. It’ll have the categories, which I think is helpful. Like how many intrusion symptoms are they having? Like intrusive thoughts, reenactment through play, those kinds of things. How much arousal and hyper or hyporeactivity are they having? Cognitions and mood alteration all of the different symptoms, avoidance is the other one.

    So it splits them up really nicely. You can talk about it in the report, and with the parents that these are the four categories that we think of as post-traumatic stress. And like your child is really showing a lot of avoidance, but maybe not some of the other ones. So although they don’t technically meet the criteria, they are showing some symptoms. And I usually word it by the way like PTS symptoms, rather than [00:39:00] PTSD symptoms, just a small wording change. But just to say I don’t know because I think when people see in the report, Oh, you’re looking at this disorder, then later, it’s harder to explain if your diagnosis on the page…

    Dr. Sharp: Doesn’t make sense.

    Dr. Julia: It’s more of a qualitative, like yes, you’re having these symptoms. And that might be just a remnant of when I was in the schools that we weren’t allowed to say PTSD. So symptom measures would get those four categories. I was laughing because I heard like the podcast is sponsored WPS, and I did not get money from them at all, but like we always have used their measures so that the trauma symptom checklist for young children, TSCYC is one of the only ones I know of that is a symptom measure for PTSD that also has norms. So the CPS doesn’t…

    The other one I forgot to mention is the UCLA PTSD reaction index which is now I think a paid measure, but those are cutoff scores. And [00:40:00] they give good qualitative information, but to really get standardized scores that TSCYC is great. That’s the one that’s the apparent report I think like younger ages. And then I think 8 to 18 maybe can do to self-report version. There’s a little overlap. So that one’ gives you all four categories of PTS symptoms and also like an overall PTS score. But it also gives you a score for anxiety, depression, anger, and aggression, dissociation, and sexual concerns.

    So it’s like all this extra nice stuff that you get. And you can actually say. Hey, we know that she didn’t meet the cutoff, but look compared to other kids she’s like having this 99th percentile of women’s symptoms. So that might be something to look at.

    Dr. Sharp: Sure, sure.

    Dr. Julia: But yeah, those are my favorites.

    Dr. Sharp: Well then. And I’ll just mention that as an aside because they would kill me if I didn’t. Our podcast is sponsored by PAR and just to make that clear and [00:41:00] they do offer that TSCYC and the TSCC as people will hear in the ad rolls.

    Dr. Julia: To think at some point in my life I wanted to work for a text publisher. They just might recruit.

    Dr. Sharp: Well, maybe WPS will call you. I don’t know.

    Dr. Julia: No, no, yeah. but it is good. Those measures are good. And they’re from the 90s. So they haven’t been rewarmed in a while I’m hoping they’ll update them soon, but it’s like all we have. And they’re good. They’re solid. Like I said, those are the only ones for kids that I know of that are normed.

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

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

    Dr. Julia: I know on the MMPI you can get a PTS score too. So that’s something that is newer to me because of the adult population. But you can definitely get some standardized scores to… again, I just think that’s helpful to explain to parents or to the adult themselves, whether or not you meet these criteria you are having these symptoms that are associated with that, and that can inform treatment, even [00:43:00] if you don’t have that diagnosis because that means you need to do some maybe processing of that trauma like in therapy even if you don’t have “classic PTSD”.

    Dr. Sharp: Right, yes. I love that.

    Dr. Julia: Those are the measures. I know I’m probably leaving a billion things out because that’s like a large part of what I train a lot of school people on what measures to use.

    Dr. Sharp: Can I ask about the role of more cognitive measures or neuro-psych measures? Is there any utility in bringing those measures into a trauma assessment?

    Dr. Julia: Yeah, I think they’re not diagnostic, which again, like my big fantasy in grad school was that. And I think my advisor says to we did a lot of EEG stuff and it’d be great if we could just put the EEG on you and then we could say, oh yeah, you definitely traumatized. I think there probably researchers out there who would say we’re going to get there. I don’t know philosophically if that’s possible.

    Dr. Sharp: Well, in that I’m going to go down this rabbit hole because you [00:44:00] brought it up, but isn’t that the whole thing with QEG, Neurofeedback, Brain Mapping, all of that? I don’t think I’m overstepping to say that there are people out there who think they are doing brain mapping and saying, this is a trauma brain, right?

    Dr. Julia: Yes, and I don’t want to…

    Dr. Sharp: The question of whether it’s valid or not, is what…

    Dr. Julia: Yeah, there’s a local one. I won’t name names, but there are like I said, I think in autism and in trauma, I think those fields or those topic areas, it’s like, people are so in need of help and so desperate. And like I said, they just want to help so bad, including parents. But that creates this vacuum where there’s a proliferation of junk. It’s almost like the barometric chamber of trauma. Because like autism, another thing that I do a lot. And so I spent a lot of time with that explaining the different evidence-based treatments and again, I do therapy.

    I’m not one of these, it’s like you have to do every [00:45:00] protocol exactly right. But I do have a heart for these kids, especially maltreated kids. I’m going to get all emotional, but they deserve the best we have. I know that it’s hard because it’s hard to find people and everyone says they specialize in it, whatever sidebar philosophically, don’t all mental health people have to because in some way everything is true. But yeah, there are people…Okay. So I want to be careful because one of my best friends is a neuro-psych and she did her dissertation on neurofeedback, but for ADHD. So it was separate.

    But for trauma, there are people here locally, there’s a large private Institute where they will take your $6,000 to train you on “brain mapping for trauma” And  I two years ago inquired about that trying to figure out for research like, “Is this something we can do?” [00:46:00] And through exchanges, very non-transparent exchanges with the people who really wanted to charge me a lot of money, I found out that the way they do their brain mapping is actually they just interview people and then they code the interview for what part of the brain I think that would go to. But really the thing that makes me very angry is that they present to parents a colorful brain map of all the symptoms and they never explain.

    Dr. Sharp:  Oh yeah, I have seen those.

    Dr. Julia: Yeah, they never explain like, actually, this wasn’t from brain data at all. Or even if it was like, we actually can’t say the level of specificity that they’re assuming. But it’s really sad because that’s an opportunity cost. It’s like a hope cost. Like if you’re a parent and you’re going, Oh, I know what they need. I always joke with my students because, on those reports, the reason I learned about is that someone in a local school sent me one. I was like, “Have you seen this before? What is this?” And we looked at it. Well in that report, they have these problems with the cerebellum [00:47:00] and therefore they need to participate in drum circles.

    And it was like, Yeah, I love music. Like I have no doubt that that’s fun, but what’s the time cost there that you could be getting other services that we know are a little more effective. I want to be careful not to disparage people from trying new things because sometimes with the trauma you do have to think outside the box, but I think it’s really a disservice to convince people that we know more than we do.

    So that’s something that… I guess I’m getting a little emotional about that because it just really can be frustrating. And I know probably even the people that designed it really want to do the best and they want to help, but it can be something that’s very frustrating especially when you get a client who’s been through those things and they’re like, we did this, we spent $8,000 on this and metronome treatment. And then that didn’t work and it’s like, Okay. Well, has anyone told you maybe just talk therapy is what you need? That’s [00:48:00] probably the best we have.

    So anyway, I don’t know if that answers a QEG question. I’m not as familiar with cause that’s what I thought that would be.

    And then it turned out to be coding from an interview, but I think there are people out there who are doing that. And in 10 years, if you all come back and say that worked out well. That’s great.  But I think in the world of autism, we don’t want to oversell our confidence in things, especially as professionals like we’ll lose trust, right? Like, it’s not a gamble I’m willing to take.

    Dr. Sharp: That’s fair. Well, the phrase that stood out to me from all of that was hope cost, and that’s pretty powerful, just something of a powerful thing to consider that parents don’t get invested in kids at a certain age, I think they probably know enough to get invested in something they think might work. And if that’s the best path and we have a responsibility to steer down a different path.

    Dr. Julia: Yeah. For sure. It’s not to say [00:49:00] like, Oh, you shouldn’t do that. I mean, you’re the parent. That’s up to them for sure. But I’m always like, let’s do addition and subtraction. If you like that, keep doing it. If you have the money. Great. But let’s also add on some things that we know are effective like TF CBT, or other trauma-focused therapies that we know to be effective.

    Dr. Sharp:  Sure. Well, now we’ll get into intervention a little bit more as we go along, but thanks for taking that detour. This is a thing I think we all want neurofeedback to work.

    Dr. Julia: Yes, it’ll be so great.

    Dr. Sharp: We all want it to be as amazing as some folks say it is, and maybe I hope that it will be at some point.

    Dr. Julia:  Yeah. I’m with you.

    Dr. Sharp: At least right now.

    Dr. Julia: I hope they come back later and say supplements actually do cure autism. I’ll be like, good. Now we have a cure but I’m a little doubtful.

    Dr. Sharp: So we haven’t talked a whole lot about differentiating trauma from other concerns. I get that question a lot from my supervisees and [00:50:00] even the other psychologists, our practice, podcast, Facebook group. It’s everywhere. It’s like, how do you separate between trauma and ADHD or trauma and autism or trauma and depression. And I would love to dive into that with you.

    Dr. Julia: Yeah. I’m thinking so many things. As you say that question I’m thinking about, yes. I have a friend who will call me sometimes and she’ll say, listen, I’m a neuro-psych, I got this kid with trauma. Oh my God. Like she’ll freeze. I don’t want to go any further. And it’s like, well, you’re not going to mess them up. So I think there is a strong, as we talked about in the beginning, like the temptation to kind of separate everything out, parse out. We love that we’re in grad school, we’re going to parse these things, parse this. And like, unfortunately, I have a regression equation for individuals.

    I think to me, I’ve grown to address that concern more by actually I want to integrate it more. Like instead of thinking of separating things out, which is probably not really reflective of [00:51:00] reality, trying to integrate things. So there’s that part of it, like the watercolor idea, right?

    Like everything’s going together, but again, I know we have to do our boxes.

    So as bad as the DSM is in some ways like there are nice little algorithms and pointers. And so our criteria are really descriptive. So if you’re talking about a criterion and sense use that system as bad as it is. So, if I have a kid or an adult who meets the criteria for PTSD, then they also meet the criteria for a major depressive episode. I’m probably going to give them both. So like they meet that criteria. It’s not a rule-out, that’s a big thing in schools too. Trauma cannot rule out other things. Just because they have trauma doesn’t mean they can’t be depressed. In fact, it probably makes them more likely to have all these other issues.

