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

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

    Hey, everyone. Welcome back. I’m really excited for this episode here today. I think I’m excited about most episodes. I can’t remember an episode I wasn’t excited about but it’s always genuine.

    Today’s episode is interesting. It is a little bit of an addendum to the international assessment series that I did several months ago. During that [00:01:00] time, Dr. Michael Roth reached out to me and asked if I’d be interested in chatting about his experience as a school psychologist in Israel. And while at the time he didn’t quite work out to have it be part of the original international assessment series, I am so glad that we set up a time to do this interview, and I’m happy to release it a few months later here as a little bit of an add-on to the original series.

    Let me tell you a little bit about Michael. He’s a licensed school psychologist and supervisor, and the Director of School Psychology Services for the town of Bet El Israel. He’s also a member of the Psychologist’s Registry Board and a member of the Jerusalem District Committee for testing accommodations for students with learning disabilities. He maintains a private practice primarily focused on psychoeducational testing and school-based issues.

    What makes his story quite interesting is that prior to moving to [00:02:00] Israel in 20005, he worked as a school psychologist in the US and was educated here in the US. So it was a pretty compelling experience and perspective to share as far as practicing both domestically and internationally.

    I will give a little disclaimer. The sound on this episode is slightly below par but absolutely understandable. I don’t think much is lost there. That’s due in part to me having a little bit of a cold and a sound quite congested. I think you’ll be able to get past that and enjoy this conversation with Michael.

    So without further ado, let’s transition to my interview with Dr. Michael Roth.

    Hey, Michael, welcome to the podcast.

    Dr. Roth: Thanks for having me. I’m really excited to be able to share my story.

    Dr. Sharp: I’m excited to talk with you about your story. I’m very curious to dive into this practice in Israel. A lot of people know that we did an international practice series a few months ago, and then you reached out to me during that series and said, Hey, do you need somebody else? And even though it wrapped up, I was really interested. I’ve looked forward to having this be an epilogue to our international assessments series. So, thanks for being here.

    Dr. Roth: My pleasure. I really enjoyed listening to the guests that you had on. And as I was listening, I thought to myself, well I have some interesting experiences also to share. And [00:04:00] so, I’m really glad that you let me have this time.

    Dr. Sharp: Oh yeah, I love that. I love that you reached out.

    Well, I’d like to start just with your story. I think that’s always an interesting part of folks practicing internationally, especially when you start in the US and then go elsewhere. So, take that where you may, but I would love for folks to hear how you ended up where you are.

    Dr. Roth: Yeah, sure. I was born and raised in New Jersey. The reason that I came to Israel, I think it’s intertwined with the history of the state of Israel. So I need to give a brief history of how the state of Israel came to being and then can understand how I make my way here.

    The state of Israel was created in 1948 after the Holocaust tragedy. The Holocaust is a place for Jews to seek refuge. And following people came to Israel from all over the world both to seek a better opportunity and [00:05:00] also ideologically, the Homeland for the Jewish people.

    I came to this role for the first time when I was 13 as part of a family trip. I tell people that I had almost a physiological reaction when I got off the plane. I felt that this is where I need to be. It’s hard to almost even describe- just the culture, the people, the history, it really made a powerful impact on me. That’s when I was 13 and I knew that I was going to end up here.

    I spent some time here after high school and my gap year getting to know the people, learning the culture, and speaking the language. I went back to the states for my college and graduate training. I got married along the way. I had two kids. But I knew that I was going to end up here. And in 2005, two years after I got my doctorate, I moved to Israel. And it’s been [00:06:00] a thrill. So I’ve been here since 2005. And that’s pretty much how I ended up here.

    Dr. Sharp: I love that. That’s so interesting. We were talking with some guests the other night, dinner guests about a similar experience. I don’t know if this is maybe what you felt but one of our guests was describing this experience of going back to, I think in her case it was Norway. They knew there was some family history there and the ancestry line and so forth. She described a very similar experience where she got there and it just felt it was almost indescribable, but there was a very felt sensation of this is just where my people are. This is where I need to be.

    Dr. Roth: Connection- a total connection. That’s exactly what I felt.

    Dr. Sharp: Yeah. Well, we could go down that path for a while, I suppose. It sounds like a powerful experience for you. You knew right away.

    [00:07:00] Dr. Roth: Yeah.

    Dr. Sharp: So then, did you have it in your mind when you got into grad school that that’s where you were going to go? I mean, did you always have that goal of moving to Israel?

    Dr. Roth: Yeah. Like I said, I knew that this is where I was going to end up. I wasn’t sure exactly when but what factored into it pretty much was that my oldest child was going to first grade and I said, this is the time to do it. If they get a little older and I have to move them away from their friends, it’s going to be more complicated. So that was the factor that determined when I went. I had worked for seven years as a psychologist in the states prior to that, and then then I came here.

    Dr. Sharp: I got you. So tell me a little bit more about the time that you spent in your gap year and what it was about that experience that really solidified things?

    Dr. Roth: It’s very common for [00:08:00] more of the religious students after high school in the states to come to Israel for a year and they enroll in different institutions here to further their religious studies. So I did that. Most of my friends did as well. It’s a thing that you do after you finished high school. And then I actually, for my second year volunteered in the army here. I drove a tank on my job. I did that for a year. So I spent two years after high school here. And after that, I went back to my college for undergraduate.

    Dr. Sharp: I see. So I’m so curious about this whole development of how you got there. When did becoming a psychologist fit into this picture? It sounds like you knew you wanted to end up in Israel. [00:09:00] So then being a psychologist was secondary to that, but I’m curious how that came to play.

    Dr. Roth: When I started college, I had no idea what I wanted to do. I had a really great psychology professor in college that I was really close with. And to be honest, I was looking into the field of music therapy, because I also do music. I play music. I’m an amateur musician and I thought maybe I do that. I volunteered for some summers in an inpatient facility shadowing the music therapists there. And this professor I was close to, at one point, said to me, why limit yourself to music therapy? You can be a psychologist and maybe if you want use music as a modality if you choose, but maybe broaden yourself a little bit.

    And then through my studies, I like was attracted to the field of learning disabilities and testing and those kinds of things. So that’s where that decision [00:10:00] came together for me.

    Dr. Sharp: I love that. I have to ask. What’s your instrument of choice?

    Dr. Roth: I play drums.

    Dr. Sharp: Oh, I love it. I always say…

    Dr. Roth: Yes, that’s my therapy. That’s what I talked about, my therapy.

    Dr. Sharp: That’s fantastic. I don’t think I mentioned this on the podcast, but playing the drums is like one of my lifelong, I guess regrets/dreams. I wish I’d started a long time ago and hope to maybe still do it.

    Dr. Roth: Go for it for sure. It’s a great mental health escape for sure.

    Dr. Sharp: Nice. So tell me, when did you start preparing for this? So you moved two years after grad school, is that right?

    Dr. Roth: Yeah. I started my master’s program in, I think was 1995. I finished in 1997. And then got accepted to a doctoral [00:11:00] program right after that. I got my doctorate in 2003, all in school psychology. And then I moved in 2005.

    Dr. Sharp: I hear you. I’m just curious about when you decided you were going to move and what that preparation looked like? Was that happening during grad school or was it all after or how did that begin?

    Dr. Roth: It was a difficult process getting ready. There is getting organized in terms of moving your whole family, my wife and all. And then there was professionally getting ready. And that was even more challenging because there weren’t a lot of people to talk to at that time. I had one contact here who every time I tried to ask me for details of responsibility, said, just come you’ll love it. It’ll be fine. And that was just a typical Jewish answer. Don’t worry. It’ll be fine.

    [00:12:00] Looking back I wish that he had prepared me more because coming here was a bit of a shock professionally, and I can expand on a little bit more if you want, but since then, things have been a lot more streamlined. There are different organizations that help people who come over in the field of mental health professionals. So there are people who are guiding you. I actually got a lot of emails from people and I try to give them as much information as I can so that they can make a decision as to whether that’s the right choice for them.

    Also the regulations, as far as people coming over from different countries with licenses or certifications when I came over, certain things weren’t written down, weren’t consolidated, now that we can find everything online. Again, it’s been improved a lot since I moved, but when I came, it was a little bit of a struggle actually [00:13:00] making that adjustment professionally.

    Dr. Sharp: Yeah. I was going to ask, were there any resources in particular that helped you, but it sounds like you’re saying there weren’t. It was not consolidated.

    Dr. Roth: Yeah. Compared to what they have now, again, everything is available online and it’s really great. There weren’t those resources when I was moving. And like I said, the person who I was in contact with by phone or even by letters, once upon a time used to send letters, he was a great guy but not very helpful in terms of what I needed to know when I needed to know. So it was a big shock for me.

    Dr. Sharp: I got you. It sounds very enthusiastic not super thorough.

    Dr. Roth: Exactly.

    Dr. Sharp: So you mentioned some professional hurdles or hoops that you had to jump [00:14:00] through. Can you remember back then and if those are similar to the present day, what professional issues do you have to deal with to make that move?

    Dr. Roth: Yeah, certainly. The most basic one is though is the language. Here the language is Hebrew. So you’re working in Hebrew. You’re communicating to clients in Hebrew. I thought that I was pretty good at speaking Hebrew, but there’s a complete difference obviously between conversational Hebrew and professional Hebrew, and that took me a while to get adjusted to and learn.

    I’ve worked the seven years giving intelligence tests to kids, but giving it in a different language is something different. So I almost have to relearn that. I remember testing 6-year-old kids and I give them the first questions on the exam, which obviously everybody knew and I had to sit there and make sure that I understood the question, I understood their [00:15:00] response. So that’s an example.

    The other thing is the model. The education system in Israel is different than in the US. I can give several examples. The kindergartens and the pre-Ks are not housed in the same building as the school. They have their own separate buildings. That’s just one example. The class size. It’s not uncommon here to have classes of between 35 and 40 students.

    The service delivery of the psychologist is a very different model. So whereas in the States you basically worked in the school, for the municipality, but you were placed in the school. Here you work for the psychological services. So you come to work, you go to the psychological services building, and then you’re assigned different schools or kindergarten. Now you pop in and out during the week. So you don’t spend your day in [00:16:00] the school. So that are just two examples.

    And the other major issue was the salary. School psychologists here are not paid well. I wish that I was more prepared for that because that caused a lot of anxiety. Struggling financially was a major issue when we first moved here and that is still an issue actually. In 15 years, things haven’t changed much in terms of salaries for psychologists here.

    Dr. Sharp: I see. So even compared to the United States, it’s relatively low?

    Dr. Roth: Yes. In the States, you can make a decent respectable living as a school psychologist even without a private practice. Here in Israel, it’s expected that you supplement your school psychology income with [00:17:00] private practice. And so, a lot of people do that, and unfortunately, it’s almost like a vicious cycle where people after completing their internships and once they get their licenses, they’ll just run out and open up a private practice instead of staying in public service.

    Dr. Sharp: Yeah, that makes sense.

    Dr. Roth: It’s a struggle.

    Dr. Sharp: So I was going to ask about your moving process. Did you have a job lined up when you moved or did you move there and then find a job? How did that work?

    Dr. Roth: Yeah. So luckily, the person that I was in contact with, I mentioned before, was actually in charge of placing immigrants school psychologists. So that wasn’t an issue, actually. He basically said to me, I remember going to interview with him when he came to America, and I had bought a whole lot of my documents and my diplomas and my recommendations and other openings, and he said, “No, [00:18:00] don’t worry about that.” He goes, “Do you want to work?” I said, “Yeah.” He goes, “Okay, you’ll find work.” That was the interview basically.

    That’s the other part of school psychology here is that there’s a huge lack of a psychologist in Israel. So I tell people who are thinking of coming over, that’s not an issue. In other words, you will work wherever you want to work. That’s not a problem. You won’t get paid that much, but you’ll have a place to work.

    Dr. Sharp: Oh, I see. Do you have any insight into the low payment? Is there poor funding for public services across the board or is it specifically education or what?

    Dr. Roth: Yeah, unfortunately, in the political scheme we don’t have a lot of power. So when it comes time to negotiate the salaries, there is not a lot of leverage. That’s one of the issues. But in the public sector, there are social workers who also don’t make tons of money here. It’s just not [00:19:00] considered real significant important parts or important enough. There’s a lot more awareness now. There’s movement, especially from the younger generation. The millennials are really making a strong meeting with politicians and really making our case. So there’s a lot more awareness than it used to be but we’ll see what happens.

    Dr. Sharp: Sure. I didn’t want to ask too about just the transfer of licensure. How was the US license recognized? Did you have to jump through some hoops to practice with it?

    Dr. Roth: So I’m actually on the board of registry for psychologists in Israel. So I can definitely speak to that. And again, when I came, things were not streamlined. The [00:20:00] director of psychology services where I first worked really, I would ask every week. So I’m like, can I get my license? She would have really no idea what to answer to me. It took about three years actually before I found the right person.

    It turns out there was a person who was in charge of people coming from out of the country. I met with her. I showed her all my papers and she said, yeah, it seems like you know what you’re doing. A week later, I got my license. That was the process. It’s a lot more rigorous now and streamlined, but essentially what happens is, I’ll speak like this:

    There’s basically a two-pronged process for getting your license in Israel. I’ll start with what Israelis have to go to. So Israelis in order to become a psychologist, you have to have a BA bachelor’s degree in psychology and a master’s degree in psychology. Once you have your master’s degree in psychology, you could apply to become a [00:21:00] registered psychologist. What that means is that you are allowed to do an internship.

    Israel has six areas of recognized areas of psychology: Clinical rehabilitative which would be the equivalent I guess neuro-psychology in the States, Medical psychology, elemental, industrial, organizational, and school psychology, six areas.

    So once they’re registered as a psychologist, they can start their internship in any one of these six areas. The internship takes around four years to complete. Most people work part-time, as I said. There aren’t a lot of full-time positions for interns in psychology. And once you complete your internship, the Israelis have to take a very rigorous oral exam.

    [00:22:00] There are three areas of expertise that they have to show proficiency. In school psychology, the first area would be systems-level intervention- understanding the school system. Secondary would be individual intervention- so counseling, therapy, and those issues. And then the third area is psychodiagnostic testing and assessment.

    All Israelis have to take oral exams and show proficiency in those three areas. And once you pass the oral exams, you are considered an expert psychologist and that’s equivalent to a US license. So that means that you can actually practice privately. So that was one of the steps for an Israeli who wants to become a psychologist.

    If you are from say, the state or somewhere else, and you come with a license, you have to go through both processes. You first submit your paperwork to the registry [00:23:00] of psychologists. They look at your training and background. And if they see that that’s sufficient, then they’ll tell you, okay, you may have to do a year or two of an internship to learn the system in Israel, learn the language, and then they can grant the expert status.

    Dr. Sharp: I see. How often does that happen? I’m thinking, for Israeli citizens, you have a year or two for a master’s and then four years of internship. That’s basically a doctoral degree.

    Dr. Roth: Yes.

    Dr. Sharp: So for folks coming from the US, is it pretty common for them to have to do an extra year or two of internship to get acquainted and be ready?

    Dr. Roth: So it varies. Usually again, like I said, there’s the registry board that will look at your training, and then there’s the professional board which will look at what was your actual experience [00:24:00] in the States and then will consider how much of an internship you have to do based on your experience in the States?

    I find that in school psychology it’s really necessary to take time to understand the system, whereas in clinical psychology, maybe you’re just doing a year of an internship in maybe a hospital or something, but I find in school psychology, the system is so different that it really takes time to understand it. So I would tell people, don’t rush into things. Be patient. It may take some time. There’s a different way of doing things here. That’s just the bottom line. The instruments that we use here are quite different than what is used in the States. Like I said, the approach to intervention and therapy is quite different. So you really need to learn how things are done.

    Dr. Sharp: Sure. I wonder [00:25:00] if that might be a good segue to what the practice actually looks like there especially compared to the US? I think that’s probably where most people are going to be comparing. So, can you speak to that? So let’s start on a broad level. So as a school psychologist, what do your duties look like there?

    Dr. Roth: Okay. So I direct the school psychological services for a small municipality. So my job is very administrative. I have a staff of 5 psychologists and I send them to the schools within the municipality. The predominant area that school psychology is responsible for is consulting with teachers, school staff, and principals.

    Another difference between the Israeli system and the American system, [00:26:00] the Israeli position of the guidance counselor is a very dominant position in the Israeli school system. Whereas in the states guidance counseling may have two responsibilities. In Israel, the guidance counselor was very dominant. And so we worked very closely with the guidance counselor there. And she refers students to a psychologist for further evaluation intervention with parents et cetera. So, you do a lot of consulting, testing, and evaluation, and obviously, what would be considered eligibility meetings, I guess in the states, the same thing here we sit in those meetings as well.

    Dr. Sharp: Yeah. So it sounds like it’s fairly similar. A good bit of testing.

    Dr. Roth: Yeah, it’s just the way that things are done are different, but in terms of the knowledge area right there, it’s not very different.

    Dr. Sharp: Sure. [00:27:00] What’s the view over there or the conceptualization, I suppose, of mental health and particularly in the schools? And this is a very naive question, but are learning disorders a thing? Is autism a thing over there that you’re actually being concerned about?

    Dr. Roth: Yeah. So what I tell people is that in Israel we’re very advanced in certain areas of mental health and we’re very behind in other areas because Israel is in the high tension area in the Middle East. We’ve experienced worse terrorist attacks things like that. So we’re actually pretty good with things like trauma, PTSD, anxiety, all those things. We’re pretty good at treating.

    Where we’re behind is in the area of learning disabilities, diagnostics, [00:28:00] treatment approaches is a very heavy European psychoanalytic psychodynamic influence in Israel that’s starting to change but it’s still very dominant, especially with the older psychologists who are supervisors. You still definitely feel that approach.

    And so that was a big adjustment for myself because when I was training, I was at a time like the late 90s, early 2000 where you read, I really felt the shift between moving away from dynamic more towards behavioral interventions. And then coming here, there’s very little in the way of behavioral intervention, both in terms of the training and implementation. So psychologists don’t have much background here in behavioral interventions.

    Dr. Sharp: Even in the schools? [00:29:00] I mean, even with kids?

    Dr. Roth: Yeah. We’re not great at data collection. Constructing an evidence-based treatment is foreign to psychologists here.

    Dr. Sharp: How does that work in the schools then with intervention? I mean, what intervention even happens in the schools over there? And do you measure the progress or the data? What does all that look like?

    Dr. Roth: Yeah, I’ve been attending the NASP convention for the last three years and my mind is blown between the two professions. After having not attended for so many years and not really being up to speed about what you guys are doing in the states, it’s almost a different profession. You guys are talking about MTSS RTI, really strict behavioral stuff and we are not there at all. [00:30:00] We’re not doing any of that. Here and there you’re starting to hear RTI filter into Israel now, but we are very far from being at that stage.

    Dr. Sharp: I see. So does that mean, are you collecting that at all on these kids and their progress, or is it just, I’m just very curious now, like what interventions are happening and how do you know if a kid is doing better?

    Dr. Roth: Yeah. So like I said, the data collection, that’s just culturally I think just very foreign. We don’t do that. It’s not something that a psychologist will do. When I’m doing supervision and training, I try to bring that in a little bit more, evidence-based intervention data collection, but you’ll find very little of that here. There’s a very heavy clinical influence also. So [00:31:00] you’ll find people take you a child and working with the child or working with the parents as an intervention, not necessarily developing a classroom-wide intervention, but working with individual kinds of things.

    Dr. Sharp: I see. Yeah. That is fascinating. And to me, it just makes me go down this rabbit hole of what is the testing for? So maybe that’s maybe a question you can answer? What role does testing play in this whole process then?

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    Dr. Roth: Yeah. The interesting about testing here in Israel, when I was working in the states as a psychologist I did mostly IQ tests. I didn’t really do any educational kinds of evaluations. I was doing consulting in that area. And in Israel, the psychologist is expected to do both or at least be prepared to do, and is trained to do both. So that was actually one of the exciting things.

    And although our instruments are very behind, [00:33:00] but actually being able to look at kids’ achievement and get a sense of where it is reading and math levels are. That was exciting because I had not done that in the states. So that’s one area that’s interesting.

    Yeah, we’re asking those questions as well. And again, the whole movement in the states about we want to keep testing kids, we want to minimize the testing. That’s starting to be discussed here. We’re moving more towards let’s help the kid first and then test, that kind of movement. I don’t want to call it RTI because that’s not what it is, but that philosophy is filtering in, but psychologists are expecting to test a lot of times that is for eligibility meetings to find out what the diagnosis classifications are going to be.

    One project that I got involved in over the last [00:34:00] year is that high school students have to take a series of national tests in various academic subjects, almost like the British model. And the ministry of education came to the realization two years ago that the numbers were inflated with regard to how many students are getting testing accommodations and those huge inflations.

    So you would have kids, especially kids who could afford it would go for private evaluations and would have a whole slew of recommendations without any extra time, the test has to be read, this and that. That was becoming a major business. And so, the ministry of education became more aware of that and they started this pilot project where they really want to cut down the number of students and take a real good look at who’s getting those common testing accommodations.

    And so I coordinate that project in another city and that’s also really [00:35:00] interesting. That was for a long time another area for a psychologist to test kids who need to get accommodation through those national press.

    Dr. Sharp: Right. Can you share any of the findings from some of that work, conclusions, or anything that you’ve taken away?

    Dr. Roth: Yeah. Well, I agree. In other words, the intention is correct. There’s real inflation. Like I said, the kids from the wealthy areas were the ones with the accommodation whereas the kids within the periphery or the NLD, the socioeconomic levels who couldn’t afford to get private tests were really struggling. And obviously, it’s not fair, not equitable. So I agree with the intention of the program.

    The problem that we’re seeing is that there are a lot of kids were struggling and [00:36:00] they’re in a hard place because on the one hand, they’re not eligible for the testing accommodation because they don’t get the category of learning disabilities necessarily. On the other hand, they’re not getting the resources that they need to be successful in school. So where do you put them? That’s where we’re at now.

    Dr. Sharp: Yeah. Well, I think that sounds like a universal problem is how do you support those who need it and keep those who are already at risk of falling behind?

    Dr. Roth: It’s almost as if they’re saying, cut down the numbers but we don’t want to give any other resources for them to be successful.

    Dr. Sharp: Yeah. It’s really a hard place to be. You’ve mentioned clearly you have some administrative responsibilities and you’re operating on a bigger level in terms of policy and [00:37:00] some of these projects. So, would you say the opportunity to do things like that is greater in Israel than here?

    Dr. Roth: Well, I’ll say this, I never expected to be, I thought I’d be just your average school psychologist. I thought I was happy doing it until one day that my director said, Hey, there’s this job opening up as a director in this town. Why don’t you go for it? And I didn’t really think of myself but once I got to that place, a lot of opportunities opened up. Like I said, I’m now on the registry board of psychologists. Just things open up.

    And I think also when you’re in an administrative, you used to see things differently also in terms of your private practice, you see like the big picture of things, more of a zoom-out approach. So that was very helpful. Like I said, I didn’t think that I’d end up in that position, but I’m grateful that I did.[00:38:00]

    Dr. Sharp: That’s great. It’s funny where we find ourselves. We stumbled into these things and finally… It sounds like somebody else in the house is excited about the opportunities.

    Let’s see. I do want to talk a little bit about the nitty-gritty and the details. You mentioned earlier that you’re a little bit behind in terms of measures and processes. So can you say a little more about that?

    Dr. Roth: Yes, for sure. So when I was training in 1997, I remember the WISC-III came out. And then in 2003, the WISC-IV came out. So in the span of just two years, we had these two brand-new intelligence tests. Now, when I came to Israel, [00:39:00] they were using, I guess the equivalent of the WISC-III would be. That was in 2005. So they were using the equivalent of WISC-III.

