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

We are back with International Assessment Series 2 with Michelle Ireland today. Michelle is going to be talking with us all about assessment in South Africa. Let me tell you a little bit about Michelle, and then we will get to our conversation.

Michelle is an early-career South African Educational Psychologist. She’s trained at the University of Cape Town, University of Stellenbosch and University of Pretoria in South Africa. She has specialized in psycho-educational evaluations in kids from kindergarten through the tertiary level education, which we’ll talk about.

She consults with schools who are geographically isolated to assist in [00:01:00] developing inclusion practices within limited resourced environments. Staff development and training and parent education programs are a big part of her work in those remote areas.

So much like last time, we’re going to be talking through the ins and outs of assessment in South Africa, what it looks like from a private practice perspective, health insurance, environmental factors, measures, all sorts of things like that. So if you enjoyed the conversation last time with Debbie Anderson, then I think you will enjoy this one as well.

If you have not rated and subscribed to the podcast, now’s a great time to do that. A very small fraction of our listeners have rated the podcast. So if you have a quick second, that would be amazing if you jump on in iTunes, give it a quick rating and help spread the word and increase the exposure for the [00:02:00] podcast.

All right, let’s get to my conversation with Michelle Ireland.

Hey everybody, welcome back to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. Today I am thrilled to be talking with Michelle Ireland who is an educational psychologist in Cape Town, South Africa.

I am excited to be talking with Michelle. This is obviously a part of our International Assessment Series. I’m excited and grateful to have her on to talk about assessment in her part of the world.

Michelle, welcome to the podcast.

Michelle: Thanks very much, Jeremy. It’s good to have a conversation with you.

Dr. Sharp: Yeah. I’ve been looking forward to this for a long time. So [00:03:00] here we are. We’ve had a two folks, now that I think about it, all of the folks on the international assessment series are going to be from the southern hemisphere; very different parts of the world, but you have that in common.

I have to ask right off the bat what the weather is like there right now, because I’m curious about that.

Michelle: It’s pretty freezing. We’ve just started our winter and so it’s pretty cold.

Dr. Sharp: Okay. Fair enough. When you say pretty cold, is that like snow? Is it icing?

Michelle: No, it’s not snow, but we’re African so we don’t handle cold very well. There’s no snow, but it’s cold enough to need two sweaters.

Dr. Sharp: Okay. Fair enough. It sounds like we have that in common right now. We’re supposed to be in summertime, but it was about 35 degrees this morning here, not cool.

[00:04:00] I like to hear about your journey to get where you’re at right now. You said before we started recording that you were born and raised here in South Africa, I’m curious what’s life been like up to this point and how’d you get to where you are?

Michelle: I’m fairly new career, and so I’ve just come off the bat of my long degree process. I’m feeling quite relieved to be out of that washing machine as I experienced it to be. I’m happy to be applying my knowledge and my skills and figuring out how the theoretical components work within my country and my environment. That’s what my day-to-day experiences has been centered around.

Dr. Sharp: Got you. Is this a second career for you or is this your [00:05:00] first career or what?

Michelle: I’m an educational psychologist, so in South Africa, to register as an educational psychologist, you essentially have to do not entirely two degrees but you have to have qualifications in both psychology and education. And so I’m some experience in both as well.

I have done some teaching and worked in a school context, which has been super useful for my current work. So I’m not entirely fresh but fresh to my expertise on this field.

Dr. Sharp: Sure. Do you have any sense what led you to go down this path in the first place? Why educational psychology?

Michelle: For me, educational psychology was just a really beautiful gap filling the gap between education [00:06:00] and psychology. And working in the South African context, you cannot separate education from psychological well-being. It’s a part of the culture.

Lack of psychological well-being is so pervasive that it seriously has very serious impacts on education. It’s been great to be the bridge between those two fields and help support on both ends. I think that’s what’s landed me in this space.

Dr. Sharp: I think that can be said around the world, of course, but to hear you put it that way, it’s very poignant that they’re intertwined so closely.

Michelle: Yeah.

Dr. Sharp: Did you, I’m jumping into personal questions right away so [00:07:00] feel free to ignore this or tell me to a different direction but did you have any experiences growing up with the educational environment that led you to think we need to work more closely with the psychologists or bridge the gap here a little more?

Michelle: I don’t think there were any huge moments for me. It’s definitely a cumulative process. South Africa was just declared the most unequal society in South Africa. I’ve been fortunate enough to not be on the lower end of that discrepancy.

Many of my close friends and my colleagues as I was growing up and working through school were on the opposite end of that trajectory. It was quite enlightening to see that, and that definitely shaped my perceptions of the world which [00:08:00] inevitably shaped my career choices.