    But that’s tough because I know we all want the most [00:52:00] parsimonious explanation we want. This is just trauma and everything can be explained by that, but I think we have to be careful about overshadowing of, Oh, we have PTSD so we can explain everything in your life. I see that a lot with autism. So strangely, like you wouldn’t think autism, but there is some overlap with both the social-emotional part and sometimes the repetitive behaviors, the rigidity and if they have both, I’ll talk about both.

    I have a Venn diagram that I made a couple of years ago for people in schools to look at the overlapping symptoms of autism and trauma, which again, you wouldn’t think that is a thing. But it is and especially with people coming out and talking about girls and autism, like, oh my god, how much overlap does dad have? I’ve had a couple of girls now that had both complex trauma and autism. And again, we were talking about uncomfortable too. Like how do we tease this apart? And it started making more sense to me to not tease it apart.

    Let’s just say for the purposes of insurance billing, you have PTSD and autism. And then when [00:53:00] I go talk to your mom and to you, we’re going to explain what that means. And we’re going to inter,…that’s the time to integrate it. Maybe you don’t need that in your report. Even maybe you don’t need that in the insurance billing, but how did one lead to the other? Maybe we can’t say. The timeline, of course, if it’s a single incident trauma, I think that makes it a little easier because of the timeline. Right? So COVID right now in our schools locally, we’ve been training people. There’s a UCLA COVID screening measure for COVID-related trauma. I don’t know if you’ve seen that? It’s free.

    Dr. Sharp: No, oh, someone else mentioned that in a previous podcast but I never looked it up. Thanks for the reminder.

    Dr. Julia: I feel like I should know the answer because I listened to them all. But yeah, there is a measure. And I’ll send you the link, but there’s one for COVID specifically and there’s almost exactly the same one but for just “regular trauma” on their website. Now, they have the full measures but these are just screeners.

    And so those can be really helpful and one thing we’ve been telling people in schools is when you give the COVID screener [00:54:00] measure and it asks about specific things, like, has someone died, have you been quarantined for long periods of time? Various specific things but then we look at the timeline of their symptoms.

    So if you’re being referred for ADHD, okay, well, did you have any symptoms before this? And the annoying thing is that maybe you did, but no one noticed until now, but now you’re at home all day and your mom’s like, oh my God, you are so hyper and I never knew it. Or like online school is exacerbating it. I think that is maybe a question that we can’t answer yet, but certainly, I’m excited to see all the research specifically COVID that comes out, but there is a timeline with the complex trauma course, it’s harder to tell this timeline.

    But I hate to identify with this, but If I go back to behaviorism at heart whenever I’m posed with this like, what box do I put them in? if we’re going to be super logistical about it, then let’s just be logistical. So do you meet the [00:55:00] criteria? Okay. Yeah. You have depression and this other thing is good.

    I think what comes up for people is you have the same symptom and you’re trying to figure it out. For example, irritability or hyperarousal, which is another name for irritability sometimes, right? That’s a trauma symptom and it’s a symptom of bipolar disorder and it’s a symptom of ODD and it’s a symptom of depression. And so, yeah, I think that’s where it just becomes I’m going to take the psychology professor way out, just like that’s where your multiple sources and multiple pieces of data come in because you can’t look at that one symptom and say like, well, that’s definitely from trauma because we can trace it back.

    But I will ask teenagers a lot. I’ll sit there and do a lifetime line with them like I would in therapy, like, okay what happened then? And what happened then? And how are you feeling at that time? And when would you say the concentration stuff started?

    I have a client right now, I’m trying to figure out what the chicken or the egg. And I might not be able to answer that question and I think [00:56:00] I’ll have to be comfortable with that uncertainty. And I’ll have to, at the end of the day, make a diagnosis that fits behaviorally and descriptively, and then explain to the parents and the child.

    One thing that helps with that as well is that when I’m doing these kinds of assessments, I always have a little more couching, a little more caveat in the wording than I normally would. I often have a paragraph for younger kids especially, please note the symptoms of ADHD and trauma can overlap. And so sometimes we’ll almost suggest a test by the intervention like coming back after a year of stable caregiving, or intervention.

    And if the ADHD symptoms have gone away with the trauma, then we know we have our answer, but if they’re still there, then we’ll do some more assessment. And maybe we’ll do more ADHD, specific things. We did that a lot of like. Hey, come back sooner than you normally would because there’s so much that’s changing across development [00:57:00] anyway.

    And then add on the trauma piece add on if they’ve just changed homes or they’re having visits with their bio parents or something like that, that can really mess it up. So I’m learning to become just more comfortable with it. We’re not really sure right now, but here are the possibilities and follow up sooner than you might want to.

    I’ve been offering parents or when I do these trauma ones you want to come back six months from now and let’s talk about how she’s doing and see if there’s more testing needed. You don’t have to go through the whole intake again, let’s just follow up. I think that it’s really hard to do in practice because of the logistics, but super important to follow up because they… especially kids, Oh my Gosh, so many kids that have ADHD and PTSD diagnosis as a five-year-old and then as they grow up, if they get stable caregiving, there’s so much research to suggest that one or both of those things can definitely go away completely. So you don’t want them to be stuck with that if it’s [00:58:00] not accurate.

    Dr. Sharp: Right.

    Dr. Julia: I have some Venn diagrams I can send you. For the people out there that want the diagram, I have one or two. I have one for ADHD and autism that just shows like, what are some common symptoms and at the bottom, it’ll say like, where do you look for this? Do you look in the records? Do you look at the test? I wish there was a nice differentiating test that could just tell you.

    Dr. Sharp: Still working on it.

    Dr. Julia: That’s right. On my next life.

    Dr. Sharp: Well, you mentioned a couple of things in there that I just want to highlight because they’re things that we do as well. One is the testing by intervention and just the implicit message in there is just that it’s okay to not know. It’s okay to not specifically know, but as long as you’re pointing someone down the right path to try, you’re not going totally off in the wrong direction. Sometimes you got to work on the first layer before the next layer emerges [00:59:00] and that’s totally okay. Right?

    Dr. Julia: Yeah, like I said, I’m every day working on comfort with uncertainty, but especially with these guys. I think even more so with adults too because you got this whole history that I have no idea how deep it goes. And like let’s just work on this first. Like maybe your depression is the most salient thing for you right now. So maybe let’s go work on that for what I’ll refer you to some resources. And then later if you’re still… I had one, a couple of weeks ago, an adult who scored real low on that PTSD scale even though I knew she had significant trauma, and she basically gets drawn out by all the other worries. So, okay, at this time, you don’t meet that criterion but come back later and maybe once you’ve addressed some of your other anxiety, that would be something to look at.

    Dr. Sharp: Yeah, absolutely.  Well, let’s see. We have covered so much and I wonder if [01:00:00] we might talk a little bit about the feedback. How you might deliver some of these results to parents or kids. And if there is more to touch on in terms of intervention, we can do that. But I am really curious just about the feedback, particularly around just hard feedback. So just delivering, like, “Hey, this is a traumatic experience, this is PTSD or…” I think about what happens when parents are somehow implicated in the trauma. How do you handle that? Or, either directly or indirectly by neglect or something. So there are a lot of questions in there, but I’ll let you take it wherever you’d like.

    Dr. Julia: Yeah, this is the most complex question.

    Dr. Sharp: Saved the best for last

    Dr. Julia: So I think I’m going to give an aspirational, right? So I’m [01:01:00] not by any means saying that I always do these things, but these are the things that I would try to do.

    One thing is that I always when I started my postdoc in this, I was so terrified of that very thing. Like, Oh my God, I’m going to have to tell someone that like their kid was abused and now they’re going to have a… but to be honest, I’ve rarely come across where I had to give like that big of news.

    So either they already know about whatever the situation is. Mostly, the hard part is maybe they don’t understand how significant that could be or that the behavioral effects could be part of that. So I never say it’s absolutely certain that the trauma causes, but a lot of these kids you mentioned earlier that come out like ODD CD, they’re very overmedicated with like anti-psychotics and things like that. Sometimes not so much now in private practice, but more Memphis, like talking about all these things that you see as manipulative or oppositional, [01:02:00] think about trying to get them in their kid’s head, think about your internal world. You’re growing up these things happen to you.

    You don’t think you can trust anyone. You have very poo delayed discounting. So you want things now. Does it make more sense to you now that they’re stealing food? Often most parents and guardians are I think less reactive than I always expect them to be. They’re always like, we want the best. And so usually they’re like, oh yeah, that makes more sense. And the most common reaction I get is, oh my God, that makes so much sense. Right? It’s like when you give someone a diagnosis like autism and they’re 21 and there, oh my God, my whole life makes sense.

    I find that a lot, especially with parents. I’ve had a couple where the child was maybe abused and they found out about it later and the parent was still dealing with that, which I think you alluded to earlier. And so sometimes you get a lot of tears and like, oh my gosh, how [01:03:00] did I not know?

    I always recommend so not always but I’m thinking of several moms I’ve had who just broke down and they just could not stand the thought that they let this happen. And of course, then you need your own therapy. That’s not going to go in the report, but I really encourage you this is something that you’re going to need support for. So that’s huge getting your own help trying to help them understand that. I know different schools of thought are different on this, but I’m actually huge on psychoeducation that transparency, right?

    I’ll even quote stats to parents. We know that 80% of the people that go to therapy are better off than those who don’t, who have the same thing. So I try to sell it a little bit. And then also a lot of reassurance, in the report I’ll even put any, I learned this in Memphis from my supervisors there, but at the very bottom we’ll put like Mr. So-and-so is to be [01:04:00] commended for The gentle way he has approached this child, the things he’s tried to teach them, just like really reinforcing those things that they are doing really well. Like, hey mom, you’re actually… from the amount of concern I see in your face, I know you’re a good mom.

    I know you’re trying your best. Just that reassurance, that human connection again, I’m not here to just read out your report to you. It is a little therapeutic, right? It has to be sometimes. I know that this is really a hard thing to deal with and man, look at all the things y’all have been through, how have you managed to cope so far? And they’ll say like, well, I guess I am helping her with her homework every day. So just kind of like highlighting all the things they’re already doing that they should keep doing and how important that relationship is. That’s huge. 