    This year, over the summer, they just finished this huge project of translating and norming the Woodcock-Johnson for the Israeli population. It was a project that took years. And I just underwent a month of training on the Woodcock-Johnson and that is going to be our test of the future. But you can find people who are even Jeremy, I dare say they’re using the original Couchman test from 1982 or 1983.

    Dr. Sharp: Oh my goodness.

    Dr. Roth: That’s where we are. So we’re very behind, I think I remember listening to a South African psychologist and she was using the WISC from 1989. That’s where I saw that. Okay. [00:40:00] So I felt for her because I know exactly what that’s like.

    Dr. Sharp: And what is driving that as far as you can tell? I’ll leave that open. I have some guesses.

    Dr. Roth: I have a bunch of punches and factors I think that goes into it. I find that a lot of psychologists are just not interested in testing. Even though obviously it’s one of our responsibilities, they don’t look at it as the glorious part of the job or the glamorous part of the job. And like I said, there’s a very heavy clinical influence, school psychologists to be almost like a clinical psychologist and the therapy and the talking and then less of the testing. That’s one factor.

    I think you don’t see a lot of people going into research also as far as [00:41:00] diagnostic, learning disabilities, those areas, you don’t see people continuing in that. I think another factor is that we have so many different populations here in Israel. Also, it’s a very immigrant population. I think, per capita, we have the most immigrants out of any country in the world. So we have people from literally every corner of the earth coming to Israel and finding some instrument that will be useful for everybody or funding and norming it is a huge undertaking. So that’s why I think it’s taking a long time.

    Dr. Sharp: I wanted to ask about that. Are there measures that are, let’s just stick with Hebrew, it sounds like there’s a very diverse population there, but are there measures that have truly been normed and developed in Hebrew?

    Dr. Roth: Yes, there are. The WISC-IV was translated into Hebrew. The WAIS is [00:42:00] translated to Hebrew and both of those are also translated into Arabic as well. We obviously have a Palestinian Arabic community here. So a lot of the measures are translated both to Hebrew and into Arabic and this brand new Woodcock-Johnson is translated and normed with various populations in Israel as well.

    Dr. Sharp: Yeah. That’s great to hear. So the WJ is what is coming out?

    Dr. Roth: Yes, the expectation is by the end of the school year we’ll basically transfer over to that test.

    Dr. Sharp: Sure. So I don’t want to put either of us on the spot and really have to get into the weeds of test norming and development, but can you speak at all to the concerns or the validity of translating a measure versus actually norming a measure in a certain language or culture?

    [00:43:00] Dr. Roth: Sure. So I’ll give you an example. We have a population that is the ultra-Orthodox population in Israel. So they’re more the religiously observant sets of Judaism. Their philosophy is that they don’t really believe in secular education. Most of their studies are religious studies but they do get funding from the government. So we do provide services for them.

    So if you ask them certain questions, even if you translate items on a test, they may not be culturally appropriate for them. I’m trying to think of an example, but things that have to do with television. Most of them don’t own televisions. I remember on the old cows from cartoon characters or television characters that they have to recognize that obviously, it’s not appropriate [00:44:00] at all. But that’s an example. So it doesn’t matter if you translate it. It’s just not culturally appropriate for that population.

    Dr. Sharp: Right. That is a great example. I think that’s an ongoing concern. Not many of the folks that I’ve spoken with internationally or even in the US unit who work with language-diverse populations have measures that actually have been normed or even translated. It’s very challenging.

    Culturally speaking, how has that been either? We talked about professionally, if there’s anything else you want to add professionally, but personally too, how has it been to move to another country and particularly this area of Israel? What’s that been like for you and your family?

    Dr. Roth: It’s always interesting here. There’s always something whether it’s politics. It’s a very interesting place to live. The [00:45:00] people have energy and drive. They are very, I would say almost short-tempered. Israelis are almost short-tempered. They’re the same without giving the shirts off their back if you were stuck somewhere so they have this complex kind of personality.

    But there are definitely things that you have to learn. I remember coming here and I was trained in the CBT model and it took a while for me to understand that that model may not be so appropriate to work with Israelis, giving them assignments and giving them tests that they’re not willing or just culturally, might not be appropriate for them.

    So it took me a while to learn that [00:46:00] but just living in this country is great. It’s great for my kids. My kids love being here. We used to visit the states every summer and at the end of the summer, they all want to go back home now. And I was always afraid that they’d get stuck in America. I call it Disneyland. It’s huge. There are places to shop. It’s great. It’s wonderful. But they all want to go back to their friends.

    And then the other half of the step, that’s the difficult part is that we left family behind in the states. That’s been the most challenging. It’s being there on her own. And luckily actually before COVID our family came over to visit family occasions like that’s been a challenge.

    Dr. Sharp: Yeah, of course. Well, for some people, one of the hardest parts is leaving family, or at least [00:47:00] those that you’re close to if that’s family or not. Can you speak to that dimension of Israeli culture in terms of a collective culture are they individualist or what?

    Dr. Roth: It really depends. That’s the best answer I can say because there are so many different cultures and populations. It really depends. The immigrants that have come from the north African areas tend to be more family-oriented but then you have a lot of immigrants from the Western countries, America, England, Australia, things like that. They bring their culture from there with them. It really varies. I think that’s what makes it really nice. On my block, we have friends who are Israelis. We have friends who were Americans. We have friends who [00:48:00] are from England.

    Dr. Sharp: That’s amazing. Say it a little bit. I think we spoke off-mic about your area, but can you speak a little bit, like the area you’re in? What size of a town or city it might be, that sort of thing?

    Dr. Roth: Sure. So I work in the town, and it’s called Bet El […] I can find a lot of them in the states, but I actually work in the original. It has a lot of historical significance and a lot of biblical significance. So it’s neat to be able to work there. It’s a small town about 20 minutes north of Jerusalem. The folks that live there are all religious. About 5,000 people live in the town. The education there is separate. So we have separate schools for boys and girls, for religious reasons. That is also interesting.

    Dr. Sharp: Fantastic. So let’s see. What else? I’m always curious, advice for anyone who might be thinking about making a leap like this is- things they consider, resources that might be helpful, anything in that realm that you might be able to provide?

    Dr. Roth: The ministry of health is the board that is in charge of the licensure here. They have a website that’s available in English with instructions about what requirements are needed here for licensure, what documents you have to submit [00:50:00] et cetera. I believe you can even submit them even before you actually moved. You can submit them while you’re still overseas and then they’ll take a look at it and give you actually an idea of what’s next, what you need to make up or what’s missing, or to go find that old syllabus with all recommendations from you. They’ll tell you what you need to submit.

    I would say again, come as informed as you can. People are certainly welcome to email me. I don’t try to hide anything. It is what it is. There are a lot of challenges. It’s a great place to live. The work is challenging. I’m very upfront about the salary and that needs to be part of the consideration, I think. To be honest with that, it’s just not fair. So I would say, start with the website ministry of health.

    [00:51:00] Dr. Sharp: Great. Can you speak to other challenges? What are some of the tougher parts about being there that we haven’t touched on so far?

    Dr. Roth: Thankfully it’s been quiet in terms of politics. Geopolitically, it’s been quiet, but that hasn’t always been the case. I’m in my current position for seven years now and we’ve had bout 3 or 4 terrorist attacks including shootings and terrorists in the town that I work in. That’s not pleasant. There’s almost as chronic anxiety, I would say amongst the people that live there.

    Dr. Sharp: Do you see that in your work? I mean, with the kids or families, does that show up?

    Dr. Roth: I definitely get that sense. I [00:52:00] would say yes, from working with the schools, there’s almost hyped tension and anxiety that everyone’s like almost on edge. That’s definitely palpable. So that’s there and hopefully, they’ll remain quiet for a long time, but that’s been a challenge for sure. And the language, like I said, the language was… I find that from talking to other immigrants, a major hurdle is learning the language.

    Dr. Sharp: It’s important to keep in mind. It sounds like you were fluent before you got there and it’s still been a challenge to get up to a professional level.

    Dr. Roth: Yeah. I’d say it took me between 3 to 4 years to be comfortable writing a report in Hebrew. And I then came to the realization that no matter what, I will never write like a native Israeli. So once I came to that realization and it was like, I just need to get my [00:53:00] point across. I still have someone spellcheck or a look over my reports because I make mistakes but yeah, the professional language and that’s again, another challenge being comfortable with it.

    Dr. Sharp: Yeah, of course. It was such an undertaking. I’ve never tried to do it myself. I think here it would be Spanish. That’d be the natural second language. It’s so intimidating, especially as an adult, I think about trying to become fluent in another language.

    Dr. Roth: Yeah.

    Dr. Sharp: Let’s see, just to close, and you may not be able to speak to this. If so, that’s totally fine. Do you have a sense of like the landscape in private practice for psychologists there in terms of the market, the health insurance, do most take insurance or not, anything [00:54:00] feels relevant to add there?

    Dr. Roth: Yeah. The way it works is that most people who see a private psychologist pay privately. Some psychologists have arrangements with the different insurance programs so they can get some kind of payment back or a rebate or whatever you might call it. I find that the testing market, if I can like look into the future is that the market for testing is probably going to go down because the ministry of education, again, part of this pilot is they’re working to take over the whole testing process and to have everything on come under their auspices. I can see that as a trend.

    There might not be a lot of… I know in my own practice, the demand for testing is not as great as it once was. [00:55:00] So private therapy, psychotherapy, I think that’s going to continue to exist. English speakers, there are pockets of neighborhoods that have a concentration of English speakers. And obviously, it’s easier for them to communicate in English. So they’re looking for English-speaking therapists. So that’ll continue to exist I imagine.

    Dr. Sharp: Nice. I appreciate you talking through all these different aspects of living and practicing over there. I feel like many of these there are so many trails we could go down and paths we could take. But it at least gives an overview and a sense of what it might look like for someone to take this leap.

    Dr. Roth: Yeah. I really appreciate you taking the time to talk with me.

    Dr. Sharp: Of course. You’ve said two times you’re open to speaking with others. What’s the best way to reach [00:56:00] you if someone wants to get in touch?

    Dr. Roth: Definitely through email. That’s the best way. And I can get back to you in a day or two.

    Dr. Sharp: Great. Right. We’ll make sure to put your email address in the show notes if people want to get in touch. I think especially these days, there are a lot of folks in the US thinking about not living in the US so I’ve heard a lot of talk of how to get to other countries and where, and what that might look like. I’ll be curious if folks reach out to you.

    Dr. Roth: Yeah. If I can help, it’d be my pleasure.

    Dr. Sharp: Well, Michael, thank you again. This was just personally very interesting. And I think a lot of people will probably find it helpful as well. So thanks.

    Dr. Roth: Thank you.

    Dr. Sharp: All right, y’all. Thanks so much for tuning into my episode with Dr. Michael Roth about school psychology in Israel. I hope you could tell, Michael is just a kind [00:57:00] genuine down-to-earth guy. This was a really enjoyable conversation. And if nothing else, it just paints a picture of what it might look like to practice internationally. I know that my family has been talking about moving internationally for years here and there and each of these conversations just gives me more hope that it is possible if that comes to bear. So thanks again.

    If you have not rated or subscribed to the podcast, I would love for you to do that. I put out a call recently to try to get us to 100 ratings in the apple podcast app. As of this moment, we’re at 96. So I am just OCD enough to care enough to ask you to get us to 100. So if you have not rated the podcast, I know we have a ton of subscribers and if just a small fraction of y’all will take a second in the apple podcast app and tap the ratings, that would be awesome [00:58:00] to get us to 100.

    So thank you all so much as always. Take care. We will catch you next time.

    The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychologic, 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 the listeners of this [00:59:00] 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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  • 156: Coaching: Is First-Year Profit Possible? w/ Dr. Kylee Miller

    156: Coaching: Is First-Year Profit Possible? w/ Dr. Kylee Miller

    Would you rather read the transcript? Click here.

    Welcome, everyone, to the first episode in another new podcast format – on-air coaching! Today I’m speaking with Dr. Kylee Miller. Kylee is a hospital-based psychologist in Oregon who currently has one day each week to devote to private practice. We work together to run the numbers and figure out how many clients she would need to see to come out “in the black” during her first year in practice, accounting for overhead and start-up costs. 

    As always, let me know what you think of this new format! If you’d like to apply for an on-air coaching call, you can fill out this application.

    Cool Things Mentioned

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    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.

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  • 156 Transcript

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

    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.

    Okay, everybody. Welcome back. Today’s episode is another new format for the podcast. I am really trying to experiment with a few different things here during this last quarter of 2020. So, please give me some feedback. Let me know how you liked that masterclass episode last time, and let me know what you think about this one too.

    This time we’re going to be doing an on-air live coaching call with Dr. Kylee Miller. The idea here is that I meet with clinicians, we do coaching here on the podcast, and release it as a podcast episode. My hope is to cover issues that are relevant and current for many of you.

    And to that end, what I am talking about today with Kylee is, how to be profitable your first year in private practice when you only have a part-time practice.

    And we dig into questions like, can you even expect to be profitable that first year? If so, how do you balance overhead with the number of hours you need to work to come out in the black? We dig into her local insurance rates, private pay rates, and her overhead for testing including startup costs and monthly ongoing costs. We work through that math and figure out whether she can sustain a private practice and still come out in the black. So check this out. I would love for you, like I said, to give me any feedback and let me know whether you like this format.

    Kudos to Kylee for being willing to engage in a little bit of an experiment and just go for it here on the recording. But this is super enjoyable for me. Like I said in the past, this is a big part of what I do. I love coaching practice owners. I hope that y’all will find this helpful.

    Let’s jump into my conversation with Dr. Kylee Miller.

    Hey Kylee, welcome to the podcast.

    Dr. Miller: Hi, thanks for having me.

    Dr. Sharp: Yes. Thank you so much for coming on and being willing to experiment a little bit with a new podcast format here where we’re going to just dive in and do a live coaching call around some of your questions. So I appreciate you being willing to do it.

    Dr. Miller: Wonderful. Thanks for having me.

    Dr. Sharp: Yes. Let’s just start. I would love for you to talk about your professional world; what your practice looks like and where you hope to take your practice.

    Dr. Miller: Absolutely. I live in two different worlds professionally right now. My main employment is through a university hospital system where I do three-quarters time. So 30 hours a week of testing. I am a testing psychologist with a very narrow scope of focus and that actually applies to my private practice as well.

    In my private practice, I have an even more niche focus. I serve people with neurodevelopmental disabilities. I do complex diagnostics on that. And then in my private practice, I supposedly travel. I don’t have a brick-and-mortar. I don’t have to bill insurance. I do evaluations for individuals on death row that have suspected or been diagnosed with neurodevelopmental delays.

    I am looking to grow my private practice into continuing to serve people with neurodevelopmental disabilities, but brick and mortar in the town that I’m living in, and parlay my university hospital work life into my private practice.

    Dr. Sharp: Sure. We were talking about this before we started to record, but that little niche area of evaluations with folks on death row is quite fascinating. I just want to acknowledge that and say to the audience, I’m sorry, we’re not going to dive into that. We’ve got a different topic here today. Maybe in the future.

    Dr. Miller: Absolutely.

    Dr. Sharp: Can you say a little bit about what you hope your practice would look like say in six months? If all was going well, what your schedule would look like and what kind of kids you’d be seeing.

    Dr. Miller: Right. If all went really well, and it’s somewhat dictated by insurance I think in the state that I’m in, but I would be seeing exclusively kiddos with neurodevelopmental disabilities. I’m actually in the department of pediatrics at the hospital which is new to me. I just moved to this state two years ago. Previously, I was in the department of psychiatry and I was able to see all age ranges. I would love to go back to that. There’s absolutely a need for that in this state. And I would be seeing exclusively those patients.

    In five years’ time, I’d love to have students with me. I would love to have other professions. I would love to have an interdisciplinary but definitely, multi-disciplinary clinic. I always work with speech-language pathologists, OTs. So I’m really trying to set up my license, this is another topic, but I’m trying to set up my private practice license to be able to be a supervisory health service provider for other disciplines as well.

    And so as I look into these EHRs, I’m really trying to see, what coverage do I need to be able to bill for those services as well? That’s down the road, but financial planning.

    Dr. Sharp: Yeah, certainly. Well, I think it’s nice to have a vision as early as you can. So, if you know in your future your ideal is to have a group practice and you’re supervising folks in some allied health services, that can drive some decisions here early on.

    Dr. Miller: I think so. Yeah.

    Dr. Sharp: Nice. So, could you just say… Let’s see, what would we like to tackle during this call? What is top of mind for you here as you’re launching this other part of your practice that we can get into?

    Dr. Miller: I have so many questions, but I think the big umbrella is how do I come out in the black? Is that even feasible in the first year? How much do I have to take in to be able to make money to be able to support myself? Do I have to keep my university hospital job to see the patients that I want or to make money or both? And how does that translate into my fixed expenses, my annual budget, my startup costs, like what does all of that, it was a lot, but what does all that translate to? So I guess for us through the trays, how much money do I need to make to be okay?

    Dr. Sharp: Sure. I love it. I think this is a question that a lot of folks who are starting out are being anxious about. That’s what we worry about, right? If I leap into private practice, can I make the money that I need to without drowning?

    Dr. Miller: Right. I think I love this.

    Dr. Sharp: Yeah. You phrased it like, what do I need to make to just come out in the black? And we’ll see. I think that’s a relatively easy number to figure out, but I always like to think too, what if you weren’t just in the black but you were swimming in black? Ideally, what would you like to have, and is that possible through your private practice? So not just breaking even, but maybe even enjoying it, thriving and being financially totally secure, all those things.

    Dr. Miller: Living in the university hospital system, that is a totally foreign concept. Literally, my goal is, how do I continue to serve people, but maybe I need to think, and maybe I need to have a different mindset. Maybe there is a thrive here financially because that would be a game-changer for me.

    Dr. Sharp: Cool. Well, we’ll see. Let’s work through some numbers and see what we come up with. I really liked this question. I’ve said on the podcast in the past that a lot of anxiety can be solved with math. And this is one of those cases where hopefully math will come to our aid and help us out a little bit.

    Let’s start. Whenever I do something like this with coaching folks, I always like to start with what the expenses are just to give us an idea of what you’re actually going to have to put out each month. And some of that might be a discussion too around what do I really need when I launch a private practice? So, have you done some of that work to have some ballpark of your monthly overhead in private practice so far?

    Dr. Miller: Yes, I have.

    Dr. Sharp: Cool. So let’s talk through that. Let’s talk through the components that you’ve identified, the things you’re going to be paying for basically. Can you tell me what you’ve gotten so far? 

    Dr. Miller: Right. I’ve parsed it out so far into two main categories. The first one is startup costs, so one-time fees. And then I have recurring costs that are set- fixed expenses. 

    Dr. Sharp: Great. Let’s start with those.

    Dr. Miller: So, which one would you like to start with?

    Dr. Sharp: Let’s start with the start-up.

    Dr. Miller: Okay. So the startup costs, I’ve got the attorney fees. I’ve spoken to an attorney twice now. She charges about $550 for a one-time licensing, like an LLC. I currently have a sole proprietorship. And so I’m discussing with her reasons that I would need an LLC. So there’s the startup cost.

    The test kits, which having a very… This is part of my question. Do I go for more general assessments at first and not serve the people that I generally serve because mainly I do hearing-impaired, visual impairment, physical disabilities, which requires a very different test battery that is very expensive? So if I were to do that, that would be closer to the $20,000 mark, whereas if I did the typical, have a general cognitive, a general academic, and then a social communication assessment for autism because I can’t divorce myself from that. I will be doing those. That’s more like $6000 to $10,000. 

    Dr. Sharp: Great.

    Dr. Miller: So I’m trying to go through that.

    Dr. Sharp: Did you look at the possibility of how much of this might be covered with something like Q-interactive, if you’re open to that option or?

    Dr. Miller: I am open to it. I’ve had a terrible time with it with the current clientele that I serve. It is not working. I have almost totally abandoned it. So if I serve a different clientele, I would absolutely be open to it. I’ve used it before. I’ve done it with higher functioning individuals, but as it stands now, no, but I would be open to that.

    I’ve also looked into, can I borrow these test kits from anyone for a little while just to cut my initial costs as I start to build up capital to sink it back into the practice? I can’t borrow it from my current position because people are always using the stuff at the hospital. And so I can’t borrow, unfortunately, there.

    Dr. Sharp: Okay. So we’ll call it $20,000. I like to be conservative and just shoot for the high side and see where we end up. So let’s keep it at $20,000 and then see where we go. 

    Dr. Miller: Got you. Okay. And then furniture. I don’t have a number for that yet, but 2 chairs and a table.

    Dr. Sharp: Let’s call it $1000. I always ballpark $1000 for an office. You might come in a little bit under or a little bit over, but I think that’s a decent ballpark.

    Dr. Miller: Okay. And then a computer. And I just called that $1000 because I was just trying to do even numbers.

    Dr. Sharp: Sure. I like even numbers. Would you prefer Mac or windows?

    Dr. Miller: Windows.

    Dr. Sharp: You’re okay. You might be able to get that under $1000, but that’s a good round number. We’ll keep that.

    Dr. Miller: Yeah. And then marketing. I feel like marketing costs, in the beginning, it’s actually a double-dip line item for me because I feel like there’s ongoing marketing stuff. Initially, it’s going to be I think, more time-intensive going out, selling myself to pediatrician’s offices or family practice places, which will require a different level of marketing, and being a little bit savvier on my part because I also have my university hospital position and I can’t detract from that. So I cannot talk about that at all in my marketing. I don’t have a non-compete but I can’t take. And that makes sense. And I don’t want to.

    Dr. Sharp: Of course. I think that’s fair. Unless you were, I mean, if you were considering something like Google ads, there’s also often a setup fee that could be between $500 and $1000 just to get your ads up and running. And then there’s an ongoing monthly fee, but yeah, if you are open to the idea of just building relationships and doing the networking thing, then that’s relatively inexpensive.

    Dr. Miller: Right. I’m trying to cut costs and keep a budget. So, that was it for my startup costs.

    Dr. Sharp: Okay, great. So what do you have for ongoing?

    Dr. Miller: I have malpractice insurance which is $2200. So these are annual. Do you want me to break it down annually or monthly?

    Dr. Sharp: Let’s go monthly if you’ve got that

    Dr. Miller:  But I am interested in an EMR that does it all. I’m like, let’s just take the guesswork out of it because I’m already like, oh my goodness, there are so many moving parts here. I’d like to reduce those moving parts in the hope that that drives me towards success.

    Dr. Sharp: Of course. I think that makes a lot of sense. So simplifying and consolidating is ideal. I’ll be honest. 

    I’m not an expert. I haven’t done a lot of work with TheraNest, and this is gosh, at the time of our recording, just ahead of a little series I’m going to do on EHR reviews. So, I don’t have that knowledge yet, but I am going to look at TheraNest.

    I will say that something like TherapyNotes or a SimplePractice, I know you can get away around $50 a month and they include calendar notes, insurance billing, keeping track of patient balances, and almost everything you would need to do within your practice. So just to throw that out there as an option. You may be able to get away. And it’s all one unified system. I’m a big fan of keeping everything under the same roof if you can.

    Dr. Miller:  That is of the most interest to me here. As I launch this truly, the fewer moving parts I have, the better off things are going to go.

    Dr. Sharp: Okay. So, just for the sake of our discussion, let’s split the difference and maybe say $75 for an EHR per month. And if we’re a little off on that, it won’t be a huge issue. 