Dr. Sharp: Of course, that makes sense. Let’s jump into the educational part. Talk to me about the educational system there. I found at least so far with talking to folks internationally, that the trajectory is very different than the U.S., even going back to elementary, middle or high school. So how do you go down this path to become an educational psychologist in South Africa?

Michelle: South African education system is very different to the American education system. It’s based off of a British curriculum. South Africa is an ex British colony, the same with Australia. So we’ve got a lot in common with Australian and British systems.

[00:09:00] From the very ground up, we don’t even have what you call kindergarten. We have what we call Grade R, which is reception year, and then elementary school. We don’t have middle school. They’re just divided into two. So we call them primary schools, which is your elementary school. And then high school, which is from 8th grade until 12th grade.

When you’re done with elementary and high school, then you move on to tertiary education. For me specifically, that looked like 3 years of undergraduate training which is already specialized, mine was into education and psychology. So it’s a 3-year undergraduate program. You take two majors and [00:10:00] you whittle them down by the time you get to the end of your 3rd year.

For me, I kept the education and the psychology. After that, for me, I decided to go the teacher training route. And so I did what they call postgraduate certificate in education which allowed me to be a teacher. And so I worked in teaching for a little while.

And then in order to go into the psychology field, you do a 1-year honors degree and then a 2-year master’s degree with an additional year of internship and clinical training. And then depending on which specialization you go into, you may have to also do community service before you can register.

Dr. Sharp: Got you. I was trying to track all of that and maybe did not do a good job. What does that end up being [00:11:00] after undergraduate, four years, five years?

Michelle: I had them all up. For me, it was probably about 8 years total.

Dr. Sharp: Okay. Including undergraduate.

Michelle: Including undergraduate.

Dr. Sharp: Got you. Okay. My gosh. I might ask a lot of dumb questions here. Just trying to …

Michelle: Not dumb questions, useful.

Dr. Sharp: Thank you. It sounds like a similar amount of time, my doctoral program was 5 years after undergraduate, but it just is broken up in different ways, it sounds like.

When you say that you went that direction even in undergraduate, is there anything that happened in high school where you had to even choose your [00:12:00] track at that point or do you wait till you get to university to figure that out or how does that work?

Michelle: There are two options for studying psychology in South Africa. And so you can begin your undergraduate degree in what they used to call a BPsych program. It’s mostly been discontinued at the moment, but that would have been an option for me.

There’s two parts to your question. The first one is, can you start off your undergraduate in a very specialized way? The answer is yes, you can. I didn’t. At the high school level, yes, you do need to select subjects that you take but for the most part, that wasn’t really relevant for the psychology degree.

There are certain entrance requirements. You needed to have a baseline of your home language, and you also needed to have a baseline in [00:13:00] mathematics because you’re required to do certain statistical courses within psychology as well.

Dr. Sharp: Of course. I got you. So then once you started to progress through undergraduate, could you have done anything with those degrees in education and psychology if you didn’t do any post-undergraduate training or do you have to go to graduate school or get that postgraduate certificate?

Michelle: Yeah, you can’t do much with a 3-year degree. You probably could get a higher paying job or a higher placement in a company and based on it but not necessarily in your field. You could possibly do like research assistantship and that kind of thing but that would be the closest you would get to psychology or education.

Dr. Sharp: Okay. Got you. Oh, it’s [00:14:00] similar to here, we can’t do much with an undergraduate in psychology.

Michelle: Yeah.

Dr. Sharp: I got you. Did you know from the beginning when you started undergraduate that you wanted to go for more postgraduate training and be a practicing psychologist.

Michelle: No, I didn’t. I figured it out as I went along. For me, I did a specialization. We could pick various modules for psychology. One of my 3rd year specializations was developmental psychology. It was only at that point where it clicked for me that this is something that I really want to do.

It’s quite daunting, especially when you’re at that young age coming fresh off the back of high school that you realize the implications of wanting to go down the route of being a psychologist and how long it takes.

[00:15:00] In South Africa, I’m sure it’s the same in the USA, and in most parts of the world, it’s extremely competitive to get into the postgraduate programs. And so there’s really no guarantee of you getting in even at the honors level.

And so your results have to be extremely high and you have to be very conscious of that’s where you’re heading towards by the end of your degree. Luckily, I realized that before quite the end of my degree but it’s pretty tough to get into the training courses.

Dr. Sharp: I got you

Michelle: To be able to use your expertise and knowledge.

Dr. Sharp: I see. I know here in the U.S. we have what are called professional schools, which tend to admit bigger [00:16:00] incoming classes, and they’re generally more for profit than some other universities. Do you have professional schools in psychology there or are the programs all pretty small and fairly limited?

Michelle: In South Africa, the majority of education is done through state institutions so the universities are all state owned. Majority are funded through their own research initiatives, but they are state owned.