    I think my most common rec on kid reports these days of any kind is the special time spending time with your child. Sounds so easy. But as a parent I [01:05:00] know is not always easy, but yeah, just emphasizing that piece of it. Like, Hey, we’re going to give you a bunch of concrete recommendations, but even if you never get to any of these things or none of them work, we know from research that the number one most important factor is a supportive relationship with an adult.

    And so at the end of the day, if you can give them that and continue to give them that. And we didn’t get into rad, but reactive attachment, even a lot of parents will come to me wondering about that. A great article about that. That’s a questionable diagnosis in our field, but even with that, you see these awful news stories, they’ll never have attachments.

    And actually, the research says that after about a year, obviously, this is variable, but there’s actually no kid that still shows symptoms of “rad” after they’ve had a long time in a stable caregiving environment. So we don’t actually think that’s a death sentence. I think [01:06:00] on media and stuff, you see these awful stories of this kid in their room with a knife, and like, he’s never going to be able to have relationships. Well, that’s true, there’s something else going on because most of the stuff that happens with kids with maltreatment. Our Intervention and relationships are so important and as long as they get into that stable, responsive caregiving system, can overcome tons of this stuff without thousands of dollars and on whatever you want to spend your money on. I think that could be reassuring, right?  It’s just your human nature. You’re being a good mom. You’re being a good dad, supporting her.

    Dr. Sharp: Yeah. Well, and there’s maybe a side message in there too. I think about the kids in the foster system where at least in my experience can be rare for kids to have a year of stable placement and just how that’s just doubling down on.

    Dr. Julia: Yes. [01:07:00] That’s the flip side. As I said, look it’s so easy to just have one year of school placement which is not in the cards for some people. So that’s hard. But I guess the hope is we do know that it’s reversible. All this, even the brain level, right? all this stuff now, a trauma in the brain. I guess that’s true. But also neuroplasticity and relationships build up the brain. And we know that. And so it’s not like your brain has atrophied. There’s this famous picture that I used to use in my training and I don’t anymore but you might’ve seen it.

    It’s a brain next to a little brain. And it says that this is childhood neglect and this is a normal child. And so startling and I see it in training all the time, if you do a little digging, which I did, you find out, we actually don’t even know where that kid, it’s not from a study or anything, it’s it was presented in an article as a display which the person in the article is related to the things that I talked about earlier.

    [01:08:00] But you see these pictures of like, Oh my God, its doom and gloom. And I think it’s really important to Change that narrative too, right? It is a horrible thing. But there are also really effective things that we can do. And your natural inclination is extra resilience and a much bigger percentage of people than you would think.

    In fact, the majority of people who actually experienced abuse or neglect, most of them do not develop PTSD. And so the resilience is the default, which I think we forget because that’s so terrible. That motivates us to be compassionate, but also having the hope of we can definitely do something we don’t want to say. Oh yeah, too bad. It’s over for you.

    Dr. Sharp: Right.

    Dr. Julia: That’s really depressing.

    Dr. Sharp: Well, I think that is probably a nice note to close on. A hopeful note that there are [01:09:00] things that we can do, and there is certainly a path out of trauma or at least to a better brain place for kids.

    Dr. Julia:  Yeah. Just like integrating it with the rest of life. And I love the DVT approach of like you can have this and other things. What does that quote, you contain multitudes. Like you can have this and you don’t have to get rid of it, but you have it. And you can also have these other traits and these other amazing things in your life. Addition, not subtraction. I love that.

    Dr. Sharp: Yeah. I like that as well. Gosh, there’s so much. I feel like we can keep talking. There are so many questions. I’m like things we didn’t even touch on, but maybe this is round one. We’ll see. But I really appreciate your time and all your energy. I think it sounds like the show notes are going to be pretty extensive for [01:10:00] this episode. That’s great. We need those resources. If people do want to find you or reach out for whatever they might need in this area, what’s the best way for people to find you?

    Dr. Julia: So I have mental health on Instagram is @drjuliatx. That’s my professional page. And then if you just Google Julia Strait, the website for our practice will come up. We’re Stepping Stone Therapy in Webster, Texas outside of Huston. I have a blog on psychology today called This Emotional Mind. And I guess Your audience is mostly psychologists. So I’d give out my email address and be okay with that. But it’s straitje@gmail.com

    Dr. Sharp:  Well [01:11:00] thanks again. It was great to connect with you. Great to connect with a fellow Gamecock alumni. 

    Dr. Julia: Thank you so much. This is great. I really appreciate the opportunity.

    Dr. Sharp: Okay, everybody. Thank you. Thank you for checking out this episode. I really enjoyed talking with Julia. She knows her stuff so well, and I hope that you took away as much helpful information from this podcast as I did. It’s always a cool experience. Honestly, I have never really talked about this, but this is a great example of just learning through doing. So I go back and listen to these episodes myself because I feel like at the moment I don’t have the working memory. Maybe it is to remember everything that we talk about during the podcast and actually apply it. So this was one of those that I am really excited to go back and listen to, and actually take more [01:12:00] detailed notes and implement some of these strategies in my practice.

    There are tons of show notes, tons of resources. So make sure to go check those out. Now, like I mentioned, in the beginning, if you’re a beginner practice owner and you want to launch a practice in 2021, I would love to help you with that. I’m launching the beginner practice mastermind group starting in March. And this is a group coaching experience for folks who are right in that beginner stage.

    We’ll provide accountability and support and guidance as you launch your practice and really try to help you dial it in so that it is the practice that you want to have. So we’ll talk about marketing and efficiency and scheduling and finances and business pieces that are really important in the beginning.

    You can get more information at thetestingpsychologists.com/beginner, and apply for a pre-group call. You don’t have to apply for the call. You’ll schedule a pre-group call, and then we’ll talk about [01:13:00] whether it be a good fit for you. So check that out. Spots are filling up. I have lots of calls on my schedule. So if it’s interesting to you, I would say jump in quickly and try to get something on the books and we can figure out if this is the right way to support you as you launch your practice.

    All right, everyone, pleasure as always. I will be back. Let’s see, I’m trying to keep in my mind what’s coming up next.

    I think I’m still doing EHR reviews on Thursday. So look for that. And then we’ll be off to another clinical topic the following Monday. So thanks as always for listening and take care.

    The information contained in this podcast and on The Testing, [01:14:00] 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.

    Click here to listen instead!

  • 179. Trauma-Informed Assessment, Part 2 w/ Dr. Julia Strait

    179. Trauma-Informed Assessment, Part 2 w/ Dr. Julia Strait

    Would you rather read the transcript? Click here.

    This episode is part 2 in the trauma-informed assessment mini-series with Dr. Julia Strait. If you didn’t catch the first episode last week, definitely go back and check that one out – we talked last time about how to define trauma: complex, developmental, acute, and everything in between. In the current episode, we dive deep into the actual assessment process. Here are a few topics that we get into:

    • Interviewing for traumatic experiences
    • Measures to assess trauma
    • Differential diagnosis of trauma and other concerns like ADHD, ASD, and others
    • Feedback and report-writing with a trauma-informed lens

    Cool Things Mentioned

    Featured Resource

    I am honored to partner with PAR for the next few months to bring you featured items from their catalog! Listen to each episode for specific product recommendations and links. Learn more at www.parinc.com.   

    The Testing Psychologist podcast is approved for CEU’s!

    I’ve partnered with At Health to offer CE credits for podcast episodes! Visit this link to access current and past episodes available for CE credit. You can use code “TTP10” for a discount on ALL the course credits you purchase from At Health!

    About Dr. Julia Strait

    Julia Strait, PhD specializes in treating young women with everyday stress, as well as more pervasive emotional difficulties related to depression, anxiety, and trauma. She is a Nationally Certified Trauma-Focused Behavior Therapy (TF-CBT) Therapist and has specialized training in mindfulness-, self-compassion-, and acceptance-based therapy approaches for building awareness and understanding of difficult emotions and experiences. She also has expertise in psychological testing and assessment to help with diagnosis and treatment recommendations.

    Dr. Strait earned her Bachelor’s degree from the University of Texas and her Master’s and PhD from the University of South Carolina. She did her postdoctoral training in Child Welfare and Trauma-Informed Care at the University of Tennessee Center of Excellence for Children in State Custody and has worked as a teacher, professor, researcher, and supervisor in schools, clinics, and universities across the Southeast United States.

    In her free time, Dr. Strait loves listening to podcasts, being outside, eating queso, and doing yoga and Pilates. She has two awesome kids and a very cool dog, and she blogs for Psychology Today. You can also follow her on Instagram @drjuliatx.

    About Dr. Jeremy Sharp

    I’m a licensed psychologist and Clinical Director at the Colorado Center for Assessment & Counseling, a private practice that I founded in 2009 and have grown to over 20 clinicians. I earned my undergraduate degree in Experimental Psychology from the University of South Carolina before getting my Master’s and PhD in Counseling Psychology from Colorado State University. These days, I specialize in psychological and neuropsychological evaluation with kids and adolescents.

    As the host of the Testing Psychologist Podcast, I provide private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. I live in Fort Collins, Colorado with my wife (also a therapist) and two young kids.

    Ready to grow your testing services? Click below to schedule a complimentary 30-minute pre-consulting call!

    [x_button shape=”square” size=”large” float=”none” href=”https://app.acuityscheduling.com/schedule.php?owner=13476033&appointmentType=2843005″ target=”blank” info=”none” info_place=”top” info_trigger=”hover”]Schedule Your Call[/x_button]

  • 178. EHR’s for Testing Psychologists: IntakeQ (Basics)

    178. EHR’s for Testing Psychologists: IntakeQ (Basics)

    Would you rather read the transcript? Click here.

    Hey everyone! Given all the questions about EHR’s (electronic health records) in the Facebook Community and among my coaching clients, I wanted to take a few episodes to dive in to some of the major players in the EHR space. Each of these reviews will focus primarily on the testing-specific aspects of each EHR, though I’ll also do an overview of non-testing features that are important. 

    For the FULL review experience, check out the accompanying video on the Testing Psychologist YouTube channel. Enjoy!