    Dr. Miller: Okay. And then office ally then goes out the window with that. So that’s not separate. Website, $15 a month. Does that seem high?

    Dr. Sharp: No, that seems reasonable.

    Dr. Miller: Okay. and then a phone line is $30 a month. That’s with an answering service. Mailbox, it’s interesting that I have this as a line item because I also have an office space, but the reasoning behind that is as you start to do these applications, you have to do all this credentialing, and you have to have a physical address for credentialing, but I’m not prepared to spend $550 a month renting a space yet before I’m credentialed and can actually see people. So you can rent a mailbox here locally very close to where I’m going to have an office and it’s $12 a month. And it is a physical address. It’s not a P.O Box. So that’s where that came from.

    All of these are weird little things that I never would have thought about, and I’m not sure if that’s even the right way of going about doing all of this paperwork and starting it up, but to me, it made sense because I don’t want to do the $550. And so, my next one’s office space which is $550 a month. And that is for a single office. It’s to myself in a shared space, but just a room in a shared space.

    Dr. Sharp: Is that for full-time or would that be for one day a week? 

    Dr. Miller: That is full-time. Now it’s not that much less. I can find one for like $425. And it might be the time of year that I’m looking right now and COVID, and all of that stuff that’s dictating these prices. There’s not a lot of real estates here. And so, finding something that’s like a shared office space which is what I’d really like, because again, I’m going to be working at the university hospital maybe forever, maybe not depending on how it goes, but I’d love to have a flex space that I could actually share with someone who’s doing a similar practice, either therapy or maybe assessments, and then we can rotate. I could do two days a week and then call it a day.

    Dr. Sharp: Yeah, that’d be fantastic.

    Dr. Miller: But I haven’t found anything like that. So right now my line item financially is $550 and then I can use it whenever. That wouldn’t be my choice though.

    Dr. Sharp:  Okay. I think that’s fair. We can keep it as again, that conservative estimate, but sure, if you could find a situation where you could just rent for a day a week or share with someone and even split it halftime, that would drop that significantly. Well, hopefully, it would be doable. I know geographically, it can be different, but keep that in mind.

    Dr. Miller: Hopefully doable. It’s tough here though. And then I have things like a subscription to a HIPAA compliant telehealth something. Is that part of the EHR or is that a separate thing? I haven’t quite looked into that. A document camera. Do I need that? Is that like a monthly thing or is that a fixed overhead? I have a bunch of other little things that add up to a lot but aren’t fully formed thoughts.

    Dr. Sharp: Yeah. That’s totally fair. Okay. I think you’ve covered it pretty well. This is a good ballpark of what you might need to launch. And then you know your ongoing expenses. The HIPAA compliant telehealth, a lot of the EHR platforms we’ll have that wrapped up in them. So that should be included in your monthly cost there. But for the sake of, again, just being conservative, I’d rather be surprised with money than be surprised to have to pay money.

    Dr. Miller: Yes.

    Dr. Sharp: Okay. So let’s do a little bit of math here. So for those ongoing expenses, we’re looking at, let’s see, that’s about $250, $300, so you’re up around, let’s just say $900 for monthly expenses, maybe $1000. We’ll call it $1000 just to have a nice round number. And then with the startup costs again on the high end, I think you’d be looking at around $23000 to start off if you bought…

    Dr. Miller: That’s exactly what I had. Yeah. 

    Dr. Sharp: Cool. Okay. So now let’s dig in and really just figure out how many hours would you have to bill to meet these numbers, right?

    Dr. Miller: Right.

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    Dr. Sharp:  You said before we started recording that you could foresee a big part of your population being Medicaid insured which reimburses about $50 an hour?

    Dr. Miller: Yes.

    Dr. Sharp: Okay. So, let’s just take ongoing monthly expenses. $1000 divided by $50 is super easy. And so that comes out to 20 hours to cover ongoing monthly expenses.

    So 20 hours. Let’s just say, if you’re doing one day a week ballpark, we could call it 10 hours again, to keep things even. That’d be a long day, but it also allows a little bit of flex where you’re testing maybe on that day, but then you’re writing during some other times or something.

    Dr. Miller: Yeah, that’s feasible.

    Dr. Sharp: Okay, 10 hours a day, let’s just call it four times a month. Theoretically, you have the capability to bill let’s just ballpark $2000 a month. Are you with me on that?

    Dr. Miller: Yeah, I’m with you. I’m hanging in.

    Dr. Sharp: Okay. Awesome. And this is super simplified, but again, I think we got a pretty good approximation. And maybe months with five weeks, that might be more than that, but four weeks you’ll at least have four, 10 hour days that you can bill.

    So, right off the bat, having the capability to bill let’s just say $2000 a month, that easily covers your monthly overhead, which is on the high side. I just want to remind you again. This is like a high estimate. So if you could fill those four days, I think you could easily be in the black, monthly.

    Now, if we go back to those startup costs, then if we sit at $23,000, again, this is super simple, but if you take $1000 a month, put it to your overhead, and then take the $1000 each month and put it toward your startup costs, that would take you about two years to pay off, give or take on the high side.

    Dr. Miller: Right. I think that something more reasonable would be for me to alter the types of patients that I see to make sure that I’m more financially comfortable when first starting up a business. That’s one of the sacrifices you might have to make.

    Dr. Sharp: Sure. Yeah, let’s run through that scenario. The one that we just talked about is sort of like the, I don’t want to say the worst case, because you’d be seeing the patients you really want to see, but on the financial side, that’s probably the least you would make and private practice. So if we did some kind of hybrid, do you have any idea what the private pay rate in your area is? 

    Dr. Miller: I have no clue. I’m useless. Sorry. I know that.

    Dr. Sharp: No, no, it’s all good. So this is a good time. I can just throw in a little suggestion. If you’re trying to devise your private pay rate, I always say, survey people on Psychology Today or websites, try to get a group of like 20 practitioners in your area. And if you can find the average rate for therapy, just add 10% and that can give you a good rate for testing at least to start out.

    Dr. Miller: So I was talking, and I think you and I were discussing this before you started recording that I had been interviewing some local people here that were in private practice, who were actually testing psychologists. And they said that they got about $50 an hour for the private insurance because the other number that we were discussing before was how little Medicaid pays. And so, I think that those numbers might be a little high for this area which is crazy because this is a high cost of living State. It’s the second-highest cost of living

    Dr. Sharp: Okay. So you’re saying that Medicaid would reimburse $50 an hour, that seems high?

    Dr. Miller: That seems high.

    Dr. Sharp: So maybe they would reimburse closer to $40 an hour?

    Dr. Miller: Probably $35 to $40 an hour, and then private would be $50. But I’m hoping that there’s… I’ve heard that there’s a great deal of variability between what people get reimbursed because it’s up to each individual practitioner to negotiate their rates. And having spoken to people, even at the hospital system, there’s a great deal of variability.

    Dr. Sharp: I see. Okay. 

    Dr. Miller: I’m going to have to educate myself in that.

    Dr. Sharp: Okay. Fair enough. 

    Dr. Miller: All that to say, I don’t know if I’d be comfortable calculating private pay rates higher than $50 an hour because it’s unlikely. 

    Dr. Sharp: Oh my goodness. That seems super low.

    Dr. Miller: Right. Which is part of the reason why I’m terrified because when I crunched these numbers, I’m like, huh, I’m either just giving my services away.

    Dr. Sharp: Right. Thinking about the private pay rate in your area, I know that you said that not many folks are doing private pay and the commercial insurance reimbursement is a little bit of a question mark. I’ll tell you what, let’s do a little bit of a hybrid here and say, if you’re able to get some private pay cases since you are pretty specialized and maybe you take some insurance, maybe take some Medicaid at least to get off the ground, I wonder if we could hit an average of $100 an hour for your reimbursement rate between all those sources.

    Dr. Miller: Okay. That sounds reasonable.

    Dr. Sharp: Okay. So that puts us in a little bit of a different place. If you were to get reimbursed $100 an hour on average compared to that $40 or $50, that changes things. So now you’re bringing in about $4000 a month. You put $1000 toward overhead, and then you have roughly $3000 to put toward other things. So on the high end, that would take you about eight months to pay off the startup costs. And then you would be in the clear for the rest of your life.

    Dr. Miller: It sounds a lot better.

    Dr. Sharp: It sounds a lot better, right?

    Dr. Miller: That sounds a lot better.

    Dr. Sharp: That sounds a lot better. Yes. So the short story I think is, the likelihood is that you’ll probably end up somewhere in the middle, maybe closer to, and we’ll see. There’s some market research to do. It’s hard to know what insurance panels reimburse until you start getting those contracts coming in, but the likelihood is that you might end up more around like $75, let’s say. So we’ll split the difference.

    So, at least from my perspective, covering that $1000 a month overhead is pretty easy. That seems very doable based on the time that you have to work. And this also doesn’t take into account any of the money that would be coming from your other little branch or private practice where you’re doing the death row evaluations.

    Dr. Miller: Right. And those pay well.

    Dr. Sharp: Good. So, again, the most conservative estimate, you’re fine on the monthly overhead. And then it might take you two years to pay off the startup costs. But then, more of a best-case scenario, you’re more looking at eight months to pay off the startup costs and then you’re free and clear. And then the likelihood is that it’ll be somewhere in the middle.

    Dr. Miller: Okay.

    Dr. Sharp: So, how does that feel?

    Dr. Miller: It feels better. It’s nice to walk through those. Thank you. Walkthrough those calculations. I still have in my mind the taxes. That’s something that automatically comes out, right? A solo practitioner, it would be like 20% or 25%, I think, for taxes. So automatically, that’s coming out. So my take-home is not very much. And then if you’re talking about retirement and all that stuff, in my mind, I’m like, “I cannot see 100% of the patients that I went to many, many years of schooling to specialize in to see.”

    That’s so boring but also nice to know that I can branch out. I can still see some of those people. I don’t have to give that up, but the trade-off is having more control over my schedule, having more control over my finances because then it’s up to me to alter those numbers to slide one way that scale that you just described. And then maybe that opens me up to do other things like doing training in a different way that I don’t currently do now. Taking on different students or publishing different papers. There’s a season for things and maybe it’s a different season for me right now. These numbers really opened my eyes to different possibilities.

    Dr. Sharp: That’s good to hear. At least for me, it’s always been helpful just to put things down on paper and know what I’m working with and then you know what you need to do. And it’s not just this scary, like a black ball of a mystery that we don’t know about, you know? And I think it’s important…

    I’m glad you brought up taxes. I didn’t say a whole lot about taxes because largely we were talking about how to cover your overhead and then get out of debt. So you wouldn’t really be paying taxes on any of that until you start making a profit, which wouldn’t happen until you’ve paid off your debt in that first year. So taxes, certainly about 25% is a good ballpark to pull out once you get in the black.

    The other thing I wanted to say though, too, you had this question at the beginning of, will I ever be able to leave this full-time job or a three-quarter-time job? And the thing to keep in mind, which you’ve maybe thought about is that these fixed monthly costs, that’s as high as they will go whether you’re full-time or part-time. So when you expand to have your private practice fill three days a week or four days a week, the scaling accelerates quickly in terms of how much you’re bringing in and how little that overhead actually accounts for.

    Dr. Miller: Right. There’s definitely a minimum amount of hours that you can work, right?

    Dr. Sharp: Yes.

    Dr. Miller: Yeah, so part of it was like, what’s the minimum amount that I have to work. And then at what point can I start scaling back if I want to change the scope of my work in terms of clients served? This is very helpful. Thank you.

    Dr. Sharp: Oh, good. I hope so. And thanks for being willing to walk through this kind of in the moment and experiment with this format. So I appreciate it.

    Dr. Miller: I think it’s very useful.

    Dr. Sharp: Cool. Are there any other little questions or things to wrap up before I let you go?

    Dr. Miller: I don’t think so. Now, that seems much more doable. 

    Dr. Sharp: That’s great. That’s what I’m shooting for. Doable is good.

    Dr. Miller: Yes.

    Dr. Sharp: Awesome. Well, it was great to chat with you and work through this a little bit. I’m glad it was helpful. Best of luck as you build your practice.

    Dr. Miller: Thank you so much.

    Dr. Sharp: All right y’all, thanks so much for tuning in to this new experiment in on-air coaching. Hope that you enjoyed it. If you did, give me some feedback, if you didn’t give me some feedback, jeremy@thetestingpsychologist.com. I plan to do about one of these coaching calls every quarter. I have a long list of folks who’ve applied to do these calls on a variety of topics. So I’m excited about that.

    If you have not subscribed to the podcast, I would love for you to do that. If you have not rated the podcast, I’d love for you to do that. We are at 89 ratings on the Apple Podcast app. Can I get 11 people to jump in and tap those stars in the podcast out to get us to 100? I’m just OCD enough that I want nice even numbers. So can we possibly get to 100? That’s my challenge. That’d be super grateful.

    All right. Y’all stay tuned to the podcast. I’ll be back with another clinical episode on Monday. I hope you all are well. Have a great weekend.

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

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

    Click here to listen instead!

  • 155: Masterclass: Psychosis w/ Dr. Stephanie Nelson

    155: Masterclass: Psychosis w/ Dr. Stephanie Nelson

    Would you rather read the transcript? Click here.

    Hello everyone! Welcome to the first episode of a brand new podcast format: the Masterclass. During these episodes, I will host an expert in the field to present a case for us to talk through. We will take a detailed plunge into complicated clinical issues so that you can hear exactly how accomplished clinicians interview, test, and conceptualize challenging cases. My hope is to air one masterclass episode per quarter.

    Today’s Masterclass on differentiating adolescent-onset psychosis comes from Dr. Stephanie Nelson. Stephanie has a wonderful balance of clinical acumen, knowledge of the research, and humility that is on full display during this presentation. Here are just a few topics that we cover:

    • The role of viral infection and birth date in risk for psychosis
    • Relationship between trauma and auditory hallucinations
    • Relationship between medical issues and psychosis
    • Typical “causes” of psychosis – acute vs. episodic
    • A battery for assessing psychosis 
    • Delivering feedback for a psychosis diagnosis

    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. Stephanie Nelson

    Dr. Stephanie Nelson is a pediatric neuropsychologist who specializes in complex differential diagnosis. She is board certified in both clinical neuropsychology (ABPP-CN) and pediatric neuropsychology (ABPdN). Dr. Nelson earned her undergraduate degree at Williams College and her doctorate in clinical psychology at the University of Vermont. She completed her internship and postdoctoral fellowship in pediatric neuropsychology at the University of Minnesota Medical Center. After a few years in group practice in the Boston area, Dr. Nelson returned home to the Pacific Northwest in 2014 and opened her own practice. In 2018, she founded Skylight Neuropsychology in Seattle, WA. She currently provides comprehensive neuropsychological assessments and outreach to the community through presentations, workshops, and volunteer work. She also provides consultation to psychologists and neuropsychologists who specialize in pediatric assessment.

    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!

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  • 155 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.

    Okay, everyone. Welcome to the episode. I am so excited about this episode y’all.

    Today is the first episode in a brand new format that I’m trying out called masterclasses. The intent behind masterclass episodes is to bring on an expert practitioner in our field to talk through a case [00:01:00] presentation or case conceptualization in great detail so that we can really get some insight into the thought processes, the battery selection, the interviewing strategies, and of course, the way that someone might pull together the data to make a diagnosis or diagnoses.

    In this case, we are starting off with a bang. I’ve got Dr. Stephanie Nelson here to do a masterclass with us all about psychosis. This is a fantastic episode. If you have not heard Stephanie on the podcast before, she did come on probably about a year ago, maybe a little more in episode number 84. It was a very popular episode.

    Let me tell you a little bit about Stephanie.

    She’s a pediatric neuropsychologist who specializes in complex differential diagnoses. She’s board-certified in both clinical neuropsychology and pediatric neuropsychology. Stephanie was also recently elected to a [00:02:00] member at large position on the ABPdN board.

    She got her undergrad degree at Williams College and her doctorate in clinical psychology at the University of Vermont. She completed her internship and post-doc in pediatric neuropsychology at the University of Minnesota Medical Center.

    After a few years in group practice in the Boston area, she returned home to the Pacific Northwest in 2014 and opened her own practice. Then in 2018, she founded Skylight Neuropsychology in Seattle. Stephanie currently provides comprehensive neuropsychology assessments and outreach to the community through presentations, workshops, and volunteer work. She also provides consultation to psychologists and neuropsychologists who specialize in pediatric assessment through her website, thepeerconsult.com.

    So hot on the heels of our consultation episode from last week I believe. If you listened to this episode and find yourself wanting some consultation, Stephanie is an expert, [00:03:00] certainly in psychosis, but many other areas. She has frankly gotten rave reviews in the Facebook community about her case conceptualization and supervisory skills. So definitely check that out if you need a supervisor or consultant.

    One last thing I’ll mention is that Stephanie did provide a very comprehensive PowerPoint presentation with all of the key points from our discussion and resources and so forth. She even included a transcript of the feedback session that she conducted with his family. So be sure to check that out in the show notes as well.

    Okay. Without any more delay, let’s transition to our masterclass on psychosis with Dr. Stephanie Nelson.

    [00:04:00] Hey Stephanie. Welcome back to the podcast.

    Dr. Stephanie: Thanks so much. Glad to be here.

    Dr. Sharp: It’s good to see you again. I’m so grateful to have you back. I think since your last episode, your celebrity status has only grown- your star shooting higher and higher in The Testing Psychologist Community. We are very lucky to have you back and have some more of your knowledge and thoughts. So thank you.

    Dr. Stephanie: I don’t think any of that is necessarily true, but thank you for the warm welcome.

    Dr. Sharp: Well, that’s what I do. I’m trying to make you comfortable, warm you up, and get ready to go here. No, all true.

    Well, I’m excited about this. Like I said, this is a little bit different format. It’s a masterclass format. So something new here on the podcast, relatively new. I’m really thrilled to see where we end up on this.

    We’re going to be talking today about [00:05:00] diagnosing psychosis and thought-disordered stuff in a kid. So I will turn it over to you here at the beginning and just let you dive into the background, and then we’ll proceed from there. So present away.

    Dr. Stephanie: Fantastic. And you’re going to interrupt me anytime you have questions or thoughts, or if I get a little bit off track, but let me just start by telling you a tiny little bit about this young man and tell you what happened during the introductory phone call. I’m going to call this young man, I’m going to amalgamate a lot of different cases, to keep this de-identified. So if there are any continuity gaps, please forgive that. But that sometimes happens when you’re amalgamating.

    But I’m going to call this child, his name is Alexander, but his family has always called him Sasha. They’re [00:06:00] the second generation. His father immigrated from Russia when he was very little. And so they keep their ties to Russia. He is 17 years old and is in the 11th grade. And then for the last name in case I need it, I’m just going to say Case. So we’ll just pretend the last name is Case.

    He’s an only child. His dad is a CEO of a local major company, so a very high-up individual, and his mom describes herself as a household manager. He’s their only child. I told you a little bit about dad’s background. The other thing to know about dad is that his brother is a famous musician in this country. So they also have that as part of their history. And I knew a little bit about just from the intake questionnaire about their family history. What they wrote on the intake questionnaire, which we’ll find out was maybe not all [00:07:00] of the background history is that there’s some anxiety, depression, migraine, headaches, things like that. They didn’t really endorse too much.

    I first heard from them when they gave me a call. That was back in the day when I answered my own phone. Now I have a virtual assistant, but I answered the phone and they told me that they had this son who is brilliant and musically talented and has a lot of what they called the angst emotion of a genius creator.

    They said he’s been diagnosed with ADHD, anxiety with features of OCD, and depression at various points in his development. And they tied that in a lot to his angst and emotions that they see as fairly typical of a creator, but they feel like these concerns might be getting worse. They also said that something is a little bit off with his thinking. It feels like he’s [00:08:00] not really connecting cause and effect. Like he wants to be a famous musician and he is this incredible music prodigy, but he’s not practicing at all.

    So they wanted to know what they can do to support him there and thought an evaluation might be the next best step. And then we arranged all the details for the intake. And then they added right there at the end, Oh, by the way, make sure you don’t wear any lipstick when you meet with him because he thinks it’s deeply disgusting. Your face is now doing what my face was doing on the phone because I was like, oh, okay. But it was one of those when people are leaving the room and they just add right as their hand is on the doorknob, this little thing that may have been important to bring up earlier.

    It was right at the end of the phone call. So it was just like, oh, okay. I don’t [00:09:00] normally, so that’ll be fine. But it gives us a little insight into what the family is thinking about and how they’re thinking about this individual before I even sit down to meet with them. And so that’s the information that I had going into it.

    And so now I’m thinking about doing the intake and I have this process that I do- these 10 steps that I do. My first step is really looking at finding really good referral questions that are going to be really helpful in clarifying the diagnosis and in writing a report and giving feedback that actually helps this family.

    The way I was trained, the referral question is diagnosis and treatment recommendations, right? That’s what I want to do correctly and get my gold star for getting the right [00:10:00] diagnosis. But that’s not necessarily what the family has in mind. They may or may not be moved by the right diagnosis. Probably they want treatment recommendations, but they also probably have a lot more than they want from this process: reassurance, answers to some of their questions that they’re afraid to tell me about, and a deeper understanding of their child.

    So what I’m trying to do during my intake is figure out what those referral questions are, so that I can really be helpful to see this is this family beyond just getting the answer, “right” as to whether or not this is psychosis.

    Dr. Sharp: Are you asking that explicitly or is there a process or is it more of an implicit process that happens throughout the intake?

    Dr. Stephanie: That’s such a great question. What I’m thinking about is I’m [00:11:00] looking at five different factors. I’m looking at the content, like what they actually say during the intake. That’s obviously going to be really helpful for me and something that I think we all do as part of our interviews, but I’m also looking at the process. So I’m looking at how they say it. I’m looking at how they tell the story, what they prioritize, and how they explain things, to get a sense of what they really want to know.

    I’m also thinking about their behavior observations during the intake. So not just how they say it, but how they look while they’re saying it or how they act while they’re saying it and their interaction with me. So the fourth thing I’m looking at is how they relate to me, as I’m saying things. If I say something that, if I try to reflect and reflection is a little off, how do they respond to that? How do we regroup for example? And then, of course, I’m also [00:12:00] looking at what I call the white space- what they don’t say, what goes unspoken. So that is the fifth thing that I’m really looking at.

    And I do some of these things more implicitly and some of them more explicitly. So I will actually at some point say what’s the worst thing that I could tell you as a result of this evaluation, which is a way to get at what they might not be saying themselves.

    Dr. Sharp: I like that. I agree.

    Dr. Stephanie: Okay. So what I thought we would do is since we only have a short amount of time, I’m going to focus mostly on the content and the process and a little bit on the white space and not as much on the behavior observations and interactions, just to condense this a little bit.

    Dr. Sharp: Great.

    Dr. Stephanie: So let’s just jump right into the context. Most of the time we get the birth history. What this family told me is that this is their only child, Mrs. Case experienced multiple previous [00:13:00] pregnancy losses before she had this child. And this was a much longed-for baby. Her pregnancy was mostly uneventful, but she did have a viral infection late in the second trimester and was briefly hospitalized for that.

    The baby was born in February. He was 41 weeks gestation, 9 lb 3 ozs. Labor was induced because he was late. And during the delivery, he had too slow of a heart rate after each contraction. And so they eventually went to a C-section, but he was in good condition at birth, at bars of 89% at 1hr 5 minutes. As a baby, they described him as alert. He was sleeping okay. I asked, was he an affectionate baby? And they said he was slightly below average in affection, which was an interesting way to put that.