There are some private organizations, which I guess, in some ways would be similar to your professional training programs. We have one college that’s called the South African College of Applied Psychology. They do a lot more practical components.

In South Africa, like I said, to be a [00:17:00] psychologist, you need to have done at least master’s level training, but there is one category which they call a registered psychological counselor, which is an honors degree level. For example, that South African College of Applied Psychology focuses very strongly on that type of category whereas the professional training for psychologists happens more at the government owned training universities.

Dr. Sharp: Got you. Am I remembering right that honors level is that 1-year postgraduate training after undergraduate?

Michelle: Yeah. It’s a flimsy category. The professional opinions on it differ, but in my experience, it’s been a flimsy category that was developed for good reasons [00:18:00] to tackle the huge need that my country has.

It was developed at the time where HIV was ravaging the country and there was a need for both pre and post HIV counseling and pre and post HIV testing counseling as well as adherence counseling. So medication adherence counseling. And so they created this category, which is not very well-defined.

Dr. Sharp: I see. Oh, that’s wild. So it was in response to a national crisis in a way just to certify more counselors. Okay.

Michelle: Yeah.

Dr. Sharp: Got you. You had to go through that year to get to your master’s program. Is that right?

Michelle: Yeah. There are different options for that honors year program. I call myself an educational psychologist [00:19:00] in South Africa. There’s five categories and educational psychologist is one of them.

Some of the categories have specialist honors training. So an educational psychology is one of those. And my honors training was already specialized towards educational psychology before I went into my master’s training.

Dr. Sharp: Got you. Do some of the other categories not require that honors designation?

Michelle: They all require it, but some of them, you can do a general honors in psychology and then your master’s training would be more specialized.

Dr. Sharp: Got you. Okay. So you did your honors year. Then you did your master’s program. Then community something.

Michelle: I didn’t have to do community service because of my registration category. Yeah, [00:20:00] it’s very complicated. I had to do an internship training; professional onsite training at different organizations and institutions like supervised practice and then you write an ethical board exam and then you can register.

Dr. Sharp: Got you. And then that’s it.

Michelle: And that’s it. Then you’re in the big bad world.

Dr. Sharp: Right. Do it. It’s terrifying.

Michelle: Yeah.

Dr. Sharp: Let me ask a few more questions with the education part. You also said that you did this teacher training after undergraduate, right?

Michelle: Yeah.

Dr. Sharp: Does everyone have to do something like that to go to a master’s program in psychology or was that just your choice?

Michelle: No, it’s [00:21:00] specifically for the educational psychology category. I guess, in the U.S. context, the closest category to what I have experienced as majority of U.S. psychologists practice in would be the equivalent of our clinical psychology.

The differentiation is educational psychologists work predominantly with children and learning based factors, whereas clinical psychologists work more with psychopathology but the trajectory is probably closest to the U.S. training system where you do a more broad undergraduate which has psychology in it, then you specialize a little further when you do your honors training.

And then you do your master’s training, which is very specific in clinical psychology and psychopathology. Those are the students who also need to [00:22:00] do community service which is done in our government hospitals.

Dr. Sharp: I see. And with education part with the master’s program or at any point post-undergraduate, are all psychologists trained in assessment or is that something that you have to pick and specialize in or what?

Michelle: All psychologists are trained in assessment measures of some type. Not all of them are trained in everything. For example, only clinical and educational psychologists, sometimes counseling psychologists, are trained in, for example, IQ measures. Educational psychologists are the only ones who are trained in any kind of academic or academic performance-based assessments.

[00:23:00] And then there’s one other category, which is called industrial psychologists. Do you guys also have them?

Dr. Sharp: We have industrial organizational psychologists.

Michelle: Yeah. So that’s what we’ve got. And then they will do training in psychometrics that are purely in the industrial psychology range.

Dr. Sharp: Oh, interesting. Okay. Got you. So if you wanted to, could you have come out and opened a therapy practice where you are just doing counseling or do you have to pick an assessment versus counseling track or what?

Michelle: My program, you’re more funneled towards the population group and not so much towards therapy versus assessment. So for me, my training was in therapy and assessment of children within the educational band whereas a clinical psychologist would be funneled towards a population group that is [00:24:00] exhibiting some kind of psychopathology and so their therapy would be psychopathology oriented as well as their assessment.

Dr. Sharp: I see. Okay. This is great. Thank you for bearing with all these questions. I’m just trying to see how this looks differently. And so what do you do day-to-day now? First of all, when did you finish and get into the real world?

Michelle: I finished 2 years ago. I registered and got done with my ethics exam. I’ve been practicing officially for 2 years.

My day-to-day work initially was predominantly in schools, so I split my time between two schools. The need dictated the majority of my work. At the one school it was 50/50 counseling and family-based practice [00:25:00] with assessment and at the other schools it was purely counseling. And then I’ve slowly moved into private practice where I do psychoeducational assessments.