    IntakeQ is the star EHR for today. Here’s how the review broke down:

    Pros:

    • Free trial, no CC required
    • Feature-rich for a competitive price
    • Nailed the paperwork aspect of practice
    • Customizable testing notes with a lot of control over the format
    • Option to charge CC automatically on the day of appointments
    • Aesthetics are on point
    • Billing & codes are relatively easy to manipulate once you get it set up
    • Excellent reporting options
    • Integrations and API support

    Cons:

    • Few gender identity/demographic choices
    • Some features were unclear: writing notes, submitting claims, assigning diagnoses
    • Lots of submenus within main menus. No walkthrough at the beginning to get everything set up.

    Verdict: Definitely a possibility as a testing psychologist EHR. Takes some time to set up, but could be very smooth from that point forward.

    Cool Things Mentioned

    Featured Resource

    I am honored to partner with PAR to bring you featured items from their catalog! Listen to each episode for specific product recommendations and links. Learn more at www.parinc.com.  

    The Testing Psychologist podcast is approved for CEU’s!

    I’ve partnered with At Health to offer CE credits for podcast episodes! Visit this link to access current and past episodes available for CE credit. You can use code “TTP10” for a discount on ALL the course credits you purchase from At Health!

    About Dr. Jeremy Sharp

    I’m a licensed psychologist and Clinical Director at the Colorado Center for Assessment & Counseling, a private practice that I founded in 2009 and grew to include nine licensed clinicians, three clinicians in training, and a full administrative staff. I earned my undergraduate degree in Experimental Psychology from the University of South Carolina before getting my Master’s and PhD in Counseling Psychology from Colorado State University. These days, I specialize in psychological and neuropsychological evaluation with kids and adolescents.

    As the host of the Testing Psychologist Podcast, I provide private practice consulting for psychologists and other mental health professionals who want to start or grow psychological testing services in their practices. I live in Fort Collins, Colorado with my wife (also a therapist) and two young kids.

    Ready to grow your testing services? Click below to schedule a complimentary 30-minute pre-consulting call!

    [x_button shape=”square” size=”large” float=”none” href=”https://app.acuityscheduling.com/schedule.php?owner=13476033&appointmentType=2843005″ target=”blank” info=”none” info_place=”top” info_trigger=”hover”]Schedule Your Call[/x_button]

  • 178 Transcript

    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.

    Welcome back everybody to another episode of the Testing Psychologist Podcast. Today is another EHR review. And this is a good one. Today I’m talking about IntakeQ, which a lot of you may have heard of. IntakeQ has been around for a few years primarily as a paperwork system. So they started as a piece of software that would let you send and receive paperwork securely. And a lot of practices have used it as such over the years.

    We use it as such to send our paperwork back and forth. But over the years, IntakeQ has also built out a number of pretty robust features to really compete as a full-featured EHR. So I am talking through the pros and cons. As with all the EHR reviews, the best information is really contained in the accompanying YouTube video.

    That video is about 35 or 40 minutes long. And it’s linked in the show notes and on the blog post. So definitely go and check that out to really get a sense of what IntakeQ looks like. I should also mention that there’s a dedicated Facebook group for mental health practitioners who are using IntakeQ as an EHR. So, there are some great resources in there as well. 

    Before we get into the review, I want to invite any beginner practice owners out there who are planning to launch or just launched their practice to consider the beginner practice mastermind group. This is a group that is going to start in early March. A couple of months, not a month and a half. It’s a group coaching experience where you’ll join five or six other psychologists who are launching or have just launched their testing practices. And the idea is that we provide support and accountability. And I, as a facilitator, provide coaching around getting your practice started and doing so in a way that makes sense for you financially, making sure it’s efficient, making sure you’re using your time wisely, and not getting into any trouble with legal stuff, business stuff, anything in that realm. 

    So if you have it on your plate to launch your practice in 2021, or want to really dial in a practice that you’ve already launched, this might be for you. You can get more information at thetestingpsychologist.com/beginner.

     All right, let’s jump into the review of IntakeQ. 

    Okay, here we are. Let’s get right to it with IntakeQ. 

    Now, these review episodes tend to be pretty short and sweet. Like I said, the real information is contained in the YouTube video. So definitely check that out. But here’s the summary of my review of IntakeQ. 

    Overall, I liked IntakeQ quite a bit.  So, here are some things that went really well with IntakeQ. First of all, just basics. They do have a free trial. It’s only 14 days, but they do a free trial with no credit card required. Their pricing is competitive. It’s priced at $59.95 a month for a full-featured EHR.

    Now, if you just wanted to use it for paperwork which is really their bread and butter, it is only $49.95 a month, but I think it’s worth it to upgrade to the $59.95 to get all those full-featured EHR features. That’s the pricing. It is competitive with other EHRs.

    So I have to say right off the bat, like I mentioned in the intro, this EHR actually started as a paperwork system and they have completely nailed that aspect of the practice. So, this is that whole client portal, getting documents back and forth. They really crushed it. Their system of creating and sending and receiving paperwork securely is fantastic. I can’t say enough about that.

     It allows you to customize your forms or you can upload your existing forms and they’ll turn them into electronic forms for you for a very, very nominal fee. And they’ll do it quickly within three business days. So, lots of options to create and send forms.

    Now, with non-form, like more EHR features, they extend some of that customizability to appointment notes. So you can easily create very customized notes for your testing appointments. You have a lot of control over the format. And since they are kind of a form-based software, we have even gone so far as to create public domain questionnaires and put them into the system so we can send questionnaires via IntakeQ. And you can even set them up where IntakeQ will score the questionnaires. There’s a way to do that. So, it scores that automatically and you get it back from the client securely. That’s a really cool feature. 

    A really small thing that I noticed that jumped out I haven’t seen in any EHR so far is the option to have the system charge a client credit card automatically on the day of the appointment. I have not seen that before. That was really cool. 

    Just aesthetically speaking, I really appreciated the aesthetics. I don’t know what it is about this sort of sky blue or kind of cornflower blue color, there’s got to be research out there, but it seems like this is the color that every EHR is choosing as their main color.

    So that’s on full display here on IntakeQ as well. But they mix in some orange and some green as well. It definitely looks nice. Now, as far as the testing features. I always think about how easy it is to set up appointments into our billing codes and bill for appointments, particularly with the add-ons.

    And so that process was relatively easy. It was a little bit hard to find where to enter CPT codes and how to get those in the system, but once they were in there, it was relatively easy on the note to specify units and charges and add-on codes. Once we got it set up, it was relatively easy. I’ve seen much worse, certainly. 

    Another thing that is great about IntakeQ is that it has really nice reporting options by which I mean revenue reports are broken down by clinician and service and date range, all that stuff. That’s pretty standard. But one of the really cool things about IntakeQ is that you can export the data that you get from the questionnaires.

    So if you’re in a practice that values research or you are trying to get some research off the ground, you can export that data from the questionnaire in terms of gender, sexual orientation, race, ethnicity, all those demographic factors. You can get a report on any question that is on your forms. That was really cool. I haven’t seen that before, and I could see that coming in really handy, especially for testing folks who might be more keyed into research.

    Another aspect of IntakeQ that I really like is that it provides a number of integrations with other software programs. Right off the bat, it has API support. That may not mean much to a lot of you, but basically what that means is that IntakeQ is an open software where if you have the tech knowhow or the interest in hiring someone, they can write software or a program or whatever to connect into IntakeQ and pull data from it. That is not the case with a lot of the EHRs which are pretty closed to outside systems.

    Related to that there are a lot of integrations with IntakeQ. So they integrate really well with Google drive. That’s one of our favorite features. IntakeQ will automatically create a client folder and upload their intake forms to our Google drive when the client submits the forms, that’s pretty cool. But they also have a lot of other integrations. They have an integration with Zoom, with Zapier, with Sr fax. So you can fax documents directly from IntakeQ. That’s a cool little feature.

    There are a number of pros with IntakeQ. It has a lot going for it, that’s for sure. And one of the things that really jumped out was the ability to create custom testing notes. That’s something that a lot of the EHR struggles with. Let’s take a quick break to hear from our featured partner.

    The Feifer Assessment of Writing or FAW is a comprehensive test of written expression that examines why students may struggle with writing. It joins the FAR and the FAM to complete the Feifer Family of Diagnostic Achievement Test Batteries, all of which examined subtypes of learning disabilities using a brain-behavior perspective. 

    The FAW can identify the possibility of dysgraphia as well as the specific subtype. Also available is the FAW screening form which can be completed in 20 minutes or less. Both the FAW and the FAW screening form are available on PARiConnect – PAR’s online assessment platform allowing you to get results even faster. Learn more at parinc.com/faw.

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

    Now, as far as the things that did not go well with IntakeQ, we can talk through those. There is not a ton, but they are noteworthy. Like some other EHR that I have reviewed, there are very few demographic choices. This jumps out particularly with gender identity and sexual orientation. Those kinds of questions. There’s not a lot to let people choose. Oh, sorry, there aren’t a lot of options to enter the system.  Now, you can, of course, put all the options that you want on the questionnaires that you develop and send out. But as far as actually putting client information in the system, those don’t really exist.

    The other piece and this is something that’s come up across several EHRs, is that the navigation was a little tough. I was able to get around pretty well, but I did run into some bumps when 1) I couldn’t figure out how to assign a diagnosis to an appointment or to a client. And I didn’t want to spend the time on the review to stretch it out any further to figure that out but it’s not super intuitive. It’s not like it just gives you the option on a note. Unless you put that field in the note, it doesn’t just give you an option to assign a diagnosis to an appointment or to a client.

    The other thing, it wasn’t super clear to me how to write notes without clicking on each individual appointment. There is a task list in IntakeQ, but I couldn’t get it to populate with my appointment notes. And that could have been me doing something wrong as a beginner, but it wasn’t, again, super intuitive. 

    The same thing applied to submitting claims.It looked like the easiest way I could find was to just click on each individual appointment and submit the claims that way. That wasn’t super smooth.

    Related to the navigation, there are a lot of main menus, first of all. And then there are a lot of sub-menus within those main menus. And then paired with the fact that they don’t really do a walkthrough at the beginning to get everything set up for your practice, it can get a little bit overwhelming. And you’ll see this if you look on the YouTube video that I could’ve just kept clicking through menu after menu to keep filling in information.