    And then mom told a lot [00:14:00] of details to me about him latching and how he had a lot of trouble latching. He was very distracted during the latching and would lose the latch and they needed a lactation consultant. And to me, that’s a small little soft sign of something that may be going on in terms of his motor system. But to mom, it was obviously a really important part of the story.

    I recently had a consultee asked me, why do we gather all this information about the birth history and very early history. And I was like, that is such an amazing question because so often we don’t really stop to think about what we’re doing. We’re like, well, I’m supposed to get the birth history. And obviously, it has important implications for any neuropsychological evaluation that you might be doing or whether it’s neurodevelopmental disorders. But when you think about why you’re getting the birth history, what are you thinking about during that time?

    [00:15:00] Dr. Sharp: I think for me, it’s two different prongs. There’s the very practical piece of, okay, let’s look at the birth history and see if there are any medical complexities or problems that may have come upon the medical side. Is there anything that we need to pay attention to or know about? But there’s also this more qualitative, the narrative component for me anyway, of what story they will tell about it and how maybe like you’re alluding to, how the parents started to create their life with this kid. And it starts at birth and really before that, so maybe those two if that makes sense, and how parents would just relate to the.

    Dr. Stephanie: Exactly. And I think we all do that intuitively. That’s the exact word that I had written down, was the story. You’re getting the story from the beginning or at least how they [00:16:00] want to tell that story to you. And we have this story here that’s really important to the mom of this really longed-for baby during a pregnancy that included some scary moments, a delivery that included some scary moments, and maybe some difficulty with what the mom expected afterward.

    Whatever slightly below average and affection means, her feelings around her difficulty with getting a good latch clearly were really important to her. So starting to think already about how these parents contextualize the story of this young man, and how is that going to inform the feedback that I do with them and the report that I eventually write for them. So that’s what I’m thinking about.

    Dr. Sharp: Can I ask you a question? I love that you highlight that story piece. I think that’s right [00:17:00] on. On the medical side, you mentioned two things and just for the sake of what we’re doing here, do any of those things catch your eye? Like does a viral infection catch your eye? Does the D cells during labor catch your eye or anything like that? Because I think people hear that and they’re like, Ooh, maybe that’s a thing.

    Dr. Stephanie: Right. Maybe it’s a thing. And the answer is that maybe those are things. Some of them are non-specific. So the difficulties during the delivery is a non-specific marker that there could be some neurodevelopmental things going on and some of them might be a little bit more specific to psychosis-like we’re talking about now.

    So the viral infection during the second trimester and the February birthdate, both of those might be… the literature has suggested there could be a [00:18:00] relationship between those two things and later psychosis with the idea that there might be some viral or neuroinflammation or something that might be happening during development. There’s also an association between preterm birth and later schizophrenia. This child was not early but since we’re talking about it, I thought I’d throw that in.

    Dr. Sharp: Nice. I have to ask, what does February birthdate have? How does that relate here?

    Dr. Stephanie: There is some association in the literature between a winter birthday and later schizophrenia. Another large, more recent study actually showed a lot of people with schizophrenia have a June or July birthday, but the reason that they’re looking for this, is they’re not looking for like a horoscope association. They are thinking about possible viral infections [00:19:00] during the pregnancy and when you might have been exposed to more of those.

    Dr. Sharp: That’s okay. You’re right.

    Dr. Stephanie: All right. I’m going to jump right into the early developmental history. There really wasn’t much between the ages of zero and nine, between the ages of zero and five, the parents described him as pretty easygoing, with completely normal social relationships, really imaginative, and loved playing.

    They could tell he was very bright right from the beginning from their report. They described him as a musical prodigy with two instruments, the piano, and the guitar from an early age. They used the phrase perfect pitch. They were very invested in his musical talent. He was on time in his motor development, a little clumsy, but fine there. He was late in speaking his first words, but he got ear tubes at 18 months when they figured out he had water behind the ears and he caught up and [00:20:00] surpassed his peers in speaking.

    The first thing they noticed was he started having some specific phobias and they were both normal things like flying insects. And then also some things that were a little bit odd or he had a fear of water sprayed noise, and he had a fear of red cars. So some things that are a little bit odd, but that weren’t debilitating for him in any way. He also had some nightmares during this period, but no major medical history during this time, no accidents, injuries, nothing other than that ear tube placement, and eating is fine.

    And academically he did great in early elementary school. His teachers really liked him. He had friends. His teachers thought he was a little bit anxious. He’d overreact to small bumps and bruises. He would occasionally become afraid of certain things, but not anything that disrupted him particularly. And he was [00:21:00] nominated and tested for the gifted program twice, but he didn’t quite test in either time. So that gives me a little bit of where his premorbid functioning is at.

    Obviously, I’m thinking through this developmental history to rule in or out certain disorders later. So for example, a common question that I get from my consultees is autism versus psychosis. So here we’re really looking at that developmental history. Is it typical of, for example, autism spectrum disorder, or is it looking more like maybe something else?

    Is there anything in that section that I left out or that you typically ask about or are wondering about for him?

    Dr. Sharp: Let’s see. I may have lost track of it and I apologize. Did you talk about the social component?

    Dr. Stephanie: He did just fine socially. Parents don’t really remember any concerns. Teachers don’t remember any concerns. They described him as really imaginative, really [00:22:00] loved playing. You and I had talked about how I’m going to have a PowerPoint presentation for people to follow along, because obviously as you’re listening to a podcast, you tune out and you’re thinking about your own thoughts, and then you’re like, wait, what did we talk about? So if people want to follow along, they’ll be able to.

    Dr. Sharp: Cool. Yeah.

    Dr. Stephanie: So now we start where things started. So ages 0-9, pretty uneventful. I’m going to pick up the history again at about age 10. He’s in 5th grade at this time. And this is really where the parents started the story, is that he fell and when he fell down, he stood up and then he said that he couldn’t use his legs and that they didn’t work at all. The school took him to the ER, and at the ER, his legs were functioning fine. He was walking. So the ER said, [00:23:00] this is psychological and ruled out any medical problems and they suggested ignoring it, which the parents did. And after about a week and a half, this complaint went away, and everything went back to normal.

    But then in 6th grade, he began having what his parents called Fitz. He claimed that he would blackout and that when he woke up that it would feel like years had passed and he would flail his legs around when he woke up. And then he would also say that his parents were trying to kill him. The parents at this point thought that was odd, but they had had that earlier experience of ignoring it. And so they thought we’ll just ignore it again.

    This time it took two months for these fits to go away. So they started some counseling, but he wouldn’t really engage with the counselor at all. Basically, he wouldn’t really talk. So after three months they stopped it and said, okay, that’s not something that really [00:24:00] is helpful. And then it seemed to go away on its own.

    Dr. Sharp: Is this daytime or nighttime or both?

    Dr. Stephanie: So these are mostly happening in the school setting. But that’s a great question because you’re already thinking about hypnopompic or hypnagogic experiences or night terror experiences, or just what is this, right? And that’s the experience that I’m having listening to it as well. It’s like, oh, this is interesting. And I’m going to sneak ahead a little bit that parents did not seem as concerned about these as I think I would have been. They related this is a perfectly common part of a child’s history, but I don’t hear this type of thing that often. 

    Dr. Sharp: Yeah, me neither.

    Dr. Stephanie: Okay. So [00:25:00] when we’re thinking about psychosis, obviously, there is a high rate of abnormal EEG findings in individuals with psychosis. So I should mention that they did a neurological evaluation and completely ruled out his EEG is actually clean. So did not seem to be seizures or anything like that.

    Around 6th grade is also when he started getting really more intensely interested in music. And when his parents started deciding that he really wanted to become a famous musician and they started getting him private lessons and other experiences that would help him become a famous musician like his uncle.

    In 7th grade, he transitioned to middle school and he started having trouble paying attention as his parents assumed that it was because he was going to a new, more rigorous school. And that’s what the pediatrician that they took him to thought as well. And so he was diagnosed with ADHD that had gone unrecognized because [00:26:00] he was so bright and he was started on stimulant medication at that time.

    Between 7th and 8th grade, he started developing over the summer, some obsessional behavior around insects and sleep. He started asking his parents to check his room for spiders before he went to sleep. And then they developed a special spray that they could use to spray magically for spiders like you might do for maybe a much younger child.

    And he also started saying that the spray would help him keep away bad dreams and keep away specifically something that he called smushy darkness that he felt sometimes happened at night. He also became obsessed with fire during this time and his parents thought it would help him to overcome this. They encouraged him to start fires on purpose so that he could experiment with fire.

    He also started avoiding certain [00:27:00] colors, specifically red. He wore the same shirt for a few weeks in a row at school and he had developed some obsessional behavior around music. Now he would just play the same song over and over again for hours at a time.

    Dr. Sharp: I just have to jump in. I’m curious. What are you thinking at this point if anything? Have alarm bells started to go off or when did that start to happen for you?

    Dr. Stephanie: So alarm bells for me started to go off during that intake phone call. But when we’re thinking here, this part is making me think about that tricky differential diagnosis between OCD and psychosis. And it’s tricky because some OCD can [00:28:00] border on things that don’t necessarily seem to have a lot of touch with reality.

    And then we know that for individuals with psychosis, especially as they’re starting to experience their prodrome somewhere around a third of them, something like between 10% and 60%, depending on the study, have these obsessions and compulsions possibly as a way to organize their thinking that is trying to help give some structure to some thoughts that are feeling a little disorganized or a little scary to them.

    And the content in psychosis of the obsessions and compulsions. One of the differentials is that the content tends to be a little bit more unusual. It tends to be something that as you’re sitting in the intake, you’re thinking I’ve never heard that one before. I have never heard of obsession specifically around spiders and bad dreams that could both be taking care of the same compulsion. So [00:29:00] it’s interesting there.

    And then I’m also thinking about the smushy darkness that feels a little bit less reality-tested to me than I would expect. And I’m also starting to wonder about these parents. I’m not sure that I would respond to a child being interested in fire by saying, oh, let’s start a bunch of fires. So I’m wondering about their way of responding to his maybe increasing disorganization and whether or not that’s helpful or maybe scary or confusing for him.

    Dr. Sharp: Sure. Yeah, those things you meant, those are the same things that jumped out when you said smushy darkness. It was like, hmmm.

    Dr. Stephanie: Yeah, I can see your face. You’re like, okay. Right?

    Dr. Sharp: Yeah, it’s very clear.

    Dr. Stephanie: Exactly. The parents took him back to the pediatrician and also to a therapist. [00:30:00] He was diagnosed with anxiety, OCD features, and depression at that time. Placed on antidepressants. They try to do therapy for the OCD portion of it, but his therapist said he refused to talk. She described him as intensely private, and he wouldn’t reveal his private thoughts to her. So they discontinued therapy at that time.

    The other thing that happened, this is in 8th grade is that one of his major best friendships just completely disintegrated. And his parents don’t really know what happened. They suspect bullying or something along those lines. They’re just not sure what happened. They just know that he used to have this friendship and then it disintegrated. So they responded to that by switching him to a different school. And he switched halfway through 8th grade.

    At first, he found this alternative group of kids that he seemed to be trying to fit in with, but he wasn’t very successful. His [00:31:00] parents saw him trying to interact with these kids and they noticed he would approach them and he would talk a lot, but not really say anything is the phrase that they used. They thought he seems to be having trouble fitting in with these kids.

    And he’d started to have those academic difficulties like trouble paying attention and those didn’t really improve at the new school either. So they were starting to investigate this a little bit more. And one of the things that they found out is that one of these kids that he had tried to befriend had introduced him to marijuana and he was starting to use it daily. He would have been about 14 at that time.

    We know that there’s a relationship between marijuana and psychosis. The directionality of the relationship is not necessarily clear. Certainly, if you have a child at risk for psychosis, you would want to try and stress, let’s not [00:32:00] use marijuana, but the truth of it is that most individuals who do end up having psychosis do at some point seem to try self-medicating. And that is a common medication that they seem to self-medicate with and may possibly increase paranoia or precipitate a psychotic episode in an individual who is predisposed to that.

    Dr. Sharp: Are there any effects with the age of first user or the frequency at different ages or anything that you know of?

    Dr. Stephanie: So earlier age at first use and higher frequency are both associated with worst outcomes as you might expect.

    Dr. Sharp: Okay. Just making sure.

    Dr. Stephanie: Yeah, exactly. And again, so moving on to 9th grade, his parents made another interesting decision. They thought, well, he’s self-medicating with marijuana. So instead of [00:33:00] having him buy marijuana on his own, they decided to start giving it to him nightly as a way to control his marijuana use.

    It is legal in my state, as it is in yours, not at age 15 which he would have been at the time. But this is going to become something that we have to think about more in our evaluations as we move forward. And they’re easier access to these substances and a lot of states. So they were having him vape nightly before he went to bed.

    And other things that were happening in ninth grade, he dropped out of all of his social relationships. He wasn’t even trying to interact with other kids anymore as far as his parents could tell. He was failing classes. They had him drop one and then two classes and they were replaced with a study hall, but it didn’t really help. The only thing they thought was helpful at that time was actually marijuana. They felt like that reduced his [00:34:00] anxiety a little bit.

    By 10th grade, total school failure. He got an IEP through his local school district, even though he was at a private school. His OCD worsened according to his parents. And what they said is he started lying in a way that felt compulsive to them. And when I asked about that, they said he constantly says things that aren’t true and says things that don’t make sense. 

    I tried to get two examples of that. And they said that he says that he knows famous people. He just lies about it and won’t accept that he doesn’t know them. He says that his parents told him something that they definitely did not tell him and clings to his version is what they said. They also said that he says that people are staring at him and want to fight him, which they said was not true. [00:35:00] He also started worrying obsessively about the family cat that someone was going to hurt her or take her.

    The other behavior that his parents became really concerned about at that time is what they called stealing. They said he was helping himself to things that he found that were abandoned. Like if he found someone’s pen or a straw or a toothpick or a bit of paper, he would claim it. And sometimes even carry it around with him in like a little bag of reclaimed items.

    By 11th grade, he started seeming afraid of things that his parents said aren’t really threatening. And they said it’s almost like he’s having nightmares during the day. So I asked, of course, if they thought he was seeing things that no one else could see or hearing things that no one could hear and his parents said they weren’t sure. And that they’d never asked him. But they did notice that he was starting to avoid things that he said were disgusting and that [00:36:00] reminded him of wounds like red lipstick or shirts that had splashes of their color red on them. And he would become very afraid of those.

    His parents were really mostly concerned at this point. I could tell it was incredibly embarrassing to them about this lot, what they call lying behavior. They’d gotten him an interview with a music producer and he had told that person that he knew some famous people. He also had dressed really oddly to go to that interview. He had worn a hoodie and then like a blanket over the hoodie and they thought, well, he’s trying to be alternative and look cool, but it didn’t seem quite right to them. And he stopped practicing his music this year. And he says he doesn’t need to practice anymore because he’s going to become famous because it’s his destiny. Or he sometimes says he already is famous.

    So here we can see that although [00:37:00] the parents are not necessarily concerned, we’re pretty concerned at this point. This is not a behavior that sounds defiant even though parents are describing it as lying and stealing. It’s not behavior that sounds within what we’d be thinking about for maybe something like OCD, or even impulsivity associated with ADHD or something like that. This case is not necessarily too much of a surprise in terms of the outcomes. So we can see the hints here at least have some psychotic thinking processes that might be happening for this young man.

    Dr. Sharp: I think though, just to point out that the way that you have walked through this history, it really illustrates the slow burn of something like this, where I think for a lot of us it’s really hard unless it hits you in the face. So kiddo is 9 years [00:38:00] old and they’re seeing shadows and murderous figures and whatever, it really speaks to how hard it can be to separate some of these. Because a lot of this sounds like OCD stuff until we get later and later, and then it’s like, hmm, this is different.

    Dr. Stephanie: Exactly. You raise such great points. And there are two that you were making me think of. And one is that for one, I’m telling the story in an organized way. This is not necessarily how the parents told me. Let’s start in 5th grade. We do have the benefit of seeing that trajectory over time. And what we’re really thinking about is what the history of the prodromal period is for individuals who have a prodrome associated with their psychosis. It is often long and is often confusing and it is often only recognized in retrospect.

    I know [00:39:00] you had Michelle Friedman-Yakoobian on your podcast, and she’s with the CEDAR Clinic. The CEDAR Clinic has this really nice model where they talk about the trajectory of this case. We’re starting at age 12, there are some cognitive issues like some attention problems that didn’t seem to be there during early elementary school. And then later you get some affective problems, like some anxiety and some depression, and then you start having some of that social withdrawal, some of that educational failure. And then you get these at the end, these sub-threshold psychotic symptoms where you’re thinking as you’re listening during the intake, you’re thinking, is this psychosis, is this an atypical form of ADHD?

    I’m sure some listeners are thinking, this sounds a little bit like some kids that I’ve seen who are on the spectrum and didn’t get diagnosed until later, or people who are thinking, bipolar. [00:40:00] I’m wondering about maybe some slight psychotic symptoms as part of a mood disorder. So it’s hard to piece out. And that’s part of why I’m doing testing in addition to just the intake is because this feels like it could go in some different directions.

    Dr. Sharp: Sure. Sorry, go ahead. It’s hard not to keep asking questions. Continue, please.

    Dr. Sharp: Oh, okay. I interviewed his teacher and I interviewed his current therapist. One of his teachers said he’s not doing the work at all. He doesn’t participate. He’s sitting in the back of the class most of the time. It looks like he’s sleeping. Oh, his teacher said, or it looks like he’s turning into something else.

    And she mentioned something that the parents had not, which is that on a few occasions, he’d left school without permission and he’d been found several miles away just [00:41:00] walking with no purposeful destination. And she used a phrase where she said, I teach a lot of kids and I’m usually able to connect with them about something, but this kid feels unreachable to me. And that was the word that she used.

    And his therapist said a similar thing. He said, I work with a lot of kids and I’m just really struggling to connect with this kid. He seems really odd in ways that I can’t really put my finger on. He talks to me, but I can’t always understand what he says. And he just doesn’t seem very in touch with his emotions. The therapist thought maybe this is autism, which I think is a common differential that we get. And then he is on medication, he’s on two different stimulant medications, guanfacine, and fluoxetine. I just have that in my notes of where he was at in terms of his medication.

    Dr. Sharp: I got you. Great.  You walked us, so now we’re progressing past the intake/collateral interview and moving on to testing. So are there any other differential diagnoses that you haven’t mentioned so far that were maybe swirling in your mind at this point?

    Dr. Stephanie: So my differentials that I’m thinking about, I’m thinking about possibly psychosis. I’m also thinking that he already has three diagnoses that maybe are pretty high incidents that maybe explain a lot of what’s going on with him that maybe the previous evaluators have been right. And this is ADHD and an atypical anxiety and depression with some psychosis features. I’m thinking about OCD, of course. I’m thinking about bipolar disorder, [00:43:00] autism.

    Two other things that we didn’t mention, one would be trauma. His parents do suspect maybe some bullying there, and we know that three doses of trauma pretty reliably predicts auditory, at least hallucinations. So it is a really important rule out when we’re seeing that. And then of course the thing that I think a lot of us think about is like, could this be something medical?

    It turns out that only about 3% of cases of psychosis are caused by something medical. But I think it’s something that we often think about. It’s actually so rare that typically more than routine medical workup isn’t recommended unless the symptoms are acute or unusual or not responding to typical treatment. But sometimes people do ask me, what the causes might be.

    There are hundreds of possible causes of psychosis, but [00:44:00] roughly if they’re acute symptoms, we’re thinking about maybe something febrile, or a drug or toxicity problem, or a neoplasm, some brain tumor or a cephalic process, like some sort of inflammation type process.

    If they’re episodic or fluctuating, we’re thinking about something like epilepsy or a possible aura associated with migraine or sleep disorders would be the main roll-outs in that case.

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    Dr. Stephanie: And so those are on my mind. And what I tried to do at that point was get some more helpful information from the family that would help me know where they’re at and what they want out of this evaluation. I’m going to skip that part. [00:46:00] I have some questions that I ask that are beyond the history. And I’ll just put those in the PowerPoint presentation that I got, but I’ll highlight two of them.

    One of them, I ask families to get a sense of if there’s any, what I call secret family history. I’ll say something like, what parts of yourself do you see in your child? Or is there anyone in the family who he just really reminds you of, or sometimes anyone in the family who he’s just really different from? From those questions, I got a little bit more history, which is that mom has OCD with hoarding that she didn’t mention on the intake form and then dad’s cool older brother, who’s very successful in music has, what they said was ADHD, but sounded a lot like bipolar disorder when they described it. And then they mentioned that dad has an aunt back in Russia who lives in an [00:47:00] institution because she is so disabled with something that sounds a lot like schizophrenia.

    So that’s an example of the types of questions that I’m asking. I’m also asking anything from what are kid’s communication and memory skills like to some pretty straightforward things to things that are a little bit more oblique, like what’s a sense of humor like to get a sense of his ability to abstract or if his thought process is off. About 50% of individuals in the prodrome period have a reduced tolerance to stress, so asking about resiliency, coping skills. I’m asking about regression. Does it feel like there’s something that he used to be able to do that he can’t do now- things along those lines.

    And then, I borrow some things from the Therapeutic Assessment Model, and I know you’ve had lots of people talk about therapeutic assessment on your podcast. So hopefully listeners are really familiar with that.

    And what I did is I had the family [00:48:00] come up with questions and they asked these questions of, he wants to be a famous musician, but he doesn’t want to put in the work. Why is that? And how can we support him in reaching his dreams? They said he’s always had an artistic temperament but now as anxiety seems to be getting worse and he’s lying and stealing, and he’s putting off people with his behavior that maybe could help him like this music producer. So they want to know how to interrupt this cycle.

    They said he’s failing school. And so they wanted to know if he should just drop out so he can just focus on his music. And then they said that he’s not making social connections and his therapist is worried about autism. So they wanted to know that, is this the right therapist for him? Does his therapist see what we see?

    When I ask them that question of like, what is the worst thing that I could tell you? What they said was we’re worried that you won’t see his talents and skills. Sometimes adults overlook that. And that seemed to be how they’re viewing that [00:49:00] therapist.

    So when we’re thinking about the process and that white space of what these parents are like, people who consult with me know that one of the first questions that I always ask for a tricky case is like, just, what was it like to sit with these parents? What were they like in the room? And these parents were odd. It was an odd experience for me, with some of the decisions that they’re making.

    Dad seemed very bordering on grandiose. He wanted to know a lot about my credentials. He wanted to talk a lot about how we’d both gone to the same undergraduate school. Mom in contrast seemed anxious, depressed, and downcast. She was 10 years younger than dad, but she looked about 10 years older than him. And I could really feel that parallel process happening in the room.

    So they’re presenting as if things are [00:50:00] normal and I’m stuck with all these emotions. I’m feeling confused. I’m feeling scared. I’m feeling this pulled normalizing this kid and say, it’s fine. Things are okay. He really is the genius or I could figure out something like OCD that we could fix, really feeling that in the room. And I can tell that they’re giving that to me. And then I use that to think about what are the secret questions these parents might have? What are they not asking me? Does anything jump out at you about what they’re not asking me that you might ask if this were your child?

    Dr. Sharp: Well, I think deep down, if it were my child, unless I was totally oblivious, which people have accused me of being at times, with the question that, deep down I’ll be like, is there something really wrong with my kid? Or like, [00:51:00] do I need to be worried about my kid? Should I be scared? That’s the first thing that comes to mind.

    Dr. Stephanie: Yeah. That’s literally the first secret question that I had on my list of like, what I think this family is not asking me, is there something really wrong with my child? Another thing I was thinking about is I could feel that they’re really invested in their dreams for this much-longed-for child who they think of as a genius. And they’re thinking, are we going to have to give those dreams up? I could tell from mom’s discussion of the latching and some of the other things she said during the intake that she’s wondering if she might’ve done something that could have caused the problems that he’s having now. And I could tell that dad was worried that their child is going to end up like his aunt who is in an institution. So those are the secret unvoiced questions that I think we’re also in the room with us.

    Dr. Sharp: Yeah. I love how [00:52:00] you’re highlighting that and calling out white space- all this process piece to the intake. It is so important and easy to forget or maybe not to forget, but hard to operationalize or execute on these harsh terms, but you see what I’m saying. It’s easy to look past and not know what to do with these things.

    Dr. Stephanie: I know exactly what you’re saying. We are taught to get the facts. But that old trope of like we’re psychologists first and then assessment psychologists, there is all this other information. And trying to figure out what are some ways that we can use that in what, I think it was Erickson who called it a disciplined subjectivity, how do we gather that data in a way that’s useful and will really [00:53:00] inform the evaluation we’re doing, the recommendations we are making, the reports we’re writing in a systematic way so that I’m not just writing what age he had trouble latching, or when he was diagnosed with OCD. I am telling more of a story that’s helpful to this family.

    Dr. Sharp: Right. Let me ask you a procedural question. Would you present these secret questions to a family or are these things you’re keeping in your back pocket for later?

    Dr. Stephanie: That was a great question. I’m almost always presenting them obliquely during the feedback. I’m trying to maybe see if I can get them in the room a little bit during the intake. And if the family can do that, that’s often a good sign that the feedback is going to go well. This family, I don’t know you could do that. And that’s a sign that I’m going to have to work a lot harder during the [00:54:00] feedback.

    But really what I’m thinking is if I don’t answer these questions, the family won’t be able to hear anything else that I have to say. If I don’t tell them that there is something wrong with their child but we know what it is and what to do with it, and if we do intervene early, we have a good chance that he won’t end up like dad’s aunt. If I don’t tell them they didn’t cause this, if I don’t help them understand, you do have to have different dreams for your child, but that doesn’t mean I’m giving up on dreams altogether. If I don’t answer those, they won’t hear anything else that I say.

    Dr. Sharp: Such a great. Let me ask you one more question before we move forward. And that is, I’m guessing people are listening and thinking. That sounds great. I’m not sure if I have those skills. So there’s a little bit of intuition here. There’s some clinical experience. There’s some [00:55:00] training I’m sure. But are there particular resources or strategies or ways that you’ve worked to hone those skills? And if not, that’s okay. You can say, I’m just intuitive. I just do it. And that’s totally okay. But are there any resources that folks may benefit from?

    Dr. Stephanie: Let me answer your question in two ways. The first is that anyone who’s listening to this podcast does have these skills already. They have them. I was listening to your interview with, Jordan Ray, and I thought it was funny because he was saying he expects everyone to suck at assessment at first. I go the other way. I think everybody is amazing at assessment at first, and then we build on these layers that make us less effective. And that part of what we need to do is chip away at those a little bit and get back in touch with our natural curiosity and empathy.

    [00:56:00] You’re just sitting here listening to a story of a kid who wasn’t even in your office, and I can see that from your facial expressions, part of it is catching your attention. And you’re like, oh, what’s going on there? And it’s grasping your curiosity. So part of it is just getting back in touch with the parts of us that are already great at this because if you have people who are listening to this podcast, they’re interested in the topic and they already are amazing at this, but to give yourself permission to do that, I would recommend looking at the therapeutic assessment literature. , they do a really great job of that.

    And then I am absolutely in love with this book called Psychological Testing That Matters, which is by Anthony D. Bram and Mary Jo Peebles, that talks a lot about white space and the conditions under which kids or adults thrive. I’m looking for those during the evaluation. So those are two… When you’re carving your [00:57:00] marble to find the statue of David underneath to make your stuff into the evaluator that you want to be, those are two resources that I think will really give you permission to do that.

    Dr. Sharp: Wonderful. Thank you.

    Dr. Stephanie: So we’ve gotten through step 1 of my processes. That’s obviously the biggest one. Step 2, we also touched on a little bit. I call step two my preflight checklist, which is where I’m really trying to generate all the possible hypotheses of what this might be. And I’m thinking about all of the base rates of those different hypotheses so that I don’t over-identify with one particular thing. Schizophrenia, for example, is a pretty low-base rate disorder. So I better have really good evidence of that if I’m going to say that that’s what it is as opposed to something like ADHD and anxiety [00:58:00] and depression, all of which are much higher.

    Autism that has been undiagnosed until 17 in an individual who is high functioning is an even lower base rate than schizophrenia. So I better have really extraordinary evidence if I’m going to think that it’s that.

    This is called taking the outside view. And if you read any of that literature, I know you from one of your… I’m sorry, I sound like a super fan that stocks you on your podcast, …but I know that you talked about The Book Range and how you’ve read that book. And he talks about some of this decision-making research by Philip Tetlock or Daniel Conaman or people like that, where they’re talking about making really good decisions and how you have to start with this outside view where you assume this kid is no different than any kid off the street so that you’re not over-identifying with any particular diagnosis and that you’re thinking about all of your possible options.

    [00:59:00] So what I do is I literally just start Googling. I’m like, here are my hypotheses, let me Google what the base rate of these is because I don’t know them all off the top of my head. And then I type in like autism versus psychosis review. And I look for what are the discriminators, what are the things the research shows me best discriminate between these two disorders and how can I look for those during my evaluation?

    I’ll include some information about that if people are really interested in that. But just for the sake of time, let me move on to the next step which is thinking about the context of this kid. So this is another thing that gets trained out of us as we learn to become evaluators is we’re all told kids exist in this really rich matrix of family and culture and education [01:00:00] and environment. And we’re supposed to be thinking a lot about those as we’re doing our evaluation, but we don’t usually do it in any way that as you put it sort of that’s operationalized.

    So I have this thing that I call my preflight checklist. That’s literally just a checklist of all of the context areas that I need to be thinking about what I know and whether or not that explains or adds to the problem in each of these areas. This is similar to Pamela Hayes. I think her name is Pamela. Pamela Hayes’s ADDRESSING framework, for example, or Daryl Fujii has an ECLECTIC framework .

    And I just had my own thing where I think through the physical health of this child, what do I know about how his body responds to stress, his arousal levels, things like that. I’m thinking about the development of this child. What developmental [01:01:00] task is he on or stuck on? How attached is he to his family? Were there any disruptions during development that may be traumatic that help explains what’s going on? And then I think through the culture of this child- is there anything I need to know there, et cetera.

    I literally write down, what do I know in this area? Does this explain or add to my understanding of the problem? And then I think, is this child different than his family or what his family expects in this area? And then I also think, is this kid different from me in this area? So that I don’t over or under identify with certain things.

    Like I have a tendency as someone who self-identifies as an introvert to think, oh, well, this kid’s just introverted in an extroverted family. Is he? Or is that me over-identifying with something that describes me? [01:02:00] So I just go through that.

    Let me highlight one area here that I’m thinking about for this kid. I’m thinking about what developmental task is he on. And I’m thinking he’s really struggling a lot with those tasks of finding his peer group and establishing his own identity. He’s really not doing a lot of, much of anything really, but he’s not driving or dating or showing any sexual interest or showing any interest in getting a job other than becoming famous. So I’m thinking about that.

    And what I really noticed is, dad did not have any trouble with this developmental stage. He already had his friends and his whole life planned out for him when he was probably in middle school. And is really puzzled and stuck with how different he is from this kid in this area. So I’m thinking about that [01:03:00] as well as the DSM type differentials that I’m making if, that makes sense.

    Dr. Sharp: Great.

    Dr. Stephanie: All right. We got to get into the testing.

    Dr. Sharp: Let’s start.

    Dr. Stephanie: So I’m going to just condense steps 3, 4, and 5. And basically what we’re trying to do in this area is again, to think about the content of the kid, the actual scores that he gets, and also the process of how he responds, his behavioral observations during the testing. I’m thinking about his interaction with me and what that’s like, and I’m thinking about that white space. What does he not do those other kids his age typically do, or that I wish he would have done to make the situation more comfortable or more motivated for me.

    So those are the things that I’m thinking about. I’m also trying to refine refute or recontextualize any of my hypotheses. I have like a dozen [01:04:00] at this point. I want to be able to reject 11 of them, if I can. I’ll take rejecting nine of them, right? And then during this stage, I’m looking for repetition of things that seem to keep popping up. I’m looking for convergence- multiple data sources that all point to the same thing. I’m looking for representativeness- how much does this profile look like any particular disorder? And then I’m also looking for singularity. So for example, one of the things that this kid did was a lot of clang associations at neologisms during memory and verbal fluency tasks.

    Dr. Sharp: What is the first thing you said?

    Dr. Stephanie: Clang associations.

    Dr. Sharp: Could you explain that a little bit?

    Dr. Stephanie: Yeah. That is when you give a rhyming answer, usually, that’s off-topic. For example, he was listing fruits I think during a fluency task. And he said, cantaloupe and then antelope and then said [01:05:00] cantaloupe, which I think was meant to be kind of like a joke. And at another point, I’m trying to remember another one. At some point he rhymed pantaloons with Spanish doubloons, which is not something that I’ve had a child or any other kid does during testing.

    So those are clang associations. And those are pretty singular to some disorders with a psychotic thought process. So I’m looking for those. I don’t have to see very many of those to be concerned. So I don’t necessarily need as much convergence or repetition if I’m seeing those or if I’m seeing a lot of unusual neologisms where the child is making up their own word. That is not necessarily specific to psychosis, but it’s more specific to [01:06:00] psychosis than a lot of other things that I might be seeing.

    I tend to, in my testing, follow similar to the matrix consensus battery that’s out there on the areas that I’m wanting to look at that have been shown to be affected in individuals with schizophrenia or individuals who are in an ultra high-risk state. So I’m looking at overall reasoning and problem-solving, processing speed, working memory, verbal learning, social cognition, attention, and vigilance. And then I add in a few things in addition to that.

    If people are thinking, where do I even start, start with looking up the matrix consensus cognitive battery and see what you can give in those domains for example. I would also really recommend any of the articles by Fusar-Poli [01:07:00] and colleagues on individuals in the high-risk state. And they have a lot of good information on the cognitive deficits that you can see in this area.

    But really my battery doesn’t look that different for individuals who I think of as tricky cases versus regular cases that I might be spending more time on, more personality type measures, and social cognitive type measures than I might on academics, for example, but roughly I’m covering a lot of the same domains. I do add in prodromal-type questionnaires. So in this case, I gave Sasha the prodromal questionnaire, the BRIEF version, which is 16 items. And I’ll include a link to that.

    There are a lot of them. You could also use the PRIME or you could use the [01:08:00]Early Psychosis Screener from Columbia University. We’ll include links to all of these if people want to look at them, but really they’re ways to get kids to endorse if they’re having these attenuated positive symptoms. And sometimes you can get it through interviews and sometimes, kids are guarded during the interview and don’t necessarily want to say, or they’re not good reporters or they have so many negative symptoms that they really can’t report. So these are other ways of getting at this same information.

    In this case, I gave him, like I said, the prodromal questionnaire. There are 16 items and he endorsed, I think about 7 or 8 of them. And 6 is the cutoff where you get concerned. So he’s endorsing anhedonia, some auditory hallucinations, confusion, anxiety when meeting people, possible.[01:09:00] delusions of reference, possible delusions of grandiosity, some paranoid delusions, things along those lines. He’s endorsing all of those.

    And then you can also look at some interview options to get some of the same information. There’s the K-SADS or the SIPS, or some of those things that I know other people have talked about. One thing that I really liked that I haven’t heard anyone mention on your podcasts is just, I think his first name is James Morrison’s book, The First Interview. He has some nice interview questions if you don’t interview around this a lot; how to interview around seeing or hearing things that you haven’t seen that the other people can’t see or hear, tasting or smelling things.

    And then if they say, yes, he has some other questions. Like how lifelike are the voices? Do they sound as real as my voice is [01:10:00] right now? When did you start hearing them? Sometimes I like to ask, if I met you in 5th grade, would the voice be there? How often are they occurring things along those lines? So that’s a good resource that you could pick up a used copy of Amazon if you’re wondering about what questions can I ask if the questions in K-SADS seem a little abrupt to you.

    Dr. Sharp: I got you. Nice. Yeah. And this will be extensive show notes for this episode. I’m putting all these things in there, so don’t worry folks about remembering all these things. There’ll be links.

    Dr. Stephanie: Perfect. And then, of course, I’m also looking for negative symptoms as well as positive symptoms but there are not as many ways to get at those. You can do something like the PANSS, the positive and negative symptoms of schizophrenia, I think it’s called or the [01:11:00] scale of prodromal symptoms where they’re clinician-rated and you’re looking for these things. I do it a little bit more informally and I follow the CAMPS Model.

    I call it the CAMPS Model. I don’t think the authors call it that, but I’m looking for problems and communication. Problems in an affect or emotional expressiveness. Problems with motivation, psychomotor problems, and social problems. And so those are some of the things that I’m looking for. And Sasha definitely had a lot of these. He was talkative, but there was what’s called poverty in the content of his speech. His speech was vague, it was disconnected, it was overly generalized. It was hard to understand what he was saying. The same thing that his parents and therapist had called out.

    He also had started this blunted effect, not a lot of spontaneous movement during social interactions, not being able to describe his emotions. I asked [01:12:00] him if he could demonstrate what it looks like to feel happy and sad, and he could not do either in a way that seemed comfortable. Also a lot of reduced initiation. During the interview, he definitely reported he is not interested in dating or sex or activities of self-care. It showers grudgingly with a lot of prompting.

    Physically, he was dressed a bit oddly. He was wearing multiple shirts to look disheveled. I did see some gazing blankly in no particular direction, which is often considered a psychomotor sign. And definitely, some psychomotor slowing both qualitatively but also on standardized things like the group pegboard or things like that. And mostly he just appeared odd. It was just odd to interact with him.

    So [01:13:00] that’s what I do as I’m thinking about negative symptoms. I actually have just written them down on a piece of paper. I keep notes in each of those areas if this is one of the things that I’m thinking about. Obviously, a lot of those overlap with some other disorders as well.

    And then I gave him an extensive battery of testing, and let’s just hit the highlights. Overall, IQ is a 95, which I think is well below what my estimate of his premorbid functioning would be. I did the RIAS with him. It looks like I did the first edition, so this must have been a while ago. And he really liked actually that. There was a lot of structure to it. So part of what I’m getting as well is not just the test score, but when he does best. He seemed to do best with those really familiar verbal questions.

    It was very slow on the [01:14:00] non-verbal questions where you pick an answer. So I scored it on timed. I didn’t penalize him if he didn’t give me an answer in 20 seconds because he couldn’t. He did seem very internally distracted during this. He kept referring to me as she, as opposed to you. So I noticed some pronoun slips during that. He also had some… I did not wear lipstick, but I accidentally had a scratch on my face and he kept asking me if his face was red, like staring at the scratch and asking if his face was red. And that seemed to distract him during that task.

    But overall, he was able to get a score in the broad average range, just, I think a lot lower than what his parents led me to believe might be the case based on his premorbid functioning.

    Tests of [01:15:00] processing speed and working memory were in the low average range around about the 10th percentile. He liked doing the CPT. Most kids hate that, but he seemed to enjoy the structure of that. He had seven atypical scores, but they were all low atypical, T scores in the low 60s. Obviously, attention is not great. Comprehensive trails, he got a T score in the first percentile. I told you a little bit about verbal fluency and how there are a lot of set losses and clang associations during that task. And he didn’t do that well on it.

    The other thing I did after the D-KEFS was 20 questions and it was the most interesting 20 questions that I’ve ever done. He was trying to guess based on what he could tell about me, what choice I would pick out of the options. So he was trying to read me to see what choice I [01:16:00] might make based on what he could read. He was also very paranoid about what I was writing down. And he only got two of the categories, but he was also guessing things that were not on the page. So I did not score it because I don’t even know if he understood the task. I also didn’t score the Tower of London because the first two items, which are relatively simple, he could not do within the 20 moves. So we discontinued that.

    But there is some evidence that individuals with psychosis might be better able to do something that involves immediate feedback, like the Wisconsin card sort. So I don’t always give that, but I pulled that out for this kid and he did get all six categories and he got a standard score, the broad average range on that task. So he is showing better skills when he gets immediate feedback. But when things are unstructured, he rarely couldn’t do them.

    Your viewers [01:17:00] won’t be able to see this, but I’m going to show you what he did for the Rey if you ever give the Rey.

    Dr. Sharp: Yes.

    Dr. Stephanie: Well, how would you describe that?

    Dr. Sharp: I would describe that as an abstract mouse that is injured and two ways. I’m reaching here.

    Dr. Stephanie: I think that’s a great description. You can see the slash mark with the five hash marks. You can see the O with the dots. So you could see portions of it, but a mouse that’s abstract and has been injured is a good description. So we didn’t score that either. And you could see, he also wrote some notes to me on there, but it’s unreadable.

    Dr. Sharp: Was that the copy by the way?

    Dr. Stephanie: That was the copy. We didn’t do anything else. I’ve made [01:18:00] a copy of this copy, so it’s not in color, but yeah, that’s the drawing there.

    Other things that were intact for him, the Boston Naming Test was fine. So he did okay on that, but he did make odd errors. I won’t give away any item content, but there are a lot of musical instruments on there. And one of the musical instruments that he didn’t know, he said, is that the box that you keep your trophies in? I don’t even know what he might have been seeing at that moment.

    So those are the types of singular responses that you’re looking for. Obviously, I don’t want to make a diagnosis just based on that, but it goes in the category of like I’m getting this across multiple tests that he is struggling with.

    Regular verbal, memory for stories was okay. Nonverbal memories were not, but list learning was terrible. 1st [01:19:00] percentile on the CVLT-3. Intrusions set losses, neologisms, more clang associations just really couldn’t do that task, but he did fine on the TOMM. So validity was okay. It wasn’t great, but he passed on that.

    The PEGS really serious psychomotor slowing. I have standard scores here in the 30s. So several Z scores are below average. It’s not good. The VMI also just even basic drawing was a little too hard for him. I also did the ADOS with him. Obviously, his therapist is concerned about autism and so it was already part of my battery, but I actually really like getting to the ADOS individuals with psychosis.

    They will score above the cutoff based on the research and my clinical experience. But [01:20:00] if you give the ADOS alot, anything that kids do that’s unusual really stands out because it is a semi-structured observation. So getting information about the form and quality and function of his social interaction skills, is a nice way to gather some observations. He absolutely scored above the cutoff. His total raw score is a 14, which is well about the cutoff.

    But what I’m thinking about here is what didn’t he do that I wish that he had? What’s some of that white space that was missing? Or what did he do that was really unusual? And those are the kinds of things that I’m trying to think about that helped me in my mind. Mostly they just helped me feel really comfortable with my diagnosis. This is a heavy diagnosis to be making. So as many data points as I have that make me feel good about the more comfortable [01:21:00] that I am, the more comfortable the feedback will be. So that’s part of what I’m doing in this area.

    Dr. Sharp: I think that people will probably be wondering about this. Are there any examples from the ADOS that you can recall or that you may have recorded that stood out to you as atypical, based on your experience?

    Dr. Stephanie: So things that he did that were noticeable were, I saw a little bit of thought blocking. He would start to respond and then seemed to have to stop like something else was stopping him. So that’s not necessarily associated with autism in any way, that would be a symptom. And that really stood out.

    In general, initiation was really hard for him. So he would respond to my overachievers, but there was this long latency before he would respond. And then the [01:22:00] quality of them was blunted and flat, which is not necessarily diagnostic, but also just odd in ways that are, again, you have to just give the ADOS to know but he just didn’t really seem to understand what I was asking. His responses would contain a lot of words once he got started, but I couldn’t tell, does he know what it means to be a friend? Does he know what it feels like inside to be happy? It wasn’t just that he couldn’t explain his own experience. It’s that I couldn’t even understand what he was trying to explain.

    Those are some of the things that stood out for me.

    Dr. Sharp: Thanks, yeah.

    Dr. Stephanie: I did a lot of parent and self-report questionnaires. He was pretty good at filling out questionnaires for me. [01:23:00] Sometimes kids are not able to in the state or sometimes they don’t want to, or they’re guarded. He reported all of the things that you might expect. So when we look at the BASC, the BRIEF, and the SRS that the parents filled out, they’re all elevated for most things. His atypicality score on the BASC is a 90, T score somatization is an 88, and sense of inadequacy is an 89. So those are some of the things that he’s recording.

    I gave him the CMOCS as a questionnaire for OCD and there weren’t any elevations on that. So he’s not just reporting anything. He endorsed some things on the CMOCS but not the type of specific obsessions and compulsions that that asks for. I also gave him the MMPI-A which he was able to fill out high elevations on scales [01:24:00] 8, 7, 6, and 1. The thought disorder T score is a 91. So even if you’re not familiar with the MMPI at all, that probably stands out as a very high T score on a thought disorders index.

    The other thing I really liked doing with kids like this just to be really comfortable with my diagnosis is storytelling-type tasks. And so I did the Thematic Apperception Test with him. I am in no way doing it diagnostically. I’m not really trying to hang a diagnosis on how the individual responds to the TAT. What I’m doing is gathering hypothesis information here.

    I’m trying to see what type of themes stand out, but I’m also getting a good language sample. I’m getting a sample of how organized [01:25:00] this individual is. I’m getting a sample of what they do with something really ambiguous with something emotionally activating. And I’m trying to compare that to other things that were emotionally activating or unstructured. And to the opposite to things that were less emotionally activating and more structured, like the RIAS verbal subtests or the Boston Naming Tests, or the Wisconsin, where he was able to use that structure to do well in those areas.

    I just thought, I’d tell you one of his TAT stories, just so you can get a sense of it if that sounds all right.

    Dr. Sharp: Yes.

    Dr. Stephanie: If you’re familiar at all with the TAT, this is just card one. There was a very long latency to get started, but once he got started, he was able to give me a good response. He said, Tommy is a very religious boy and he’s praying over his violin. It’s the soul of his father who used to kill people with [01:26:00] violin wire in the gang lord style. Tommy is praying over it.

    He never really liked the violin. He liked the piano. An image appears before him. It’s not a God. It’s not his God’s brother. It’s someone who said, avenge your father. He was killed unjustly and Tommy knows exactly what to do. So he plays a verse. He tries to play the violin, but it makes no noise. And he said, “This should work.” So he goes to a psychic and asks him why the violin is not working. And the psychic says, “Go to the mountains. It’s your true calling.” And he dies climbing up the mountain.

    And then he paused for a very long time. And he said the moral is, don’t try to follow in your father’s footsteps. Be your own man. Otherwise, you’ll die trying. I didn’t ask him for a moral, obviously, that’s not part of the task, but he added one. He did for all of his stories.

    So you can see that the content is somewhat unusual. [01:27:00] The organization of it is unusual. The response to the card, that’s not the story. That’s doesn’t really necessarily match with what’s in the story, or at least not how most people respond to it. And there are also just parts where the grammar, or just following what he’s trying to say is difficult. And this is just one story, he told a lot like this, that helps me feel more confident in my diagnosis.

    One of the differentials between kids with autism and kids with psychosis, for example, is that kids with psychosis tend to tell otter stories. And this would be an example of that. This isn’t just you can’t tell what the people are feeling. This is an odd interpretation of the story. Would you agree?

    Dr. Sharp: Yeah. I would agree with that, Stephanie. Yes.