    It would take, I would guess maybe an hour, in the beginning, to get everything set up, and then you’d be ready to roll. But there was a lot to click through just to get your practice set up. And it wasn’t always super clear. I feel like they could have maybe condensed some of those menus together, But generally speaking, the overall verdict with IntakeQ is that it is definitely a possibility to use this EHR as a testing psychologist.

     I think as I said, it would take some time to set it up, but from that point forward, I think it would operate pretty well. There are a lot of pros, if nothing else, the paperwork feature is a huge draw and you can make the rest work for you if paperwork is super important. But there are plenty of other things to get on board with as well.

    And my impression and perception of IntakeQ are that they are just pouring research and money into developing these EHR features. They’ve recognized that there’s definitely a market for an EHR that’s built around the paperwork system and they are taking full advantage of that.

    My guess is that the features are just going to get better and better. I would say it’s definitely a possibility. I would keep that in the running for an EHR if you’re a testing psychologist, just depending on your needs.

     Like I said, the YouTube video is linked in the show notes. There’s also a link of course, to IntakeQ and there’s a nice list of the pros and cons that I’ve discussed.

    So make sure to check those out. And like I mentioned at the beginning of the episode, if you’re a beginner practice owner who has just launched or is hoping to launch a practice in 2021, I would invite you to check out the testing psychologist, beginner practice mastermind group. And this was a group coaching experience just for folks who are launching their practices.

    It is about five months long. It’s 10 sessions. It’s a group coaching experience where we will hold you accountable and give you a cohort of folks to go through this process with. So you’re not alone just to make sure that you are crossing the T’s and dotting the I’s and setting up your practice to work for you instead of the other way around. So if that sounds interesting, check it out at thetestingpsychologists.com/beginner and you can schedule a pre-group call there. 

    As always, thank you for listening. This episode is number five out of six in the EHR review series. I will be concluding the series next week with a dark horse EHR. That is new on the scene called Jane. Hearing good things about it. So I’m eager to check that out and if you don’t want to miss an episode we do a clinical and a business episode each week. If you don’t want to miss those, subscribe to the podcast and whatever podcast player you might be listening in.

    Always a pleasure y’all. Hope everybody’s doing well. And I will catch you next week.

    The information contained in this podcast and on The Testing Psychologist’s 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.

    Click here to listen instead!

  • 177 Transcript

    [00:00:00] Dr. Jeremy 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 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. You can learn more at parinc.com

    All right, y’all, welcome back to another episode of The Testing Psychologist podcast. 

    Hey, this is the first episode in a little mini-series on trauma-informed assessment with Dr. Julia Strait. I’ve been meaning to talk about trauma on the podcast for a long, long time. And, honestly, I  had a hard time tracking down an expert. I’m so thrilled to have Julia on for this two-part mini-series where we’re going to be talking all about trauma and assessment. 

    So part one which is what you will hear today really focuses on the definition of trauma. So we’ll talk about acute trauma versus developmental or complex or ongoing trauma.  We’ll talk about trauma and what it looks like in kids versus adults in terms of outcomes and presentations and so forth. One thing we’ll also get into is the idea of concept creep. So this is the idea of how you delineate between “real trauma and just events that were traumatic” if that’s even a thing. So, as you can see, just asking that question is an interesting sort of philosophical question to consider that has real implications. So, we’ll dig into that quite a bit as well as how we define trauma. Is it according to someone’s personal experience or diagnostic criteria or what?

    [00:02:11] So, in part two, we’ll focus more on the assessment component. I will talk more about that when the episode is released in a week. But for today, we’ll do a nice deep dive into the nature of trauma, how it’s defined, and what we might be looking for in our assessment process.

    Let me tell you a little bit about Julia. Julia is a psychologist. She specializes in treating young women with everyday stress, as well as more pervasive emotional difficulties like depression, anxiety, and of course, trauma. 

    She’s a nationally certified TF-CBT therapist, that’s Trauma-Focused Cognitive Behavioral Therapy. She has specialized training in mindfulness, self-compassion, and acceptance-based therapy approaches as well. She does a lot of assessments and she conducts training around the country for schools that are trying to integrate a more trauma-informed approach to their work.

    So Julia earned her bachelor’s degree from the University of Texas and master’s and Ph.D. from the University of South Carolina Gamecocks. She did her post-doc at Child Welfare and Trauma-Informed Care at the University of Tennessee Center of Excellence for Children in State Custody. She has worked as a teacher, professor, researcher, and supervisor in schools, clinics, and universities across the Southeast United States.

    [00:03:37] In her free time, she likes to listen to podcasts, go outside, eat Cayson and do yoga and Pilates. She has two kids and an awesome dog. And she also blogs for Psychology Today.  The link for that is in the show notes.

    All right, before we get to the episode, as always, I want to invite any beginner practice owners to check out the beginner practice mastermind which is a group coaching experience just for beginner practice owners. So, if you’re looking to launch your practice in 2021,  this might be right for you. This group will be starting in March 2021 with six psychologists. The group is really aimed at building accountability and helping you solve those problems that might be tough to solve on your own. If you’re interested, go to thetestingpsychologist.com/beginner and check it out. 

    All right, let’s jump to my conversation with Dr. Julia Strait.

    [00:04:53] Dr. Sharp: Julia, hey, welcome to the podcast. 

    [00:04:55]  Dr. Julia Strait: Hello. Thanks for having me on. 

    [00:04:57] Dr. Jeremy Sharp: Yes,  of course. Thank you so much for reaching out. It’s nice when guests pursue me instead of the other way around. So, I really appreciated that.

    [00:05:09] Dr. Julia Strait: Yeah. Well, I’m a fangirl of the podcast and podcasts in general. So I was like, hey, I think I can talk about something, right?

    [00:05:17] Dr. Jeremy Sharp: For sure. No, I love it. And then, as we got into some conversation, we figured out that we have a connection in Columbia and South Carolina which is very cool.

    [00:05:26] Dr. Julia Strait: That’s right. Best city in the world. I feel like, I don’t know, maybe Gamecocks.

    [00:05:35] Dr. Jeremy Sharp: Maybe too. We’ll leave it at that. I love it. We’re here, we’re going to be talking a lot about trauma-informed assessment. I’m really excited to dive into this. I know you’ve done a lot of work in this area, a lot of presentation and education. This is a topic that shockingly has not been covered in-depth on the podcast yet. So, I’m really thrilled to be able to have this conversation here today. 

    [00:06:03] Dr. Julia Strait: Well, yeah, I think that’s widespread. We did a study two of years ago, a survey of all school psychologists which you would think in schools it would be a bigger topic- which it’s becoming bigger, but we did a big survey and like, 80 to 90% of school sites said, “Yeah, we’d like to do this stuff.” I feel like I have some knowledge to offer. But a very small percentage of them felt that they actually had training or support enough to do it. And so, hopefully, that’s changing. 

    [00:06:33] Dr. Jeremy Sharp: I hope so. Well, and hopefully this will be a part of that change as well, and just exposing more people to the info. 

    [00:06:38] Dr. Julia Strait. All right.

    [00:06:39] Dr. Jeremy Sharp: So let me start just with a standard question to open these kinds of podcasts which is, why is this work important to you in the first place? 

    [00:06:51] Dr. Julia Strait: Great question. This is the origin story question, right?

    [00:06:56] Dr. Jeremy Sharp: Yeah.

    [00:06:57] Dr. Julia Strait: Superhero. Well, I’d be lying if I said that it was not personal at all. Definitely,  I don’t necessarily have a trauma background, but I definitely have had people close to me who have, and so that’s always been in the back of my mind. My original career was I was a high school teacher and I worked with a lot of kids who had varying degrees of traumatic things and circumstances. I was really always fascinated and wanted to work more with kids on that level which is why I went back to school.  

    I went to the University of South Carolina in the great city of Columbia, South Carolina to study school psychology so that I could unite this interest. When I got there, I was like, I’m just interested in everything, and my advisor convinced me to do more of the research side, neuro-psych. And I think, looking back, I was like, well, this is a sure bet. These things are objective. This is less wishy-washy. I want to stay far away from the emotions and the counseling and the trauma like that, it’s interesting, but it’s just hard to deal with it.

    And so, I really heavily pursued neuro-psych and cognitive development research and all kinds of just avenues that way. But along the way, it kept coming after me. So I feel like everywhere I went, trauma kept coming after me. So, in my first practicum in the schools, I had a very easily LD  only right? And we had a case, we were sitting in a meeting for report feedback and this girl, we were prepared to say she has a learning disability, and at the meeting, 6 people showed up that we didn’t even know were in her network. one was from family services, one was from it,  and we had no idea. Her records didn’t show anything. And it turned out she had this long history of abuse. And so we had to say, “Let’s go back to the situation room and revise.” But everywhere I’ve gone,  people are always like, “Oh, we don’t have that here. You don’t have to worry about that here. Maybe you’re just not looking, right?

    So, that’s really fascinating in the fact of just human psychology where people can convince themselves like, “Oh, yeah, what I do is totally separate from them” which I had to kind of convinced myself like, no, neuro-psych is really totally separate. Of course, it’s not. The brain, all of that. So getting ahead a little bit, but I came to my senses a couple of years later and did just a full postdoc at the University of Tennessee Center of Excellence for Children in State Custody, we call it the COE. And it’s part of the UT health science center. I don’t know if listeners, like if you’re in the school psych world or clinical, they have an APA internship there at the Boling Center for Developmental Disabilities, but our branch was… we only worked with kids who were in custody or at risk of coming into state custody.

    And so, pretty much everything I know, I learned there about how to actually intervene, how to assess. And we did tons of assessments for kids all the way like 2years and up who had come into state custody and were having either developmental problems, emotional problems, the whole range, that’s where pretty much I learned everything I’m going to talk about today. And people there were absolutely amazing like just a big group of psychiatrists, nutrition people- a very multi-disciplinary team. So that got me very interested in it. And when I went into Academia, which was what got me back to Houston,  I chose to study ACEs and some of the trauma literature a lot more. I kind of shifted and bridged that.