    Dr. Stephanie: And then for some reason I did [01:28:00] a tiny bit of academic testing with him as well. So I don’t remember why. Basic reading and spelling were fine there are almost exactly average 101 and 99, and calculation is poor probably due to limited persistence. So that’s the testing data that I have on him.

    And then what I’m trying to do to wrap it all up is, first I’m really checking myself for cognitive bias. I want to make sure that I am thinking this through really clearly. So just like I did with my preflight checklist, I also have this post-flight checklist where I go through all the various cognitive biases that I could be making, and think through is that what’s happening here.

    So a really common one, for example, would be the effective error where we want really good things for our patients and we don’t want them to have schizophrenia. So am [01:29:00] I unwilling to diagnose schizophrenia because I don’t want him to have it. I think that’s a really important thing for us to be thinking about as we’re doing that. So then I do my post-flight checklist.

    And then I think at this point, my case conceptualization feels pretty clear to me in the sense that this feels like psychosis.

    I feel like I have ruled out other explanations for what might be going on. This is beyond what we would expect for the diagnosis he currently has. It’s beyond what we would expect for OCD. He’s on paper meets the criteria for autism, but that does not in any way fully explain some of the concerns that we’re having. We’ve looked at the anxiety and depression and try to see, are they [01:30:00] more primary or are they more secondary to how confused and worried he is about these experiences that he’s having?

    So I feel reasonably confident in my diagnosis at this point of psychosis. And usually, I don’t really define it too much beyond that. I don’t necessarily unless the child is, I sometimes see young adults and they clearly meet the criteria for schizophrenia and maybe had acute onset and clearly, it’s easier to make the call. At this point, I know that parents are going to have a strong reaction to the word schizophrenia. And I also just want to hold onto the idea that I am trying to make a diagnosis of something that is emerging and that is understudied and that we don’t necessarily know a lot about.

    We do know that some individuals only [01:31:00] have one episode of psychosis and go on to recover, others have a more fluctuating course, others it will get progressively worse. I don’t know what’s going to happen to this young man. I also don’t know if it’s associated necessarily with maybe a mood component to it really. So I don’t really try to identify it much beyond this is clearly a psychosis and we clearly need to set up a plan to help his parents understand what’s happening to him, help him understand what’s happening, and then help move him in a direction that’s positive.

    Dr. Sharp: Can I ask a question there? I think that’s something to dig into a little bit just in, I think a lot of us have either been trained or just philosophically appreciate the clarity or perceived clarity that comes from a specific diagnosis. [01:32:00] I’m guessing, people are like, well, how do you do that? How do you just say it’s generally psychosis versus something a little more specific. Which for me begs the question…

    Then the follow-up question is, well, as long as he’s getting the right treatment and then the follow-up, or that’s not a question, that’s a statement. But then the follow-up question to that is, well, does treatment matter if it’s bipolar with psychotic features versus Schizoaffective disorder versus depression with mood-congruent psychotic features? Is that going to make much difference? So that’s a lot of questions wrapped up in one.

    Dr. Stephanie: Right. And those are the questions we’re all asking ourselves. And we’re all going to end up in a slightly different place in how we do that because there is no perfect answer for that. What I have found in following individuals over time and in having psychosis in my own family is, you can look at a child or an adult for years [01:33:00] and still not be able to answer the question of what exactly is this. There’s discussion in the research of does Schizoaffective disorder has, does it stands up at all as something?

    The genetic risk that comes from bipolar disorder also contribute to the risk for schizophrenia. So how separate are those? And can you really separate out schizophrenia with depression and anxiety because your life is being disrupted or is it a part and parcel of the diagnosis?

    So trying to separate out all of that, for me, isn’t as helpful in making a treatment plan. I don’t necessarily right now need to respond to insurance pressures. So part of it is I just can call it psychosis at this point. [01:34:00] And you may not be able to be at the setting that you’re at. But in terms of your question of treatment, we do know that if it is something more like Schizoaffective or bipolar with psychotic features you are likely to have a better outcome than if it doesn’t have a mood component, which is the opposite of what you might intuitively think.

    But in terms of the recommendations, it doesn’t really make a difference. We know trying to figure out people who are at what they called a clinical high risk for psychosis versus what they call bias brief intermittent psychotic symptoms versus what they call the attenuated psychotic symptoms syndrome versus genetic risk plus deterioration versus schizophrenia form versus schizotypical versus schizophrenia. That for me is something that we can watch over time and try and figure out what this [01:35:00] kid, as the family processes this information, but what the kid, what Sasha needs to know about himself, and what the case family needs to know in general is that this is psychosis. We know what it is, it’s treatable or at least manageable. We have a plan and we understand what’s happening. So that’s sort of where I land on that.

    Dr. Sharp: Yeah. That makes sense. I wonder then if that’s maybe a nice segue just briefly to what you recommended and how you presented this to them.

    Dr. Stephanie: Yeah. So there are two good models out there in the literature of ways that you could do feedback. The CEDAR clinic, for example, has one that you can find. I also really liked the work of Johnstone, who’s a neurologist who gives really difficult feedback cause he tells people that they have functional disorders and that it’s not medical. It’s not at all about schizophrenia, but it’s very difficult feedback.

    [01:36:00] He has a great model that he uses. His model is, you explain what they have, you educate them about what they do not have, you listen for and address their fears, you emphasize that this is a common and treatable problem. You hold hope for the family and you emphasize the potential for recovery, and then you direct them to specific resources and materials. So that’s one model that you can use.

    I use a pretty similar model myself. I start by asking if the family can come in. In this case, it was pre-COVID. So they could come into my office. I could make them a cup of tea. I could check in on what their experience was like. I can get them to agree with me about something so we’re in a positive frame of mind. I could be thinking about their secret questions that they have, but then I solicit their invitation to give them the test results, which is from the SPIKES protocol about giving [01:37:00] bad medical news, where they’ve shown in medicine that if you ask, if you can share the information, you get more buy-in and you help the family realize this is a dialogue.

    And so then I say, Sasha has a condition called psychosis. I explain what that means in the family’s language. I try and use the words that they used if they can. I try and say, you thought his thinking is a little off and you’re exactly right. That’s exactly what psychosis is. I try and answer their secret questions secretly at this point. So I say you didn’t cause this, for example. I say, he’s not making these things up. He’s not saying them for attention. He’s not trying to lie or steal for example.

    Then I talk about the things that Sasha can do and the things that he’ll have more trouble doing. So I say, in this case often when I’m saying what the child can do. I’m talking about strengths. Sasha doesn’t have a lot of them [01:38:00] right now. He’s really struggling. So what I focus on is that he can do things to manage his symptoms. He can build his resilience, he can build his coping skills, he can build good relationships that will help him through this illness. And then I talk about what he will need or what he’ll struggle with, which is to help manage his symptoms.

    And then I try and put together a plan and I try and keep it a three things. Sometimes I sneak, as you could tell extra things into my numbered system. But I try and say, we’re just going to do three things. Often those three things are, first, we need to make sure he’s medically healthy. So let’s share this with his pediatrician. Let’s get him on the right medication. Let’s see if we need any further medical workup. Let’s get him exercising, eating well, let’s get a sleep schedule regulated.

    The second thing is usually setting up his support team. So we got to get the school on board. We need the psychiatrist and the [01:39:00] therapist talking to each other. I try and write down names for them if they don’t have resources so that it’s written down, that they could take it away with them.

    And then the third thing is usually, well, I should say the thing I sneak in is a part of the support team is making sure that parents have support so that they’re aware that their child is counting on them to manage themselves through this difficult time. And during this, I’m trying to help them understand that part of their work is going to be having a place where they can grieve and where they can change their dreams that they might’ve had for him as they might need to, and that that’s going to be really important to his treatment and recovery.

    And then the third thing in my plan is usually making sure that Sasha knows what’s happening to him. I almost always have teenagers come back and explain to them what psychosis is and what’s happening, and that it’s treatable and that we [01:40:00] can put this together. And then I check in with how they’re feeling about it. I make sure they know that we’re holding up that he can manage these symptoms and that some recovery may be a possible outcome for him, and that this will change his life, but he can still have a meaningful important valuable life. And that I’m making sure that they know that this is an open dialogue and that they can ask me any questions.

    I try to invite them right then, but often that’s a lot. We’re usually all crying at this point. So I also make sure that we know that this is not going to be our only conversation. And I try and have the kid come in within the week. And then the parents come in again a week or two later so that they can ask the questions that they’ve had time to think about at that point.

    Dr. Sharp: Yeah. That’s heavy.

    Dr. Stephanie: It’s really heavy. [01:41:00] One of the things that I get asked a lot is, is there anything that I can do to prepare to give this news? And what I often talk to people who ask that question about is understanding that psychosis really is common and that it really is treatable. And that we do have some medications that can help manage it or help make it less of a concern. If possible, getting some experience with individuals with psychosis.

    I mentioned I happen to have it in my family, so I know in my bones that people with psychosis can have meaningful fulfilling lives. Lives that maybe we’ll not always necessarily envision as our dream for our child, but lives that are rich and rewarding and meaningful. And so really knowing that and being able to hold on to that dream while you’re [01:42:00] giving the feedback, I think helps make that conversation a little bit less heavy. But you are giving bad news. So if you’re laughing and having a good time during these feedbacks, you might want to check if that’s really right.

    Dr. Sharp: Fair enough. Check your own odd behavior in those situations.

    Dr. Stephanie: Exactly. And I will tell you, we all react to discomfort differently. So I was slightly joking in that way, but you do find yourself in a lot of discomfort and distress during these. So checking in with your peer consult group, checking in with someone who has a lot of experience in this area, talking to a friend. This is hard. And there’s also just that Pull. You want to downplay it. I can feel myself doing it right now. I’m saying like [01:43:00] you can get better and it’s true you can get a little bit better, but this is a lifelong disorder that comes with significant cognitive deterioration in most cases.

    So there is that pull that we want to minimize or soft puddle or react in an odd way. So you also have to just give yourself some grace that your feedback may not be exactly what you wanted, but what the family will remember is that you were there with them during these hard times.

    Dr. Sharp: Yeah. I think that’s such a good point to focus on- sitting with them. Ultimately, that’s what it’s about. We have this information to share and we’re going to do a great job with that. And I just think back to, I think it was Karen Postal, maybe who said, the feedback can often be just making space for grief- [01:44:00] what families are giving up and the life that they may have envisioned for their kid and adjusting expectations and the loss of some of those things. So I think that’s been a nice theme.

    Dr. Stephanie: Exactly.

    Dr. Sharp: Yeah. That’s been a nice theme throughout your presentation here is just the humanity in this process. We are psychologists first and in your case, neuropsychologists second, right? So just keep it in mind.

    Dr. Stephanie: Or third or fourth.

    Dr. Sharp: Right. So not burying those people’s skills; ability to just sit and honor someone’s experience.

    Well, this is personally speaking, pretty incredible. I really appreciate you coming through and just doing such a thorough presentation on something that is really challenging for a lot of us as [01:45:00] clinicians. I’m guessing that people are going to take a lot away from this. So huge thanks, first of all.

    Dr. Stephanie: Thanks for the opportunity.

    Dr. Sharp: Yeah. Well, I want to make sure to highlight it too… Oh, go ahead.

    Dr. Stephanie: I wanted to say, I love hearing other people’s case presentations and getting a glimpse of how other people work and how they think through things. And no matter who it is, I always learn something or take away something or jot down some notes. So I love that you’re going to be maybe doing some of these that people can borrow and learn from something we don’t always get to see our peers do.

    Dr. Sharp: Absolutely. Yeah. That’s really the intent. I think once we get into private practice and get on our own, and for a lot of us, we turned into the supervisor, and then it gets tough to get this experience where someone else’s presenting in a masterful [01:46:00] way.  So, I think it’s going to be valuable for folks.

    And I also, of course, want to highlight, you mentioned consulting a few times during the presentation that that is absolutely something that you can do, is this clinical consultation piece with folks who have tricky cases. I’ll make sure to put the link to your website, the Peer Consult, in the show notes. I’m just thankful that you are out there for those services.

    Dr. Stephanie: Thanks so much. The consultation has been just the most rewarding experience. I feel almost like I’m cheating because I almost learned as much from the people who consult with me. I think it’s just fascinating to do such rewarding work. I am saying that now because as you were talking to me, I was nodding and then I was realizing, oh, people can’t see me nod, but yes, I do consultation. And it’s [01:47:00] so wonderful. So if anybody wants to know more about that or find out if it’s right for them or anything like that, please let them shoot me an email or give me a call, or whatever works for them.

    Dr. Sharp: Sure. All right. Well, I will say goodbye for now Stephanie. I really appreciate it.

    Hey everyone. Thank you so much for tuning into this masterclass with Dr. Stephanie Nelson all about the differential diagnosis of psychosis. This was a brand new podcast format. I would love to get some feedback from you. Please let me know if you enjoyed the episode, if you did not enjoy the episode, thoughts, suggestions, et cetera. I would love to hear that. You can reach me at jeremy@thetestingpsychologist.com or you can simply leave comments on the episode webpage, which will be linked in the show notes.

    If you have not subscribed to the podcast, I would love for you to do that, of course. [01:48:00] Related to that, if you have a moment to give a quick rating, if you find the podcast helpful, I would be very appreciative. So you can do that easily in the podcast app that you are listening to. Apple was particularly easy. Others, you might have to search for it a bit, but I would be very grateful for any feedback or rating, or review that you might be willing to leave.

    Again, thank you so much for listening. I will be back next Thursday with a business episode. I hope you’re all doing well. Thanks. Take care.

    The information contained in this podcast and on The Testing Psychologists website is intended for informational and educational purposes only. Nothing in this [01:49:00] 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 the 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!

  • 154: Finding a Supervisor or Consultant for Clinical Issues

    154: Finding a Supervisor or Consultant for Clinical Issues

    Would you rather read the transcript? Click here.

    How many of you have been working on a difficult case and thought, “Wow, I wish I could talk to someone about this” or “I could really use some guidance here”? I’ve been there! Many times. Which is why I sought supervision, post-licensure, from a local pediatric neuropsychologist for nearly five years. Even though consultants and supervisors are out there, many of us don’t think about finding one as the first course of action when we’re stuck on a case. This episode is all about when you should consider consultation as well as where and how to find that individual. Enjoy!

    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. 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 12 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]



  • 154 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.

    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.

    All right, everybody. Welcome back.

    Today’s episode is a continuation of our beginner series, although it certainly applies to folks who have been in practice for quite a bit as well. I’m going to be talking about how to find a supervisor or consultant in your practice for clinical issues after you’ve already been licensed for a bit.

    [00:01:00] Now, heads up, disclaimer, I stumbled over the word consultant two times in the episode. I don’t know why I couldn’t think of that word when I was talking, but just know that that happens. My apologies. Sometimes my brain does not work.

    I hope that you’ll take a lot out of this episode. I am going to be talking about when you might want to seek consultation or supervision post-licensure, how to find that individual, and how to approach that individual. So, I hope that you take a lot away from this episode.

    Without further ado, let’s get to the conversation.

    Okay, welcome back. [00:02:00] This episode is going to be, I think, relatively short and sweet. I want to get right to the point and just give you some quick tips on when you might want to seek consultation and where to find that individual.

    I want to start just by noting the importance of finding consultation or supervision after we get licensed. As I mentioned in the intro, it can be really easy to slip into practice where we maybe do some reading, maybe do some CEs, but we really miss that one-on-one connection with another professional. That can be so valuable when we’re doing case conceptualization.

    In my career, I have found it very, very valuable to have a supervisor that I can go to if I need to. And I think all of us just, you know, we are always going to run into those cases where we need a little bit of help. So, if that sounds familiar to you, please continue to [00:03:00] listen. I’m going to dive into this topic in a little more depth.

    Here are some instances when you might want to seek consultation or supervision after you’re licensed. Keep in mind that I’m not going to really be talking about supervision pre-licensure. So, this is all just for those of us who have been licensed and are out on our own.

    The first instance is I think pretty clear. Maybe you’re seeing someone, a case or a patient, who is clearly outside your area of expertise for whatever reason. Now, there are a number of reasons where you might find yourself in this position. I think we all try to steer clear of cases that we know are outside of our expertise, but there are some of those instances where you find yourself in that situation.

    The one that comes to mind for me right away is more of a rural setting- folks that are practicing in areas where there are no other [00:04:00] practitioners for a pretty large radius and you have to… it’s sort of like something better than nothing in terms of clinical services. I’ve seen discussions like this in the Facebook group often where people say, I’m the only provider within 100 or 200 miles, and this is outside my area of expertise, but somebody has got to see this person. So that’s one instance. And I know there are other examples of getting stuck in that situation. That’s the one that comes to mind right away for me.

    Another time that seems to be a little more common for a lot of us is when you are seeing a patient or client that certainly feels within your wheelhouse or area of expertise in most regards, but then some dimension of the evaluation pops up that clearly falls outside your area of expertise.

    An [00:05:00] example that comes to mind and for me right away is if we’re say doing an autism evaluation, but all of a sudden, there are symptoms that could be construed as OCD or maybe psychosis or maybe a personality disorder in adults. So any of those times when the differential diagnosis gets a little more complicated than it seems on the surface, or you’re digging in and recognizing that some aspect of the presentation is outside your area of expertise.

    I see this a lot as well with any differential diagnosis and trauma pops up. That’s another one that often needs to be consulted on. And there are many cases, at least in my world, where there is some kind of medical concern that might be going on as well. Maybe there’s a vague incident or ill-defined incident [00:06:00] of a head injury or there’s a genetic disorder or something like that where the majority of the case feels like, Hey, I’ve got this, but there are just these little components that pop up that throw you for a loop. And you want to make sure that you’re within your scope of practice.

    The third situation that I think of in terms of seeking consultation or supervision is one that is quite personal to me. And this is when you’d like to develop a new specialty area. Now, I don’t want to get into the debate right now about psychologist versus neuropsychologist, but I’ve told the story on the podcast about how a few years into practice, I clearly recognized that there was more to evaluations than what I was taught in grad school, which was largely, I would say a traditional sort of Psychoeducation or just [00:07:00] psychological evaluation framework.

    So, I looked around. I knew that I could not go back for the formal postdoc or fellowship to become a neuropsychologist, but I really wanted to gain more expertise in the neuro-psych realm and be able to bring more of that knowledge to my conceptualization. So, I sought supervision. I looked around. I found someone, a board neuropsychologist, and paid for supervision from this individual for probably 4 or 5 years. And I still talk to her to this day here and there. So, that’s another area.

    And this has come up on the podcast a few times as well. I know Chris Mulchay talked about developing forensic expertise. And one of the best ways to start doing that is to seek consultation from trusted folks in the [00:08:00] field. So, so this is another area. You maybe have grown bored or you’d like to add a specialty area, a good way to do that is to seek consultation first to even get a roadmap for how to add that new specialty area.

    So, those are just a few instances where consultation or supervision might come in handy.

    All right. Let’s take a short 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 examine 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 [00:09:00] 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.

    Now, let’s talk about where you might find that and how to approach those individuals. In my experience, there have been a few areas, some a little more intuitive than others that can help you find a consultation source or supervisor.

    One, I’ll start with the most obvious, is old supervisors. So, people that you might know from graduate school who have a demonstrated expertise in the area that you’re interested in. If you have good relationships with those individuals, you can always get back in touch and see if they’d be willing to provide post-licensure consultation or supervision.

    [00:10:00] Another source of consultation is listservs. We’ve talked about many listservs on the podcast. There seems to be a listserv for pretty much any specialty area that you could think of. Certainly pediatric and adult neuro-psychologist listserves. There are forensic listservs. These are good sources of supervisors or consultation individuals. I’m not sure what the right word for that is. So, you can search around on listservs. There are often folks who were quite active on listservs. And you can contact them directly and simply ask if they’d be willing to provide consultation in the area that you’re interested in.

    Somewhat related to that, The testing Psychologist Community on Facebook is a great place to find a supervisor. [00:11:00] We have recently started making a regular once-a-month post called supervision Sunday, where all of the individuals who offer supervision or consultation can list their contact information, the State that they’re located, and their area of expertise. So, you can search in the group for Supervision Sunday, cruise through the list and see if there are folks who specialize in the area that you’re interested in.

    I do want to mention and just make sure to say that the Facebook group is not a substitute for formal consultation. While there’s plenty of case discussion that happens in the group, it cannot take the place of formal consultation and certainly would not hold up in court if you were to try to say that that’s how you validated your clinical opinion or anything like that. [00:12:00] So don’t use the Facebook group as formal consultation though you can get some ideas here and there. If you really want a legally defensible means of developing expertise, you need to seek a formal supervision arrangement with an individual.

    On that note, there are plenty of local and national chapters or directories or APA divisions, for example, or societies that correspond to your sub-specialty. So, you can look in those directories. This is actually how I found my supervisor is looking at the Colorado Neuropsychological Society, and just went through the list and found folks who specialized in kids and contacted each of them. So, look in the directories and try to find folks that [00:13:00] do what you want to do.

    In terms of approaching these individuals, once you found a few, 1 or 2 options, people you might want to work with, in terms of approaching them, I always just advocate being direct and explaining where you’re at in your career and what you’d like to get consultation on. The most important thing I think is to make it very clear that you are willing to pay for these services. I think it’s a big pitfall to just assume that people are going to provide supervision or consultation for free.

    So, when you reach out to these individuals, make it very clear that you’re willing to compensate them for their time and ask what that rate might be. For the majority of supervisors or consultants, you can expect to pay a ballpark around that person’s hourly rate or maybe even above their hourly [00:14:00] rate for the service, just to put that out there so that you can know what to expect in these arrangements.

    And then from there, I think it depends on what you need. You can certainly set up regular meetings. You could do a one-off hourly deal. You can do a retainer arrangement. I’m seeing those work quite well where you’re just able to call the individual when you need it. So, talk with that individual, think about what you might need, and make sure to lay out those terms as clearly as possible.

    Okay. So that’s just a little bit about when, where, and how you might find post-licensure supervision or consultation in assessment. I think this is something that is super important. And I know that there are plenty of folks out there who are willing to provide supervision or consultation, so don’t let it scare you off.

    [00:15:00] And this is part of getting better at what we do. It is a great way to not even just supplement continuing education, but really when I say supplement, that almost means continuing education is the preferred option. And that’s great, but I get so much more out of talking with an individual over a case or an issue or an area of specialty than doing CE credits. So, I think it’s not something that supplements CEs. It’s more something you said you should just pursue on its own, independent of CEs.

    So, hopefully, you took a little bit away from this episode, gained some confidence, and maybe started thinking about where you might want to seek some consultation or supervision. It can also be really fun. It’s a good way to expand our scope of expertise without necessarily going back for a full re-specialization.

    Okay. [00:16:00] Thank you as always for listening to the podcast. And stay tuned. We’ll continue with business episodes on Thursday, clinical episodes on Mondays.

    I’m really excited about this upcoming clinical episode on Monday. It’ll be the first of hopefully many quarterly masterclasses. And the masterclass this Monday is with Dr. Stephanie Nelson talking about a case where psychosis was a differential diagnosis. We talked through all the ins and outs of that case conceptualization and how she arrived at that conclusion. So, you don’t want to miss it. I think it’s going to be pretty amazing.

    And again, if you have not rated or subscribed to the podcast, I would love for you to take a couple of minutes and do that. It’s super easy in the podcast app for Apple. Spotify is pretty easy as well. I’ll be [00:17:00] very grateful like I said.

    Hope you’re all doing well. Have a great weekend. And we’ll see you on Monday.

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

    Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. [00:18:00] 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!