    [00:10:36] And we did a lot of studies with my students on like college students who had had these traumatic experiences and how were they coping? And also, how are their executive functions? How has their cognition, so how can we bridge these things?  And those things are still actually going on at the university that I’m working with students on. So this year, I decided to just do private practice because I really wanted to get back to how we were in Memphis, like actually getting to see the kids, actually getting to work with people, that was really important to me. 

    So now I do a lot of assessments and therapy, not all with kids with trauma, but like I said, if you know what you’re looking for, it starts to pop up everywhere. It’s like when you buy a new car and you’re like, “oh, all these people have Jeeps.” Or once you’re trained in trauma, you’re like, “Oh my gosh, look at all this stuff going on that I didn’t even think about as trauma before.” So, yeah, it’s pretty prevalent.

    [00:11:33]Dr. Jeremy Sharp: Right. Well, I know that that’s going to be a major topic that we cover. And yeah, it really gets at that question, I think that we’d like to… just the way our brains work, …we’d like to separate things. We’d like to say like, “Oh yeah, this is a trauma case, or this is an LD case, or this is autism, or this is ADHD,” but the direction that the field is growing and it seems like these categorical models just don’t really make sense for diagnosis and conceptualizing folks. So, that question like what is trauma and how do we find it is just getting more and more important. 

    [00:12:10] Dr. Julia Strait: Yeah, absolutely. When I was thinking about today, like, what are we going to talk about and what do I want to make sure that I say, I think that is a really important point.  What lured me into psychology in the first place was, “Oh yeah, I can put people into these boxes and they’ll make sense.” and then I can do something about it and I’ll have this control and this understanding. But the categorical models like you said, just don’t fit with trauma or anything else. But I think, especially with trauma, I do a lot of training with school personnel and I just want to reiterate, the very first question is always like, well, we don’t diagnose PTSD in the school, so we have no use for this. And it’s like, well, regardless of what diagnosis, which we’ll talk about the difference between the diagnosis of PTSD versus just traumatic experiences, regardless of what box you’re going to put them in, to me, the goal obviously with all cases but especially these guys is actually finding the best recommendations, the best resources to plug them into. And so it’s kind of like a moot point of what diagnosis they have.

    [00:13:09] Dr. Jeremy Sharp. Sure.

    [00:13:10] Dr. Julia Strait: So that’s not really the point. But that being said, of course, we have to work within the constraints of our system. So we’ll talk about that. But yeah, I think, paint by number was a really alluring thing to me.   I could just put this person in the autism box and…

    [00:13:26] Dr. Jeremy Sharp: I  think for a lot of us because we want to be helpful and at least early in our careers and maybe later in our career. The way to be helpful is to know what you’re helping and categorical systems really lend themselves to that, at least they seem. 

    [00:13:44] Dr. Julia Strait: Yeah, of course. And it’s very easy. And that’s how our brain works, right? Like, “Okay, we need to put this in a category so that we can respond to it appropriately.”

    [00:13:51] Dr. Jeremy Sharp: Right.

    [00:13:51] Dr. Julia Strait: But I think that I mentioned before when we chatted just informally a metaphor that I started to think about for trauma is, instead of thinking of it as a box, I think of it as… so you’re taking your paint by number, but then someone’s spilled like the whole water cup on your painting and now, you still have some of those colors and you still have some of those outlines, but there’s no honoring that bell, there’s no putting that water back in, and there’s no say in where it stops and where the other thing begins. So that comes up a lot too. Like is this symptom right here caused by trauma or by something else?

    [00:14:27] And it’s like, I don’t know, I don’t have a crystal ball and there’s no counterfactual. So remembering that I think is really important which most I think like it’d be us, clinicians, understand that about most diagnoses nowadays. Like you said, it’s not a nice little box. I think especially with trauma, it is like someone dumped this huge bottle of water all over your painting and you can’t… I’m just imagining my four-year-old crying because you can’t undo it. And so you’ve got to now look at it as more of this mosaic that’s bleeding together and it could still be beautiful. It’s still as beautiful in its own way. We just have to learn how to look at it. 

    [00:15:06] Dr. Jeremy Sharp: Right. Okay, well, we’ve got a lot to talk about. We’ve teased the audience too much already.

    [00:15:13] Dr. Julia Strait: Okay.

    [00:15:14] Dr. Jeremy Sharp: So let’s just dive in. Let’s start at the beginning. So talk about how you define trauma and the different kinds and what it looks like. Yes, let’s start at the beginning. 

    [00:15:29] Dr. Julia Strait: Yeah, so there’s a 10-hour seminar on that, you know.

    [00:15:33] Dr. Jeremy Sharp: Yeah, I know.

    [00:15:36] Dr. Julia Strait: It really is so nuanced, but you know, I always go back to SAMHSA-Substance Abuse and Mental Health Services Administration. I had to practice that this morning. I knew I was going to mess up. But seems to have this kind of definition that they put out that guides research, and I think that’s the best one to go by. And they explained it as trauma is not one thing, it’s not the event, it’s not the symptoms, it’s three parts. So it’s the 3E’s. So, it’s the event itself. It’s the experience of the event which many people by now I’ve heard, it’s how you perceive it and not necessarily the objective proof of it, and then also the effect. So just like our other categories that are capturing the whole idea of functional impairment in your daily life.

    So you have to have all three for us to consider that ‘trauma’. Although, I’m not going to argue with someone if they say like, “Well, I feel like this was traumatic.” If I’m in therapy and someone says that, I’m like, “Okay, let’s explore why you think that, and obviously, that’s impacting you.” That’s a different question from, ” Do you meet these criteria?”  But of course, if someone feels like they’ve experienced something traumatic, then who am I to argue with that?

    That being said, I do think there’s this idea of concept creep. So, when we call everything trauma, what’s our bar there? So if you look at assessment instruments, there might be a cut score on a certain measure which we understand as psychologists. It’s the severity and the frequency. It’s how much it disrupts your life. But a lot of people lay public, for example, like we don’t tend to think of it that way, we just think of like, Oh, well it was really scary, and it was a big deal or that there was violence and it’s very kind of nebulous idea.

    And I think it’s just interesting to think about. And again, I’m not going to be the one to draw the line.  I don’t claim to have that power, but  I think there are different questions you have to ask like, are you asking if you meet the criteria for PTSD because that is sort of an easy question that I can put you into that box. But if you’re asking like, has that cup of trauma water spilled on you a little bit? Okay. Well, like I said, if you’re saying that I did, then let’s figure out what the effects are.  But I think that is a helpful starting point.  The event, how you experienced it, and then the effects. And when we assess that, we look at all three of those things. 

    [00:18:00] Dr. Jeremy Sharp: Yes, I like that definition. It’s kind of an alternative definition, I guess, and just looking at like the DSM criteria. There are some parallels for sure but breaking it down makes it a lot simpler I think. 

    [00:18:15] Dr. Julia Strait: Yeah, it’s just a little broader because PTSD criteria, they’ve changed it quite a bit from DSM-IV, but of course, you can look it up and try and memorize it. That criteria in (A) that exposure piece, so have you been exposed to an incident? That’s the event, right? So it kind of maps on.  So we know that there’s a number of events and I didn’t want to talk about a little bit the difference between single incident trauma versus complex or developmental trauma which is probably a whole another rabbit hole. Do you want to go down that now or do you want me to wait? 

    [00:18:48] Dr. Jeremy Sharp: No, I think that’s important. Yeah, when we were talking about what is trauma, I hear a lot of like big T versus little t, I hear a lot of like chronic versus acute, there’s this [00:19:00] developmental versus complex versus single. It’s all the same ball of wax. So yeah, if we can untangle that, it’s okay. 

    [00:19:07] Dr. Julia Strait: Yeah, when I talk about this to teachers and stuff too, I always have this big, loose Venn diagram of all these things. And I think they’re all poised and ready to take notes on where the points are that I’m going to tell them. And I’m like, ” Okay, spoiler alert, I don’t know where all these things end and the other one begins,” but all those things you just said are things that people use to refer to it right? And even sometimes we hear the word crisis kind of put into that as well which in the schools we’d make the distinction of like a crisis like an acute single event that the goal is just recovery in the immediate aftermath.

    But can a crisis then turn into something traumatic? Yeah. If you look at all those effects. So, we have to remember that the PTSD criteria, the idea of trauma, big T trauma really came from war veterans, and so, [00:20:00] not that it’s one event. My brother is a veteran. I understand that it’s not just one thing. He had some chronic exposures that were not optimal. [00:20:10] So not to say that’s a ‘single event’, but it is an event trauma or a shock trauma in that there was a before. You had a life before that, and you had ideas about the world and about relationships before, and so now that’s been disrupted. And so, that kind of trauma, school shootings, a hurricane, that’s a lot of stuff we’re dealing with in my area, pandemics- even though it’s an ongoing incident, that really a lot of kids there was a before and there will be an after. And many adult clients I deal with, maybe they had a sexual assault or rape or someone was murdered, these kinds of things where of course it’s going to be super disruptive. But you can put a marker there, like, okay, I have something to compare it to.

    And where we get into the other side of it which is kind of the other version that I think of, the chronic or the developmental or the complex trauma, which is all sort of, like you said, the same ball of wax,  to me, that’s the traumas in which there was no before or there was a very brief before. But technically we think of complex trauma as like there are three kinds of components and it’s early, so early in your life and childhood usually, chronic- so ongoing, and within the primary caregiving system. So someone who was supposed to love and take care of you, but did not. And so those are kind of those components of the other kind, which is there was no before. And that’s the kind that can really disrupt relationships, attachment, internal working models of the world, your views of yourself. It’s a similar thing, but it can have a lot of different implications for treatment and for recommendations.

    [00:22:02] It used to not be a  ‘fit’ like in DSM-V, they’re thinking about putting in developmental trauma disorder and they didn’t and people were mad. What an ICD 11, there is complex trauma as a diagnosis. So if you use like your EHR systems or whatever, that is a diagnosis you can put in for ICD 11 and there’s even a scale that I just recently found and I’ll give it to you for the show notes, but it’s called the ITQ, the International Trauma Questionnaire, and it really gives a nice conceptualization of complex. So, first, it asks about PTSD criteria  DSM-V style, and then if you meet that and in addition have these three extra things, then they will call that complex trauma. And that I believe the three extra things are, one of them is disruption of relationships, of course, one of them’s affective regulation problems, and then I think the third one is that really severe self-esteem like self-blame kind of negative beliefs about self.