  • 153: Creating a Welcoming Space w/ Cheryl Janis

    153: Creating a Welcoming Space w/ Cheryl Janis

    Would you rather read the transcript? Click here.

    Have you ever thought about the psychology of design? Or truly considered how your space might influence client behavior and comfort? If not, that’s okay! Design is just one of the MANY things that were missing from our grad school education. Cheryl Janis, a nationally recognized health care design consultant, is here to talk through some of the most important components of designing your wellness space. Here are just a few things that we touch on:

    • Core elements of design that we need to pay attention to
    • How to stretch a small design budget and get the most for your money
    • Soundproofing in a stylish way
    • Colors to avoid

    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 Cheryl Janis

    Cheryl Janis has spent 15 years teaching healthcare and medical professionals how to transform their practices into nurturing spaces that increase revenue. During that time, Cheryl has used an interdisciplinary approach to design—evaluating the patient experience from the moment they walk through the door until the time they leave, and every step in between.

    Cheryl is currently taking on select clients only and spends the majority of her healthcare design time hosting and producing the Healthcare Interior Design 2.0 podcast: https://tinyurl.com/healthcaredesignpodcast.

    Cheryl is also the author of two healthcare design books, The Color Cure 2.0 and The Waiting Room Cure. You can find these book on her website at: https://cherylrjanis.design/

    Cheryl is offering a special price for a virtual healthcare office design for the listeners of The Testing Psychologist podcast. Contact Cheryl at: cheryl@cherylrjanis.com and mention you heard her on The Testing Psychologist podcast and enjoy a 20% discount off a virtual office design consultation.

    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]


  • 153 Transcript

    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  BRIEF2 ADHD form uses  BRIEF2 scores to predict the likelihood of ADHD. It’s available on PARiConnect- PAR’s online assessment platform. Learn more at parinc.com

    All right, everybody, I’m excited to have my guest today, Cheryl Janis. We are talking all about how to create a welcoming space. This is an often overlooked area in our field and just another thing that we have not gotten education on in our grad school training.

    Let me tell you a little bit about Cheryl. She has spent 15 years teaching healthcare and medical professionals how to transform their practices into nurturing spaces that also increase revenue. She takes an approach where she basically evaluates the patient experience from the moment they walk through the door until the time they leave, and every step in between to gauge the design choices.

    She has a role in two podcasts. She hosts and produces Healthcare Interior Design 2.0 podcast. And she is also the co-host and producer of The Wellness Design Podcast, where she and her co-host discuss all things healthcare design for the small office space. Cheryl has written two books, The Color Cure 2.0 and The Waiting Room Cure. You can find them on her website which will be linked in the show notes.

    Cheryl is also graciously offering a special price for virtual healthcare office design for our listeners. So if you contact her at cheryl@cherylrjanis.com and mention that you heard her on The Testing Psychologist podcast, you can enjoy a 20% discount off of virtual office design consultation.

    So I think there’s a lot to take away from this episode. We really get into the details and Cheryl offers some pretty concrete advice for how to design our space and things to stay away from and where to spend our money. That makes the most sense among many other things. So please enjoy this conversation with Cheryl Janis.

    Hey, Cheryl, welcome to the podcast.

    Cheryl: Hi Jeremy. It’s so great to be here. 

    Dr. Sharp: Yes. Thank you so much for coming on. I am really excited to talk with you.

    Cheryl: Good.

    Dr. Sharp: Good. Yeah, I think there’s a lot to talk about. This is a topic that we have not really covered in any amount of detail on the podcast, but yet something that’s very important to our listeners.

    Cheryl: Well, let’s get into the details. 

    Dr. Sharp: Let’s do it. Yes. I like it. So yeah, let’s start. I would love to hear. If you could just describe the kind of work that you do exactly and why this is important.

    Cheryl: Sure. Again, my name is Cheryl Janis. Right now, I’m a podcast host and producer of the Healthcare Interior Design 2.0 podcast.

    For the last 15 years or so, I have been helping healthcare professionals in private practice like testing psychologists and other types of healthcare and medical professionals design their spaces on a budget and with attention to patients and clients and how they feel in the space. So really focusing on some design psychology and how that turns into profitability when people like your audience and who’s listening out there actually create a space where your patients, clients, and their families really feel good there.

    Dr. Sharp: I love that.

    Cheryl: Yeah, that’s what I do.

    Dr. Sharp: You put it very succinctly. There’s a lot wrapped up in that that we’re going to talk about, which is a good thing. How did you get into this?  What about this calls to you?

    Cheryl: I’m what they call a highly sensitive person. That’s a term that’s been coined by a psychologist and I forgot her name. Oh, you have to do Elaine

    Dr. Sharp:  Elaine Aronson or something like that?

    Cheryl: Yeah. So as a child, I got in a lot of accidents like children do, and I spent a lot of time in hospitals and whatnot and fell downstairs and in dentist chairs. Anyway, so I had a lot of experiences as a child and felt really terribly frightened by all those experiences.

    And so, as I grew up, I continued to have those experiences and didn’t… I had these terrible times where the lighting was horrible in these spaces. And anyway, you know how it is with children, children can become terrified and that creates trauma.

    I started studying Feng shui design probably in the early 2000s from a Western perspective. And I loved it because it looks at the psychology of space. How does the space feel? How can we work with the space to improve our health or attract relationships with others, all these kinds of things? So that led to more certifications and studying the color and studying some material design.

    I was working with residential clients for many years, and once in a while, I did healthcare or a healing practice. And I found that I really enjoyed working with healing practices or healthcare practices, small practices because the results affected so many more people than just one person living in a home.

    And so I started focusing on that. And actually, right now I only do it part-time because I’m doing other things because I’ve done it for so many years. But I’m excited today to share just so many tips for your listeners to DIY their space themselves. Well, that’s when I got into it.

    Dr. Sharp: I like that. It’s, like a lot of things, born of our own experience, right? And that’s what drives us to do what we do.

    Cheryl: Yeah.

    Dr. Sharp: Maybe we could just start at the beginning. This is a naive question but I’d love to hear. When you even say psychology of space, what does that mean? And I imagine there are people out there that are like, is that really a thing? Why do we need to be worried about that? 

    Cheryl: Well, I think that the easiest way to explain it is to look at the retail and restaurant industry and the way that they design their spaces. And I’m talking pre-COVID here.

    You know how when you walk into a restaurant and you just love it, the food is good, but you end up staying there for a long time because the ambiance in some way feels good. I don’t know. There might be some plants in there. The colors might be beautiful, the lighting, whatever it is. And then you notice that the restaurant next door is empty.

    And on Sunday morning, there’s a line out the door to this one amazing restaurant that has good food, but the place next door has pretty good food too, but it has white walls and it’s a cold feeling. 

    I think that the easiest way is to explain it through our own personal experiences. All of us on planet earth have had those kinds of experiences. And that’s really just looking at the experience of a space and the design of the space and the psychology of the space. How does color affect us? How does lighting affect our neurology? And these things are all under the umbrella of evidence-based design.

    And so there’s a lot of evidence that shows that the lighting in a space can really affect us negatively or positively. So that’s essentially what that is in a nutshell without getting too complicated.

    Dr. Sharp: Yeah, that’s fair. Well, you are piquing my interest with this phrase evidence-based design and I’m guessing a lot of the psychologists out there are like, Ooh, you always love anything that’s evidence-based. What is that?

    Cheryl:  There’s an organization called The Center for Health Design and they’re located in Concord, California, which is the East Bay. They’ve been around for a long time since the 70s, really. They officially opened, I think, in the 90s. They are your go-to resource for everything evidence-based design.

    And so, you can become a member there. There are things that are free. There are webinars. And there are just, what do they call it? There’s something they call it. I can’t think of the word. It’s just this massive resource, like the Bible of evidence-based design. And so, hospitals, big facilities, places, and architects go there. That’s one of the resources to do research for the research team.

    And this organization has set up over the years hospitals where they’ve tested stuff out. And one of the earliest evidence-based designs that they gave credibility to was Roger Orrick, who was an evidence psychologist. And I think it was in 1981, they published his study.

    He did a study at a hospital on gallbladder surgery patients. So the same 7 or, I don’t know the amount, I think it was around 7 or 14 patients who were having gallbladder surgery stayed in a certain kind of room. And then the other ones stayed in another kind of room and nothing else was changed. They had the same nurses. They had the same doctors. They had the same surgeries. They had the same medications. Everything else was the same.

    And the differences between these two rooms was one thing. One of the rooms had a window with a view of a tree, and one of the rooms have a view of a brick wall of another building. And guess what happened? Well, as you can probably guess because we all love being in nature, we know the benefits. Nobody has to tell us any evidence for that although there exists plenty of it. The patients that have the surgery in the room with the tree got out of the hospital earlier. They had less pain. They didn’t need as many pain medicines.

    And so, I think this was the very first study that was accepted by the science community as, okay, yeah, you followed every little protocol for this. And he’s a famous person now in this industry because of that. He’s also, I heard, a very cool guy.

    Dr. Sharp: That doesn’t hurt.

    Cheryl: So the Center for Health Design if you’re really interested in the evidence, and it has just really piqued your interest, and we’ll talk about some of it here when we go through some of these tips that you can do for your office.

    Dr. Sharp: I love that. I think I could be making this up, but it came from somewhere this idea that having a window in your office space is the most highly desirable characteristic of a job or something like that, independent of so many other factors you’d think would be more important. But that idea seems to transcend

    Cheryl: We all know that. We all feel that. We all feel better with natural light when we’re in an office.

    Dr. Sharp: Absolutely. I wonder if we could set a little bit of a framework. You mentioned lighting and color. Are there other core elements of design that we really need to be thinking about as we put our space together?

    Cheryl: Yeah. So we’re going to talk about specifically the testing psychologist’s office. Who’s a psychologist? Let’s talk about what happens in the space.

    So what happens in this space is the client comes in and the client might be a younger person who needs to take a test. And they might sit at a desk to take that in a certain place with a computer, and then their parents usually come or their family members. Am I missing anything?

    Dr. Sharp: No, that’s petty good. You nailed it.

    Cheryl: Okay. So let’s talk about that. We now have an understanding. The first piece is understanding who your clients or patients are. Who are they? How old are they? And then looking at that and establishing what are their needs?

    Let’s imagine now what happens when they come into the space. That’s a great place to start because let’s talk about first impressions. We do know that within the first 15 seconds of someone meeting somebody else, there’s an impression that’s made from the brain. I like this person. I don’t like this person. And it happens unconsciously. And the same thing happens when we will walk into a space. And then we make that association with the person in the space.

    Like nobody thinks of the DMV as a comforting place. Everybody just cringes when we have to go in there. So that’s a great example that everybody can understand. So let’s go back to the testing psychologist’s office.

    So first impressions, what do your patients and their family see when they first walk in? Do they see a box of… Do they see a trash can? Do they see a box of clutter somewhere that’s just been stacked up or do they see a sofa? Do they see an art piece- a simple art piece on the wall that sends their brain a signal that they’re in the right place that they can feel comfortable here immediately?

    So the first thing to write down is that, first impressions. What do my clients see when they first walk into the space? Now, this may seem like common sense, but a lot of people out there just are so busy. And especially now with all the new CDC requirements and you have to have your [00:16:00] space at social distancing, and that makes it more stressful for everybody. So on and so forth.

    So not everybody knows this. Think about this. So think about this and look at what they see when they first walk in. So I’d say typically people now walk into a waiting room, is that right? In a testing psychologist, there’s some kind of a waiting room. It might be small. It might be medium.

    And so, you want to think, okay, how many… well, now you need to think about social distancing, …how many people are in here during my busiest time. So it might be 3. Let’s just give an example of 3 kids with their parents. And maybe there are 2 different testing psychologists there. Everybody waits in the community area and in the waiting room.

    Okay, well, what is their experience like? So [00:17:00] let’s talk a little bit about space planning in that waiting room. One of the things that had been coming into fashion in private practices that is actually really good for social distancing now is to not just have a sofa and chairs in your waiting room but to actually have a High Top cafe table there because young kids like it, millennials like it, and sometimes parents like it because if their kids are smaller, there may be another area where the smaller kids go to play or color or do something. And then the parents can sit at the cafe table and they can do what they need to do, and of course, you have wifi and all that stuff.

    So, thinking about different areas to do that with. And within that, I’m just going to interject that [00:18:00] one really key piece, you can put a little asterisk next to it, is to blend those shapes when you’re decorating your waiting room and your entire office. What I mean by that is don’t just have all square and rectal linear side tables and coffee tables. There’s a lot of research that shows that the brain doesn’t like that. It makes somebody feel anxious and uncomfortable.

    And so, if you add curved shapes, which is very simple and easy to do, round side tables, round coffee tables, a round chair, anything that has a curve in it, people love that. For example, I’ve had clients in the past that said, Cheryl, all I did was replace the coffee table with a round table and suddenly, my clients are noticing things in the waiting room they haven’t noticed before. And [00:19:00] so it makes a lot of sense.

    There’s that saying from the 60s or50s, don’t be a square. We’ve heard that on shows like Ozzie and Harriet don’t be a square. So there’s actually research that shows that the brain doesn’t like that. Our nervous systems do not like spaces. And all I have to do is think of nature. Think of all the different shapes.

    So, thinking about that your space planning, maybe add High top table maybe, and then 2 chairs. Now with the pandemic, I think maybe not even having sofas might be important because it’s important to get materials that are cleanable. And I know that many testing psychologists are on a shoestring budget. So, there are lots of ways that you can work with this.

    So the patient comes in. [00:20:00] The first thing they see is something beautiful. It might be a plant. It might be a piece of artwork or it might even be a hospitality table. That’s one thing that patients, especially parents really love and feel a lot of gratitude for. If you have a hospitality table, I don’t know what the CDC requirements are on this, but let’s just talk pre-COVID, and then maybe you can adjust it. If you have a hospitality table, which is simply a table, like a buffet or small table water or tea on it, and it’s sort of like a self-service station. And for kids, you can have these silicone cups that don’t drop.

    That one small act of generosity will return to you in dividends because there is this thing that happens where people feel really grateful about that. They feel like you care [00:21:00] about them. They can relax. And then they’re going to feel more comfortable with you by the time they’re seeing you. This is especially important for first-time clients. So that might be across from… that might be a first impression thing. So it depends where the door is and all that stuff. Does that make sense?

    Dr. Sharp: It does. I have two questions about that. One of them is, for those of us who may have an administrative assistant or an admin desk of some sort, how does that play into a waiting room space? Do you have thoughts on where you might place that individual or that desk?

    Cheryl: Yes. So it depends. Everybody has a different preference. If you want to be seen as… I’m trying to think of the right word, …if you want to be seen as more formal, [00:22:00] more professional because you feel like you need to garner respect, you feel like you’re not, that’s something that’s important to you for whatever reason, then you would probably want to have that across from the door.

    When somebody walks in, they see that. They see someone sitting there. You want to have at least 6 feet between that front door. Otherwise, it just gets too off-putting like, ah, hello, you know, face. And so, it’s a different vibe when you walk into that. So that’s the first impression. And then next you see the little waiting area where you can relax. And it really depends on your setup. That’s a [00:23:00] choice. And then, if that were the only choice, then behind that the admin person or the reception person, it would definitely want to have a sign of your business.

    Some of the research they’ve done around people not knowing where they are, even if there’s not even if they know that the address was right, but they come in and they don’t see a sign of the business, it provokes anxiety. So, I’m just wanting to be really clear on that. And that goes for wherever your desk is, but that’s a nice addition. And then maybe having a plant on the desk or a water feature or something that softens that hardness of walking into a desk, walking to the person.

    And of course, you want that person, of course, to be really friendly and all that. And if they’re not on top of [00:24:00] it being opposite the door, then that’s not going to be the greatest experience. But I know that everybody thinks they know that, but in a lot of situations, receptionists and people are not present in there, and they’re busy or stressed out.

    Now, the other thing you can do is to have it off to the side, the desk. That way, when someone walks in, all they have to do is turn their head and see that they’re in the right place. And instead, when they walk in, they’re greeted with maybe it’s an arrangement of furniture, maybe it’s the high-top table with a beautiful hanging lamp, that’s super cheap and affordable that you can get hanging over it. And you don’t have like a million lights bulbs in the ceiling.

    A lot of people have, we can talk about that later, lights, but a lot of people have those soundproofing tiles in the ceiling, and then they have these [00:25:00] fluorescent lights feel not good. Everybody knows that. That’s common sense. So those are the different options. And it really depends on how your space is laid out.

    Dr. Sharp: Sure. And what about for those of us, I’m just going to keep on this waiting area trend, those of us who don’t have an admin, and it’s just an “empty waiting area?” What are ways that we can help folks feel comfortable and welcome and know they’re in the right place and know what to do once they walk in?

    Cheryl: You definitely want to have a beautiful color on the wall. And we’ll get into colors later. I just want to say one thing about colors. You definitely want to blend a mix of warms and cools. A lot of times you’ll see yellow walls with brown furniture and a warm-colored rug, and that provokes anxiety and makes people feel hot. When you go in the sun, it’s imagined being in the sun all day without any shade. So you [00:26:00] definitely want that.

    I don’t know. It really depends on the space. If you don’t have a person out there and just have a hallway and people are listening to see who comes in the door, maybe there’s some kind of a bell that goes off, I would have a really beautiful waiting area with 2 seats with arms and upholster a chair, make sure they’re comfortable, make sure they’re spaced out and then design it as we were talking about with the circular or the oval or curved items, and then have a hospitality table and have a sign.

    Have a sign opposite the door. Maybe it’s over the chairs that are opposite the front door. And it says your name. And so people know that they’re there. I mean, it just takes that little thing and then some nice lighting. And then you come out just in a few moments you hear [00:27:00] them.  Or there might be a sign, I’ll be right with you and maybe some further instruction. 

    Dr. Sharp: I like that.

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    [00:28:00] So, you started to talk about color. I don’t want to jump the gun too much here. Let’s keep that in mind. I want to ask about colors for sure. I have a lot of questions about that, but I also want to walk through things in order. So, we’ve got our waiting area and you are talking about what people see first, right? This is all first impression. So then where do we go from there in terms of, what are we mindful of in our design?

    Cheryl: Well, a good thing to do is walk through the space as if you were the patient. A lot of my clients actually do this. Regardless of their practice, they and their team will actually do that. And you can actually learn a lot.

    So notice things. Walk-in yourself, see where you would sit, notice what you would look at. You [00:29:00] might be looking at a wall. You might be looking at a window. If you’re looking at a window, what are you looking at? Really treat this as an experiential process. It just takes curiosity. It doesn’t take any money. It just takes some curiosity and time and consideration to think about these things.

    We talked a little bit about space planning. So, now someone is there and they either are greeted by a receptionist that checks them in and says, go wait in the waiting room.

    Gives them a mask, checks their temperature, whatever. And then, even if you can have a self-service hospitality table, I highly recommend that you offer people something in that way. So maybe you just have to serve that or your receptionist can serve it.

    Now let’s say, I don’t know, give me an example of a client. So, [00:30:00] it’s a single mom with the kid or 2 parents?

    Dr. Sharp: Yeah, sure. Let’s go with that. Usually, for us, one parent comes in and brings their child for the testing appointment. 

    Cheryl: And how old is the child?

    Dr. Sharp: Let’s just say, 9 years old.

    Cheryl: Okay, perfect. So one parent comes in with a 9-year-old, let’s just say a boy. Now, if there’s a lot a longer wait time, what can the boy be doing? Is there anything that the boy can be doing or does the boy just usually have an iPad or some kind of technology? In that case, you don’t really need to provide anything.

    One of the things that you can provide, which I highly recommend are calming coloring books. Coloring books are known to calm the nervous system. And there are specific ones that are out there and they’re on Amazon. And all you have to do is [00:31:00] put those out. And these coloring books are really calming for the parent and the child.

    So why don’t you just get a bunch of different coloring books and you can get some kind of cleaning, clean the different pens, or whatever you need to do to keep it safe from COVID.

    They have that. Now, what are they looking at? They might be looking at a wall so we can talk about artwork. So, before you get into designing the space, take a walk through what your client does when they come in. And then write that down. Maybe it’s in the shape of a Z or maybe they come in and if there are 2 parents, they might sit over here. And if there’s one, they might sit over here. So, what next?

    Dr. Sharp: Yeah. Let’s think about the colors and the art and [00:32:00] the lighting that we might…

    Cheryl: Okay. Let’s start with lighting because that’s the thing that most testing psychologists, I would say they lease or rent the space they’re in, is that right?

    Dr. Sharp: I’d say most. Yeah.

    Cheryl: And most offices in the United States anyway tend to have bad lighting. And what I say by bad lighting is they have these fluorescent lights that provide a glare. And there’s lots of research that those kinds of lights are headache-inducing. They’re tiring. They make you tired. They’re just overall unpleasant. We all know that.

    So let’s say there’s a testing psychologist who works with a total shoestring budget. You cannot replace these lights. Your landlord has said, no, you’ve asked. So what you do is you just keep them off. We’re talking specifically about the waiting room, okay? Keep them [00:33:00] off. For any reason, you don’t turn them on. And then you get floor lamps, table lamps, and task lighting. And you start to create layers of lighting with Led warm lights. The Led light bulbs are the closest color to incandescence because although incandescent light bulbs are not efficient, their colors are amazing.

    So Led has come a long way and they offer now bulbs. There’s a cool blue and a cool white and a warm white. You always want to get the warm white, not the cool blue or the white. So, put those floor lamps behind chairs and corners. Light up those corners.

    [00:34:00] And you might have a bookshelf in there. I doubt it now because of COVID, but just light up those areas. And when you’re thinking about furniture colors, if you’re more into modern and contemporary, go with some white light round tables. Try to choose white because white feels really clean and good. And then with the chairs, you can get pretty colors, blues, or greens or oranges, or something fun.

    Back to lighting. So you want to have table lamps. You want to have floor lamps. If you can do wall sconces that just plug into the electrical socket, go on Pinterest and look up lighting and have so much fun. It’s so affordable. And you can create the prettiest space. And all of a [00:35:00] sudden that room feels really inviting and comforting, and it has that element of being at home, but it’s more professional and people can feel comfortable there.

    So that is my recommendation to turn off those lights if you can’t replace them. If you can replace them, get warm Led lights overhead. And if you can, when you get your cafe table, which is higher up, if you can, hang a little chandelier over it to really make that a cute adorable fun space. And those are also super affordable. Lighting these days you can get, even at IKEA is just really affordable.

    So that’s lighting in the waiting room. You want to have different levels. As far as wattage, I would do 60-watt bulbs are good, [00:36:00] 75-watt bulbs. I mean the equivalent in Led.

    We haven’t talked about the flooring. Even when you have a horrible rug that your landlord will never replace because they’re too cheap, you can get your own rugs, very low pile rugs that are not tripping hazards. And you can create that vignette area. All these things can be cleanable.

    For the chairs, for example, you can get 4. I wouldn’t do leather ever because leather damages when you try to clean it. I would get faux leather, which is vegan leather, or there are lots of other products out. There’s lots of other stuff. You just need to look online. When you think about chairs, you think about arms versus no arms. You want to do arms. People sit longer and chairs with arms because they can rest [00:37:00] their arms. That makes sense, right?

    Dr. Sharp: That makes sense. Yes.

    Cheryl: They’re not transitional chairs which is what chairs with no arms are called. So, that’s the lighting. You want to think about that as you extend it into your hallways. So if you just have the fluorescent lighting in your hallways, maybe you can put some wall sconces there and keep those off. You want to extend that into your testing rooms as well. For the actual testing desk, you want to get a task light or something, and Led task light, which is just a desk light. And that’s really focused light.