    And so those are the extra things. You get PTSD, plus you get all these other things. So that’s definitely different things. And I will say, it’s kind of a caveat that most of the research about trauma’s effect on the brain or on school outcomes or on life outcomes. And most of what I talk about to people is based on that latter kind, like chronic maltreatment in the early caregiving system. 

    [00:23:20]Dr. Jeremy Sharp: Yeah, I was going to say just to jump in for a second. It sounds like maybe you’re going down this path, but I would love just as a kind of naive, non-expert in this area to know if there are differences and outcomes and expectations I suppose for that developmental or complex trauma versus an acute single-event trauma. 

    [00:23:48] Dr. Julia Strait: Yeah, for sure. Like I said, a lot of the research that we have especially on young people and I should say most of my original training and work is with young people, although I work with a lot of adults now in private [00:24:00] practice, a lot of that experience that I have was from young people and young adults. So, I say that because we know, for example, that kids with complex trauma are more likely to have… like I said, those attachment disruptions, ….they’re actually more likely to have speech language, cognitive types of developmental problems because if you can imagine…, so I didn’t really talk about milk treatment as a kind of Venn diagram, but within that maltreatment world, I think we automatically think of physical and sexual abuse which of course are very detrimental, but like 70 or 80% of CPS cases are neglect. And there’s actually a big if you go to Harvard… I forget what it is …Center for the Developing Child, there’s a big push now to look at neglect because those outcomes for kids who are neglected can be worse for things like cognitive development and speech and language because think about like, if you’re not getting exposed to words and books and loving, caring relationships, if you’re not being constantly… that co-regulation of emotion that goes on between the parent and child, that back and forth rate, if you’re not really getting that or if you’re getting it inconsistently, so those things, I think attachment relationships and some of the developmental piece can be kind of extra risk factors or extra outcomes, I guess. I’m not sure which side, but so we definitely know from research and just from experience with clinical populations that the relationship piece and the developmental piece can be more severely affected in the case of developmental trauma versus a single incident.

    [00:25:42] Dr. Jeremy Sharp: Yeah, that makes sense. So you talked earlier… I really want to ask a little bit more about this idea of concept creep. So, I’m guessing that folks out there have experienced something like this where there’s this question of [00:26:00] what really ‘counts’ and that’s a hard place to be in. I think we probably all come into clinical situations with expectations or maybe heuristics or some framework to say, okay, this is trauma, this might not be trauma. But either way, whichever side we fall on, it’s the idea of does this really ‘count’?  Like if someone says it’s traumatic, but it doesn’t really…

    [00:26:33] Julia Strait: Yeah, I see much of that. And it’s like, Oh whatever

    [00:26:36] Dr. Jeremy Sharp: Yeah, well, this is a hard thing.

    [00:26:37] Dr. Julia Strait: Yeah, like we don’t want everything to be.

    [00:26:41] Dr. Jeremy Sharp: Yeah,I would like to talk through that a little bit more.

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

    [00:27:48] Dr. Julia Strait: Yeah, that’s a sticky question. It’s so hard because, on the one hand, I see why it would be beneficial to capture more people in that definition because we can help more people. So I always think of it like in special education which was where I was originally trained. It’s like, yes, we would love for everyone to get these services. But when you have a question of limited resources, like where are we going to put our most severe, our most intense resources? And so I think of it on a continuum. Like, I don’t know that there’s a nice cutoff. And for lack of better criteria, I think that PTSD criterion (A) which is the exposure to the event, there’s a lot of literature on that and what’s considered. So the wording there I think is actual or threatened death or sexual violence, or for little kids that can be learning about something like that done to their parents or witnessing it. For law enforcement and EMS and those kinds of people, it can be exposure through work. So I think there’s a long list you can find on the internet of things that count. I know in children sometimes there are things that surprise me like, Oh yeah. I didn’t think about that.  Like dog bites, [00:29:00] like being attacked by a dog that might be super threatening, they felt like their life was threatened.

    Major medical procedures, that’s one we don’t think about often either, but talk either chronic or just really major, scary medical procedures, or like I’ve had kids who woke up in the middle of surgery, something very, very, very frightening. And they used to have that criteria in there of like you had to be like terrified at the time. And now I think it’s so hard to quantify that that they’ve kind of dropped it. But in the DSM, it’s technically actual threatened development or sexual violence. And I feel like I’m forgetting a part of it. So it is the high kind of level. I’m thinking about when I was younger, I had an English teacher Ms. Anita, and I use the word tragic in an essay and I remember her being like, you have to be careful with that word because technically, tragic means that there’s some kind of death involved. And I remember feeling like, wow, I just started to learn about the boundaries of words.

    [00:29:57] For some reason, that reminds me of the trauma question where there has to be this element of like your actual life or your sexual or bodily integrity is being threatened. But again, that being said, for example, in therapy, I’m not going to argue with someone if they feel like that’s helpful to them. I’m not going to take that away. But it’s different for assessment. So yeah, to meet the criteria, I’m going to look at whether it was to that level, right? Like if I’m going to put the word PTSD on the report, I’m going to look at that criteria. And like I said, even with complex PTSD, technically for ICD 11, all the skills that go with that, they have to meet that criterion A too.

    [00:30:37] And so I think that is like an ‘easy answer’ for the diagnosis made easy folks. But of course, I work with a lot of teenagers in therapy too who have started to notice like TikTok and Instagram and stuff. It’s like, I’m so glad that there’s a community out there that’s supportive of trauma and anxiety, everything, but I think we also have to be careful like, if everyone has suffered trauma, then is it trauma anymore? I mean, reality is not a condition of the diagnosis. It doesn’t have to be. Right now everybody’s going through it. I saw a study yesterday that came out in December where they looked at nine different countries during the pandemic and it was anywhere from 7 to 54% of the adult population is feeling some symptom of PTSD right now. I believe that. I definitely have people who are high arousal and they’re getting reminders of things. So I don’t know that there’s a really nice answer to that. I would say it’s easier when you’re saying to like a parent, well, this is the criteria for the disorder, but it’s not a rule-out.

    [00:31:50] So like, just because they don’t meet that criteria, I’m not going to say, well, you don’t need therapy for it, or you don’t need these services. It’s really nice that at the private practice can say that. And [00:32:00] you know, even in special ED in schools. There is no category for PTSD. But in the school, it’s like if you’re going to be behavioral and descriptive about it,  so do they meet or ed or something? Then put them in there. But in California schools, I think sued a couple, well now it’s been 5 or 10 years. Hampton School District, a bunch of kids sued the district because they weren’t providing services for kids who had been part of gang violence and shootings and things like that.

    [00:32:32] I think that’s getting better. Like, I don’t think they actually didn’t make a new category, but they have been more responsive in terms of trauma services at school.

    [00:32:41] Dr. Jeremy Sharp: Got you, got. 

    [00:32:42] Dr. Julia Strait: That’s a long answer. 

    [00:32:43] Dr. Jeremy Sharp: No, it’s a good answer. It’s important I think because as much as we may be want to get away from these definitions and categories and so forth, it still matters in some ways. I think I have examples on both sides, right? So like, personally, we have…  so our daughter, our second kid, she had some complications, and she was in the ICU for, I think, 7or 8 or 10 days or something.  So I’m trying to think about how to tell the story. The short story is that going back to the hospital, hearing any beeping  I think I kind of had PPS, even though that doesn’t meet the definition right, for like the DSM necessarily, but then on the other side, I think we all see clients maybe older, maybe teens who say like the kids excluded me on the playground that day, and I’ve never been the same sense. Is that a trauma? I’m just thinking out loud trying to talk to you.

    [00:33:57] Dr. Julia Strait: Yeah, of course. And I was going to kind of like to tip to it because I don’t want to offend either way. I don’t want to offend someone who’s listening who is like, no, I felt like that really was, but then I don’t also want to offend someone who’s been through some of the horrific things that I have seen who was really frustrated by the fact that like, no, I’m sorry.  I want to name so many things right now that I can think of these kids that I’ve seen that are just like, Oh my gosh, you can’t even deny that. So like, is it offensive? Not offensive. But is it kind of changing how we view them? If we say, well, yes also like not being picked for your team is traumatizing. But again, I think it’s totally a continuum and there are some measures. So there’s a measure called the Macy’s out of Harvard and they consider peer like bullying, they added that like as another ‘ACE’, which was the adverse childhood experiences, which is a very like rough estimate of traumatic. It’s only 10 things. So, I’m going to talk about that.

    [00:35:01] They add that in as trauma. And again, gang violence, community violence, racial discrimination a lot of things can be considered on that continuum. Again, it’s easier if you’re trying to make the cutoff for PTSD because you can kind of say like, okay, well, do you have these symptoms to a frequency and severity that we would consider? And are there multiple people saying that not just you, like, maybe you’re a parent and a teacher, of course, like all those methods. I think that’s a really sticky question that if you ask 10 researchers and psychologists, DO you know what trauma is, they’ll all say maybe something a little bit different. 

    I have a professional Instagram where I only follow mental health things and I do get a little discouraged sometimes when I see so many things about like, hey, if you have these symptoms, it might be trauma, and sometimes it’s like a little meme about like, if you get nervous, when you go to the grocery store, I don’t really know what the [00:36:00] intent is behind that. [00:36:01] It’s great that people are trying to be compassionate. But I see what you mean about concept creep. Like psychologists are already made fun of for having so many measures and concepts and constructs. It is I think a danger to go the other way. And I’m trying not to use the phrase water it down because I know that’s not the greatest phrase. But I mean, you can’t make it so applicable. That doesn’t apply to anyone.

    I went to an NIH Child Abuse research training a few years ago in New York City and got to meet this guy, John Knutson, he is one of the first people to study abuse and disabilities in that overlap. And he even said in the training, he’s old school, he’s like fairly seasoned, and he kind of made some people mad at the training because he was going over physical abuse and disability stats. And people were asking questions like this, like, what counts? Like if you got hit once or? And he said, well, if you start pathologizing everything, then what are we even studying anymore?