    Now, what else? Where can we go from here that would make sense?

    Dr. Sharp: Let’s see. I’m still stuck on the waiting area. So let’s talk about colors. You mentioned, don’t do yellow walls with brown furniture. Is the research around [00:38:00] colors that are more common?

    Cheryl: It’s a little more subjective when it comes to hardcore research. I can tell you what I found and what some of the research shares.

    I never recommend yellow on walls cause there’s enough research and enough anecdotal stories out there, and my own research has shown me that yellow is an agitating color. So I would use yellows in pillows. And maybe a yellow piece of furniture. I wouldn’t use yellow on all the walls. I would definitely not do that.

    I would do a very soft if you… it depends on what you like too because it’s very subjective. A psychologist might be more attracted to greens or blues, which there are some beautiful greens and blues out there. And blue is a trusting color. That’s why they use it a lot on the internet. [00:39:00] People who want to invoke trust and they’re giving a lecture or something or a presentation, they’ll wear a blue shirt.

    Don’t ever paint your walls red or maroon or burgundy or anything like that because those colors are agitating. Those colors are never used in mental health facilities because they exacerbate behave certain behaviors like violence. They can trigger trauma. They can trigger certain things. Orange is a happy color though, but I still wouldn’t put it on every wall.

    I never recommend accent walls except for the ceilings. When you do accent walls in small rooms, testing psychologists usually have small spaces, let’s say the waiting room, you want to do the back wall orange and the other walls green or something like that, it chops up the [00:40:00] room. It doesn’t feel whole. You walk in and you’re kind of like, ah, ah, there’s that. Too many distractions.

    The idea here is to keep a nice flow. Keep people feeling calm and centered because they’re already stressed. They’ve got their child who’s got a learning disability or may have had one. And there’s already a lot of stress.

    This recommendation is you never want to paint an accent wall on the room except for the ceiling. I highly recommend painting ceilings. It’s something that has been a little controversial over many years because when people first hear me say that, a lot of them say, oh my God, no, that would make it too dark in here. Weird.

    It’s because of fear and people like this white thing overhead, but even when landlords allow you to paint your… Jeremy, I can [00:41:00] see you have those sound tiles in your ceiling. When they allow you to paint them because they’re really cheap to replace, do it. They only reduce the sound properties by 10%. And there is something so soothing about having a painted ceiling.

    Dr. Sharp: Are there any colors you are going for here?

    Cheryl:  Yeah. I like to use Benjamin Moore. When there’s a lot of light in the space, let’s say there’s some natural light, big windows, I like to go a little darker on the ceiling. It creates a lot of comfort and ease in the body. I don’t have a lot of research on that. Only anecdotal. Even dental operatories that have been clients of mine who have painted their ceilings, Benjamin Moore’s Tempest is one of my favorites. I don’t know if that’s in their color stories [00:42:00] pallet or not, but it’s definitely a Benjamin Moore color.

    It’s kind of like this eggplant gray. It’s so soothing. Gray ceilings are wonderful because gray is a neutral color. Anything that’s really restorative. Nobody really notices, but they feel it. They don’t say, that ceiling is a dark color.

    And oftentimes in restaurants, they do that to keep the energy down because there’s a lot of people talking and there’s a lot of energy moving around. You can also do a lighter color. I just don’t recommend white very often. Sometimes, if you go with a lot of darker walls, you want to make a real cozy womb-like space, then I might say, like to do a light gray ceiling or a creamy, really warm light.

    [00:43:00] Again, I know some of you listening out there may think that’s absolutely ridiculous. And others of you your light bulb might be going off going, oh, I want to try that. So I tried it a lot with clients and it always comes out well. It’s always a positive response.

    Dr. Sharp: I would never think to paint the ceiling. So yeah, really, you got me processing here.

    Cheryl: Cool.

    Dr. Sharp: I was going to ask you as well, you know, when we’re thinking about colors, it seems like everything now is some version of gray. Gray is really in whether it’s a little cooler or a little warmer, but like everything is gray. What’s your thought on that? Like keeping everything sort of neutral versus putting in pops of color.

    Cheryl: So it depends on your style. If you have an apartment therapy kind of a style [00:44:00] or a style that’s more boho and organic and you like white walls or lighter walls and like pops of color and your furniture and pops of color in the artwork, which I love that it’s kind of a more organic feel and you could bring in like plants and things that are made of organic materials like baskets and different things that give like a really nice organic flavor.

    I recommend doing the walls… here’s a couple of my favorite colors: French macaroon which is a Benjamin Moore color. And it is really like you want to eat it. It’s off-white but it’s so soothing. And if you want to go light gray, there’s a color called calm by Benjamin Moore, which I really love.

    And there’s a little bit of a warmer gray that [00:45:00] can work too called Grandmother’s China or Grandma’s China. French macaroon is definitely one of my favorites. There are a few others. And so you just want to… when you work with gray, gray is fabulous, but you just want to make sure that you don’t do everything gray.

    So you want to have artwork that has pops of oranges and blues. And I really like gray walls. I think they’re very, the right kind of gray, comforting, and calming. Benjamin Moore in their color stories palette has so many beautiful grays. And then you just want to bring out colors in your pillows and your rugs and other kinds of things.

    So depending on your style, and I really would embrace your style because then you get to express your style. And this is mostly with my female clients [00:46:00] because it just seems like women are more into doing that than men, as a general. Sorry, men out there if I’m offending you, but women just seem more into it. They’re more into taking the initiative. I love this and I love this and then go on with it.

    Dr. Sharp: I’m glad you said that. As a male practice owner, I was the one responsible for decorating our space. So I had this question of, when you say, go for your style or listen to your style, what if someone doesn’t know? How do you find your style?

    Cheryl: You might have to work with a professional. If interior decorating or decorating is not your thing, you might have to go with the professional. Maybe you have a sister or a cousin or your mom or dad. Maybe you know somebody who can help you if you’re on a shoestring budget and you can’t really afford to [00:47:00] hire somebody.

    So you do need to find somebody though because you can’t just like you can’t, I mean, you can but you’re going to probably make mistakes like painting the walls a warm color, and then all your furniture are warm color, and then all these rectilinear shapes. And then you’re like, I spent all this money on this and now nothing’s really changed.

    I’m just telling you don’t do it if you don’t know it. If that’s not your thing, ask somebody for help. Hire somebody for help. There are plenty of decorators out there.

    Dr. Sharp: Yes, there are.

    Cheryl: They’re not all going to understand this patient-centered stuff, but I am also offering, I’m not really taking on new clients, but I am taking on new clients for your listeners.

    Dr. Sharp: Oh, great.

    Cheryl: I think I sent you an offer. I can’t even [00:48:00] remember what it was now because I offered it a while ago, but it was a discount.

    Dr. Sharp: Great. We can dig that up.

    Cheryl: You’ll know, but just find somebody to help.

    Dr. Sharp: Yeah, I like that. Now, there’ve been times in the past when I have gone to Instagram or pals.com or something like that just to get some inspiration. Is that something that folks might pursue as well? I mean, even just to start.

    Cheryl: Yeah, I think Pinterest is the best, even being on Instagram and pals.com and everything, I just think Pinterest is the best.

    I think that’s fine. I still think though that you need some kind of desire or you want to do that and it’s fun for you. So I still think that if it’s fun for you and you know who you are, you’re going to be on Pinterest and you’re [00:49:00] probably already are, and you’re saving things and you’ve probably already seen things. And maybe you just need a coach to say, okay, yeah, this piece. Maybe you need somebody to see your ideas and stuff like that.

    Again, if you don’t, if this isn’t your thing and your work is your thing, hire it out. Spend the money. It’s worth it. I have seen this over and over again, not just in testing psychologists’ offices, psychologists, and other health care professionals. I have seen businesses increase by like 300% after they changed the design of their space in a very simple, not expensive way. I mean, you do have to spend some money. You do have to spend money. It does cost something. Even if you buy it at IKEA and get the artwork on your own and all that stuff, even if you’re a photographer and do the artwork on your [00:50:00] own, it’s going to cost something. But it’s worth it. 

    Dr. Sharp: Yeah, and I like that. I think that’s a nice segue to a couple of financial questions. If someone wanted to hire a designer, how does that work? Is that billed by the hour? Is it built by square footage? How can we expect to pay for something like that?

    Cheryl: They’re all kinds. Some people bill by the hour. Some people do it by the square footage. So generally there are firms that do everything for you. This is not what you want unless you want to spend more money. And if you have the budget, I recommend it. And it’s someone good who understands patient-centered design. You want to look at their portfolio, make sure you resonate. And then you’re going to spend some thousands of dollars. And they’re going to do everything for you.

    Now, most of you guys who are listening out there I know our DIYs. And so, you can [00:51:00] look online for just decorators in your area. You can send me an email. There’s going to be all information. So I’m here for you. I’m not, not here for you. So I’m here for you. And what I’m offering right now for your listeners are virtual consultations. So we might be in your office and you’re going to show me around and I’m going to walk you through things and give you homework. And there might be a few sessions, or you can just hire me for an hour and things like, I make it very easy.

    Now you can also look around. Not all decorators are created equal, but there are thousands of us out there. So, you might know. In that case, you’re just going to be keeping a budget of what costs what. You want to spend more on things you sit on and you can spend less on things that are like lamps and different things like that. [00:52:00] And you can find plenty of beautiful side tables and end tables for super cheap. Wayfair, Overstock, IKEA are some of my favorites. Other cute places are Urban Outfitters, there’s West Elm. There are lots of places.

    Dr. Sharp: Great. I’m going to put all of these in the show notes. I get everything Wayfair pretty much when we have to furnish new offices. It’s just so easy to make selections.

    Cheryl: Exactly. 

    Dr. Sharp: Yeah. Now, you started to get into this, but I want to flesh it out a little bit. When we’re choosing where to spend money in our offices, I talk with a number of my coaching clients and they’re like, do I spend money on the sofa or the art or the lighting, the paint, [00:53:00] all that stuff. Where do we allocate our money? Where do we need to spend more? And where can we get away with not spending as much?

    Cheryl: Sure. That’s a great question. So you want to spend more money on what you sit on. So, with COVID and everything, you’re going to have to because you’re going to have to be able to sterilize these things with alcohol and other stuff that the CDC recommends. You don’t want any pathogen living on your sofa or your chairs. So, you’re going to get performance fabric and you’re going to make sure…

    You want to spend more on those kinds of things. So the chairs. I’m not really thinking too much about sofas right now because they’re a huge surface area and they’re going to take more to clean, and you’re going to be more worried that there’s going to be [00:54:00] some kind of pathogen living in your sofa, especially if you’re busy and you have lots of families coming through and all that.

    So, if family sitting together is important to you, then that might be a consideration. Spend your money on the things you sit on. Just 2 or 3 upholstered chairs that have the kind of fabric that is going to be cleanable and is going to last. You could say that you could get cheaper chairs, you could do this before COVID and they would last two years. And then you could switch them out and get others, but now it’s a little different and I think people or your clients are going to be wondering if your space is cleaned regularly.

    So, I would spend more money on the [00:55:00] actual chairs that people sit on with arms and I would spend the least amount of money on artwork because you can free artwork on unsplash.com, high-resolution artwork. And you can get it printed pretty much anywhere on Gatorfoam. If that needs to be clean and sterilized, it depends on what the CDC requirements are. And of course, for a hospital, you have to have everything behind glass so that you can clean it. But if you don’t need that, I recommend getting it on Gator foam, which is very affordable. There are places online you can get them printed and mailed, or you could just go to your local print place and ask them how much they do it for or a framing shop can easily take a file and print it [00:56:00] large for you.

    One of my clients, and she’s a testing psychologist in San Francisco, wanted to have some acoustic properties with her artwork. So there’s a place online called Mac Acoustics. And I think they’re on the East Coast in New York, and they’re a great resource. You can send them a picture, a high-resolution file, and they could send you a canvas or something that has acoustical properties in it where echoes might be a consideration. If you’re a photographer, then you can make your own photograph.

    So I wanted to talk a little bit about what kind of artwork you should get because there’s a lot of different kinds.

    Dr. Sharp: Please, yes.

    Cheryl: If you want your clients to feel… And you want to get big pieces because small pieces just don’t have the impact.

    Dr. Sharp: Can you define that a little bit? What is big and small? I’m not even sure I know that.

    Cheryl: So you want to do like[00:57:00] 36 inches is 3 feet, which is a really good, big size. So at least one of those edges. Now, if you have a smaller wall, you can go smaller, but that’s what I consider that. And even higher. 48 inches would be just phenomenal.

    A lot of these images on unsplash.com are high enough resolution where you can send those to be printed. Now it’s really fun to think about the artwork. It’s kind of a fun thing to do. You can think about… If you want to do something in nature, if you want to do a theme in nature, maybe you flowers, and you can bring on a lot of different colors through that, and that might be really beautiful. So you look up flowers on Unsplash or tulips or roses or whatever, and maybe you have some of those around, or maybe you do ocean settings, or maybe you like the forest. So think about where you live.

    If you live in Portland, Oregon, you might want to do [00:58:00] forest images in your waiting room because that makes people feel comfortable. And not only because of the forest itself and the properties, but because they feel a sense of belonging. There’s a community there.

    If you have your testing psychologist office in Manhattan, then you might have pictures of Manhattan on the walls or some central park, for example. And that will make people feel really comfortable. I’m in the right place. The brain says I’m in the right place. This is my people. There’s a connection here versus like, if you had pictures of Hawaii all over the place and you live in Texas, maybe you want to do that because everybody in your neighborhood or in your area goes to Hawaii on their vacations. So you want to bring that in. And then people are like, oh, I remember Hawaii. And they have that beautiful feeling.

    Now, [00:59:00] sometimes it’s really fun to bring your personality into your artwork. You might have a hobby of some sort. And if you put that on the wall, you don’t want it to be a negative image, but if it’s positive, I don’t know if you have some kind of a hobby like you collect baskets. And so you, you want to put up baskets on the walls because that’s so cute and organic, and then it creates a conversation piece, right? When people come in, they go, oh my God, I love those baskets. Or maybe you’ve made them, or maybe you’re a fiber artist like I am, and I make big fiber wall art. That’s a little bit harder to clean, but the world is your oyster. You can do that.

    I just wanted to give you some guidelines so that you can think about all that. Again, large pieces. Don’t be [01:00:00] afraid of large pieces. You don’t have to be framed and expensive. You can ask a friend to take photographs of your town or your favorite place. Or you can get them on Unsplash. It just takes some leg work, but you DIYs out there are used to that. It’s so worth it. And so having, for example, a hospitality table, and then over the hospitality table, having a beautiful piece and then having a lamp on top of the hospitality table. So it lights everything up.

    That’s where I would not spend the most. I would not invest in expensive artwork because there’s just so much available for free and for low cost and you can do it yourself. You can’t make really good furniture. It’s the same with rugs and things like that. You can get them on Urban Outfitters or wherever, Overstock, Wayfair has plenty of places, low pile [01:01:00] rugs. What else? What have I not talked about? Color? No, we talked about color.

    Dr. Sharp: Yeah, we covered some color. So people always love the what not to do kind of things. Are there any what not to do that we haven’t already talked about in terms of art or color or furniture or space, just mistakes that you see?

    Cheryl: Yeah. So again, don’t paint your walls yellow. Some of you may want to, and you can blend it in another way, but it’s not my recommendation is all I want to say. Don’t paint your walls stark white because it feels cold. Don’t have too many squares and rectangular shapes in your office at all. [01:02:00] Don’t buy furniture from Goodwill if you can help it. I know you may want to. I know you may have some good finds out there, but it has old energy. It feels kind of drab for the most part because someone’s lived with that and it’s just not good for public spaces. Maybe for you personally for your home. That’s different.

    Don’t use compact fluorescent light bulbs because they are not good for your health, and they create a glow that is not healthy. It doesn’t feel good. So stick with Led lights that are warm or incandescent sometimes. So they’ve got halogen and flood LEDs have got a bunch of different stuff.

    [01:03:00] For the space where your patients are actually taking a test, don’t put them with their back to the door. Don’t make it so their back is to the door. That has been tested and there’s research on that, that shows that people become nervous when they can’t see the door.

    Dr. Sharp: Okay. Those are very good practical suggestions.

    Cheryl: Don’t do that. You can have them facing a wall, but do it in such a way that their back is not to the door if that’s a space saver. If you can, make it so they have a wall behind them and they’re catty-corner to the door. They feel empowered. They feel confident.

    Dr. Sharp: Being able to see the door is important.

    Cheryl: It’s important. And where they take the test, try [01:04:00] not to put the desk opposite the door of the office where they’re taking the test, the room. It doesn’t feel good. And if you have to do that, put a plant or something on the desk to protect that feeling. And so they can feel better. That’s not a mistake I really often see. What else?

    Dr. Sharp: These are great. Can I ask a random question?

    Cheryl: Sure.

    Dr. Sharp: How often do you recommend people update their furniture and decorations?

    Cheryl: So paint is important and that’s classic. That’ll last you just years if you choose the right colors. If you don’t choose the right colors, then you’re in trouble. If you choose the right colors and the right lighting, it should last years.

    Of course, the furniture, if you buy a [01:05:00] chair at IKEA, don’t expect it to last that long especially when you’re using harsh chemicals to keep COVID-19 off of it. So it depends if you want to spend more money on furniture. A lot of people get freaked out when they think about spending even $500 on a chair when a good commercial chair probably would be around $1500.

    Dr. Sharp: Oh my Goodness. Yeah.

    Cheryl: The one that would last you like 20 years, but you could find cheaper ones, you could find them, you can find them with faux leather and comfortable and things that you can… It’s going to take some research, but you can do it.

    If you get classic white round tables from Ikea and stuff like that, those should last. Those are made out of steel. Those should be pretty good. The high chairs for [01:06:00] the cafe table, or the bistro table, those should last. It depends. You get what you pay for, right? 

    Dr. Sharp: Yeah. What if we think of it in addition to the durability just from a decorating standpoint? I don’t know if there’s a way to quantify that, but how often should we be just freshening our look?

    Cheryl: If you’re into contemporary and modern and organic, that style has been around for a while. I might replace out the art every so often because it’s pretty affordable. You can do that. I always recommend bringing in plants if you can do that. You might replace those plants. Always clean. They [01:07:00] always make people feel good. So I might move those around.

    I had a dental client. He was an artist also. His hobby was bonsai tree plants. And so he literally had them in his garage at home and he loved them. And those are very fussy. And you have to take care of them and spend time. He would bring them into his office and just rotate those. And they created a wonderful conversation piece. He talked about them in his newsletters, so it was part of his marketing piece.

    And then, because he was an artist and his office is in McMinnville, Oregon where they have this alien UFO conference every year, and everybody loves that. That’s what they’re known for. He’ll paint some art with aliens in them in UFO’s and I’ll put them in his office and that’ll just be for during the time.

    [01:08:00]Also think about holidays. Think about Thanksgiving. Maybe you’re going to have a gratitude wall. Everybody can write what they’re grateful for and you can hang it up on the wall or. Or at Christmas, you might want to bring in different kinds of decorations for that, and really bring in little lights and bring in things that make you happy.

    If you live in a place in the United States where traditional is more your thing, then you want to get traditional furniture. You want to get traditional stuff. And you may want to have more things. My style is more California, more West Coast, more Southwest, kind of more minimal, cleaner, but you can do whatever.

    You’ll feel it. You’ll feel when the space is like, yeah. You may even move your practice. I’ve seen this happen many times. You fix up your space and then [01:09:00] you in the next year or two, you grow and then you suddenly need to get a bigger space.

    Dr. Sharp: That makes sense.

    Cheryl: Yeah. I wanted to just talk a little bit about draperies on windows. It goes on the what not to column. Sometimes those offices come with these horizontal metal blinds. Do you know what I’m talking about, Jeremy?

    Dr. Sharp: Oh, yes.

    Cheryl:  Don’t use those. If you can’t take them down, pull them up and get some affordable, either draperies or shades. Shades are quite affordable these days and you might have to get some that are anti-microbial. Again, it depends on CDC requirements. I bet they’re not as harsh as someone who doesn’t see that many people as a hospital, let’s say for example, or a health doctor’s office. 

    Dr. Sharp: Great. Is there [01:10:00] anything out there as far as culturally responsive decorating?

    Cheryl: Yes.

    Dr. Sharp: Could we touch on that before we wrap up?

    Cheryl: A great time to consider those things. Ask yourself the question, how am I honoring other cultures? How am I honoring different age groups? And how am I honoring different gender associations? Is there something there that can make people feel more comfortable and at home?

    As a therapist, you are talking to people about certain issues. As a testing psychologist, it’s specific and you definitely want to look at your patients and staff, and maybe you can open up to different cultures and be a teacher in that way.

    Dr. Sharp: Right. Well, this is this has been a great conversation. I am [01:11:00] thinking so much about our space and I imagine others are as well. So I am just really grateful that you were willing to come on to talk through some of these things.

    Cheryl: It’s been fun.

    Dr. Sharp: Good. And I’ll put all of the resources that we talked about in the show notes. Again, if people wanted to reach out and get in touch with you, what’s the best way to do that?

    Cheryl: Send me an email. I’ve written 2 books on design and those are still available on my website cheryljanisdesigns.com. And if you want to send me an email, that’s, what’s going to have to happen for me to honor this agreement and work with you, which I’m super happy and joyful to do. I would love to help you. And I’m very affordable for this in this case. So look in the show notes for the offer that I’m [01:12:00] offering to you and send me an email. And that email is cheryl@cherylrjanis.com. But that will also be in the show notes.

    And I wish you all out there to have fun and to enjoy this process and to understand that it’s so important to not only your health and your wellbeing and your financial practice but to that of your patients and clients. They will love you for this. I promise

    Dr. Sharp: Well said. I think that’s a nice note to wrap on. So thanks again, Cheryl. It’s great to talk to you.

    Cheryl: You’re welcome.

    Dr. Sharp: Okay, y’all, thank you so much for tuning into my episode with Cheryl. There are a ton of links in the show notes of resources that she mentioned. And in her bio, she lists all of the resources that she has available, her podcasts, her books, and the email address- the best means to contact her if you wanted to do a [01:13:00] consultation with her. And again, she is giving a discount for any testing psychologist listeners who want to do a virtual office consult. So certainly check that out.

    I will say that now every time I walk into our office space, all I can think about are the things that we could do differently based on Cheryl’s advice.

    Okay, y’all. If you have not subscribed to or rated the podcast, I would love for you to do that. It’s super easy. In iTunes, you can just scroll down and tap on the star rating that you would like to give in the podcast app. It takes about five seconds and subscribing is easy as well.

    I’ve been having a good time with these episodes lately. There is plenty of great content coming up. So stay tuned. Hit that Subscribe button. Make sure you don’t miss any episodes.

    All right, take care y’all. Until next time.

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

    Please note that no doctor-patient relationship is formed here. And similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you [01:15:00] need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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  • 152: Adding a Testing Practice on the Side

    152: Adding a Testing Practice on the Side

    Would you rather read the transcript? Click here

    When I started my practice, it took me about 6-8 months to reach “full time.” Up to that point, I did several things to make sure and take it slow so that I could build the practice without drastically increasing overhead. Many of you are likely in a similar position…either you have a full-time job and have limited time to build your practice, or you’d simply like to increase slowly for financial or other reasons. Here are a few topics that we get into during today’s episode:

    • Why start a practice “on the side”?
    • What are the must-haves for a part-time practice?
    • How to rent office space in a financially-responsible manner
    • Do you really need an EHR if you’re part-time?

    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. 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 12 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!

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