    [00:37:03] I don’t want to misquote, but it was something like that. Like if everything is a trauma, then what’s the point? If it’s completely normal, is it a pathology? And so I think that’s important to remember as well. He’s one of the OGs. So I feel okay talking about that, but I don’t want to exclude anyone.

    [00:37:21]Dr. Jeremy Sharp: Right, I think in these conversations, we always run the risk of coming across as a monster who is minimizing somebody’s experience. And of course, that is not the intent at all. But I hope folks understand as we work through some of these almost philosophical questions. It’s just like, how do we think about this?

    [00:37:46] Dr. Julia Strait: Yeah, it gets existential pretty quick.

    [00:37:48] Dr. Jeremy Sharp: It really does. But ultimately, then it’s like, okay, so then how does that lead to how we might help people? 

    [00:37:55] Dr. Julia Strait: Yeah, that’s the original thing you said, right? Like we got to put people in categories at some point because we have to help them and because of the way our system works, which is reflected in all these rules and everything because that’s the way our brain works. At the end of the day, we do sometimes have to make a decision. And so, limited resources can only go to so many people.

    [00:38:17] Dr. Jeremy Sharp: Right, exactly. Well, I appreciate you waiting through that.

    [00:38:23]  Dr. Julia Strait: I’m still waiting. All the time.

    [00:38:25]  Dr. Jeremy Sharp:  Yeah, we’re just waiting. So I want to ask you, I know that there are so many instances in the mental health world, diagnostically and assessment wise of disparities and differences in different groups, be they racial, ethnic SES, geographic, whatever it might be, did those things exist in the trauma world as well where certain groups are either over or underdiagnosed or undertreated or left in that way? 

    [00:39:02] Dr. Julia Strait: Yeah, I’m so glad that you mentioned that because I was reviewing some things last night. Like I said, I was studying what I want to make sure I say. I was coming across all these stats that I hadn’t thought about in a while, but one of them was, so a lot of this research has stuff comes from kids who were maltreated, and when you look at the stats, just of the prevalence of abuse and neglect, for example, just like baseline, like the event piece, right? So if you’re looking at the exposures,  there’s a long history of research there. There are some racial and SCS disparities in abuse and neglect reports. But you notice I said reports or substantiate the cases. And so, I’m actually at the NIH Institute, I was at a couple of years ago, this lady, Kathy Widen, who’s amazing and she does all this research on trauma and she was talking about how there are some more recent studies that actually say that there’s a surveillance bias, meaning like those…

    [00:40:03] So some children who are in underrepresented minority groups or low SES communities, they’re actually monitored. So they’re already involved in systems, right? Like sometimes they’re already involved in the judicial system, or maybe their parents are, or they’re involved in, CPS for some other reason for another kid. So there’s maybe a monitoring bias that affects that because there are some statistics and these are a little old now I think that from the 90s and the 2000s. But it’s something like 7% of kids, I’ll have to fact check this later, around a little under 10% of kids at some point in their life will have some contact with CPS. And that just might be like someone calling and it’s nothing, right? So a lot of cases get one report and there’s nothing.  But when you get to two or more reports, that’s when you start seeing those ill effects. But kids who are from black American communities in the nineties were getting referred at a huge rate higher than that.

    [00:41:01] I don’t want to misquote, but it was like really close to half. At some point in your life between zero and 18, at that point in time, if you were from an underrepresented minority group, you have been much, much, much exponentially higher rate of referral to seek yes. And I say that because even though that’s not the only exposure to trauma, think about all the things that come with that. So you’re referred to CPS now, you’re in this system, you’ve got people watching you. This might lead to additional systems that you’re involved in. Maybe now the government is watching your parents more closely and there are other factors that come into that and so those kids tend to get plugged into that system really early. And we all know about all these pipelines that exist. So I think that’s definitely a problem. But there is some evidence to suggest that, I don’t know if it’s actually occurring more. So think of your affluent families. I know the area I’m in, we live in a pretty diverse area, but a lot of our families in private practice are more affluent and everything.

    [00:42:03] And I mean, when I preferred to call CPS for those families, I don’t know, just anecdotally those investigations get shut down pretty quickly,  it’s like, Oh, it’s probably nothing,  I think there is a bit of a bias, right? Like we’re not looking as hurt as certain groups. And definitely, I think a lot of our kind of implicit biases and all that come in . When you look a step further like in special education, for example, kids who are in state custody, I’m kind of using as a proxy for trauma and I understand that’s not everyone, but that’s my background, kids who are in state custody or in foster care, in the ‘system’,  or juvenile justice systems kind of in that pipeline,  they’re way overrepresented in special education. And it’s certain. So they’re way overrepresented in emotional disturbance categories because it’s like, okay, behavior, classroom go straight there.

    [00:42:58] But they’re underrepresented things like intellectual disability learning disabilities because those things get overshadowed. We actually did a study in Memphis for that. We looked at all our kids that we had diagnosed with ID, which a lot of them were teenagers, like what?

    [00:43:14] Dr. Jeremy Sharp: Like when did they get that? And these kids…

    [00:43:14] Dr. Julia Strait: Yeah, you know 50s IQs, and we were the first people diagnosing them at 15, 16 years old because they had been in the behavior classroom, they’ve been highly noble. And so, yeah, I think it’s any more prevalent than we think it is in all communities, but be like, we’re looking at different variables when we look at different populations, which I don’t know if that’s really equitable. And then those kids are getting plugged straight into like ed services which all well and good. But if you have an IQ in the s60’s and you’re just getting behavior services that are geared toward typically developing kids, what does that say? So they all get missed for early intervention.

    [00:43:56] Dr. Jeremy Sharp: Sure.

    [00:43:58]Julia Strait: Definitely there’s some biases there that need to be looked at for sure. 

    [00:44:02] Dr. Jeremy Sharp: Yeah, I know in our work, we have a contract with a local  DHS department from a nearby County, and a lot of the work that we do with those evaluations is almost undoing some of the prior evaluations or diagnostics. I see so many kids who come through as like 9 or 10 or 12 or 14-year-olds, and they have ODD, ADHD, conduct disorder, and through the course of the evaluation, a lot of it is like, “Hey, I think this is maybe trauma, could we consider that and pursue treatment for that instead of these other like medications or like placements or more restrictive kind of punitive environments or whatever it might be?” And it’s heartbreaking to see these kids.

    [00:44:59] Julia Strait: Although it’s awesome that you’re like shifting the lens,  I think that’s the deal, right? so that’s I guess what we’re kind of called to do, and when we have a situation like that. It’s cool that you’re trying to like shift everybody’s… there’s this saying in the schools has gotten popular now of like, don’t ask “What’s wrong with you? ask What happened to you? I know that’s like come to be kind of a cliche, but I think that’s really important to shift the view. A lot of parents coming in like, Oh, he’s manipulative, she’s borderline,  and that’s not just the trauma obviously, but sometimes a lot of the hardest part of our job is like, well, could we look at this from another angle? 

    I have even started putting in my reports. I didn’t use to give a lot of personality tests but in private practice, I feel like it rounds out. it gives a lot of context, and so I’ve been doing personality stuff with younger kids. And I always now put in there after I explained like the impasse year or whatever we did, I put like, ” It’s important to know that these traits and symptoms are understandable given the child’s history and context. They should not be viewed as stable traits, but  as targets for events or something like that.” I always put in there, we need to be seeing that as something that we can help them with and not like, oh, well, there it is. This is the problem within the child. And you say like, this is the problem that’s in the kid and they’re possessed. We actually have a lot of people in Memphis whose parents would come and say they’re possessed because that’s kind of cultural,

    [00:46:20] Dr. Jeremy Sharp: I grew up in the South.  I know.

    [00:46:22] Dr. Julia Strait: Yes definitely, so like they’re possessed or there’s something wrong with them. I hear the word manipulative like a billion times a day.

    [00:46:29]  Dr. Jeremy Sharp: So often.

    [00:46:30]Dr. Julia Strait Yeah. But if you look at that word, manipulative… so they’ve learned in an adaptive way to get their needs met by trying to exert their will on other people. I guess if you see it in an adaptive sense, they’re really good at getting what they need because no one gave it to him when I was growing up. 

    [00:46:51] Dr. Jeremy Sharp: Sure, sure. It makes me think of, I don’t know if you’re familiar with, the Ross Green stuff, the collaborative and proactive solutions, and just that philosophy of kids do their best generally. Kids are doing their best. And whenever I hear manipulative, it’s just a trigger I guess, to say the kids probably just doing their best. We can talk through that afterward. I know we could keep going as sort of the preamble and the philosophy and what is trauma and what isn’t trauma, but the hope, I mean, we spend a lot of time on this, but the hope for anybody listening is just try to define things a little bit and at the same time, bring up some of these complexities that are hard to sort through from a clinical standpoint if we’re just like, again, generally thinking, what is trauma? what does that look like?  How do we conceptualize this? So, thank you for spending so much time on that.

    [00:48:01] Julia Strait: Hopefully that was helpful. And like I said,  there’s lists online you can do especially with kids, like what are some possible things? And it doesn’t mean they automatically count, but we would say like either potentially traumatic events. And that’s often how I write it in the report, like, which will probably get so, and so is exposed to several potentially traumatic events. And we can’t say whether or not until we assess those other pieces, the experience and then the fact.

    [00:48:31] Dr. Jeremy Sharp: Sure, well, I wonder if we might transition a bit then to the assessment process and what this looks like in real life.

    [00:48:40] Dr. Julia Strait: Sure.

    [00:48:40] Dr. Jeremy Sharp: Okay, everybody. Thank you so much for listening. Like you heard at the beginning, this is part one of a two-part series, so make sure to tune in next week for part two. We’re going to be talking all about the assessment process. So what this looks like during an interview, what measures Julia uses for trauma-informed assessment, how it plays into the report and feedback as well. So you don’t want to miss that.

    if you haven’t subscribed to the podcast, now’s a great time to do so to make sure you get those notifications and automatic downloads when new episodes are released. Like I said at the beginning, if you are interested in some group coaching and accountability to launch your practice in 2021, You might check out the beginner practice mastermind group just for testing psychologists, and you can get more information at thetestingpsychologist.com/beginner. Okay, everybody. Y’all take care and tune in on Thursday for another EHR review. Until next time.

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