Dr. Sharp: Okay. So you are in private practice now.

Michelle: I am, yes.

Dr. Sharp: Great. Congratulations on that.

Michelle: Thank you.

Dr. Sharp: Sure. What’s your private practice look like a day-to-day? I know you said you also do some consulting with schools too.

Michelle: Yeah. It was difficult to schedule this interview because my private practice is so unpredictable and my work is so unpredictable. In a good week, I am home-based and I have office space available for 3 days a week where I do face-to-face [00:26:00] interventions and assessments with children and their families.

And then the rest of the time is my favorite report writing and then international consultations with schools and international families.

Dr. Sharp: Tell me what that looks like; the international consultation with schools and families.

Michelle: I work with schools and organizations that are really restricted in terms of their location. They don’t have access to any kinds of services. South Africa is often a hub for many African countries, and so people will come to South Africa to consult with South African therapists.

Our training is really good in South Africa and it’s easy to travel to South Africa from the majority of other countries. I’m an available resource. [00:27:00] I’m available to provide expertise to environments that just don’t have any access to it.

Dr. Sharp: So this could be from all over the continent of Africa.

Michelle: Yeah.

Dr. Sharp: Folks coming from all over. Okay, I got u. Are you consulting on clinical cases or educational policy or what?

Michelle: A bit of everything. Those type of environments, they really don’t have access to any kind of support services. So whatever the school’s need is predominantly where I will put my focus.

Often, it will start off as like, hey, can you give us some advice on this case or could you have some support resources that you can refer us to? And then it will whittle down to policies that are [00:28:00] in place to support the child in their context, and those types of factors. So it really bridges the gap in all areas.

Dr. Sharp: I see. And then in terms of the cases that you see in your private practice from day-to-day, what do those look like? What kind of referral questions do you get? Where do they come from? And so forth.

Michelle: The majority of my cases come from schools and children are identified as having learning difficulties or underperformance at school for the gauntlet of reasons. And so the majority of my assessments are exploratory and making recommendations for intervention and support based on the child’s needs.

Dr. Sharp: I see. You said that a lot of your referrals [00:29:00] come from schools.

Michelle: Yeah.

Dr. Sharp: Is that right? Do the schools do much testing themselves?

Michelle: We’re really under-resourced. I have the freedom to practice as a private practitioner. There’s no restrictions on services that government must provide and services that I may provide. Officially, government services are supposed to cover assessment practices but they very often don’t, or if they do, there’s 2 to 3 year waiting list. If parents have access to it and they can obtain it privately, then they do.

Dr. Sharp: I see. Just making sure I understand, are you saying [00:30:00] that the government funds assessment through the school district? Like school districts should be providing assessment or are there other state-funded assessment practitioners available too, outside the school?

Michelle: No, it’s mostly through the district, so through your own school district.

Dr. Sharp: I got you. So this gets into the health insurance question a little bit. What does that look like in South Africa?

Michelle: I would say that probably I’m overestimating that about 10% of the population has health insurance. Of that 10%, probably about 5% of those health insurance companies will allow psychological testing to be [00:31:00] funded. So there’s very few people that can have access to services based on health insurance.

Very often, the parents that I work with choose not to do their billing for me through their, we call it medical aid here, through their health insurance because it completely depletes any access to other medical services. So they have a medical savings amount which gets dried up completely by one assessment. So the majority of parents pay privately for my assessments.

Dr. Sharp: Got you. You said that only 10% of the population has medical aid. How is the healthcare paid for the other 90%?

[00:32:00] Michelle: It’s state provided.

Dr. Sharp: Just state provided. Okay. This is getting away from assessment just a little bit, but it’s important for the context, does that include everything? Is that preventative visits, checkups, specialists, surgeries? That’s all of it.

Michelle: Yeah.

Dr. Sharp: Got you. This is a complicated question; does it seem to work well?

Michelle: For the 10%, yeah.

Dr. Sharp: For the 10%? Interesting.

Michelle: Generally, if you’re a part of the 10% who has medical aid, you can also afford not to have medical aid. So it’s more of an actual insurance policy of if you need to be hospitalized.

Government access to emergency services and long hospitalizations [00:33:00] is really poor. Morbidity rates are really high. It’s more of an insurance policy to make sure that if something really bad happens to you, you can go into a private hospital.

Access to everyday services; dentists, psychologists, gynecologists, it’s all in one bag. Psychologists, as I’m sure happens in the world around, are very much on the bottom of that pack.

Dr. Sharp: You may have mentioned this earlier, but are there psychologists that work in state-funded settings where someone could go that route, but just with a long wait list?

Michelle: Yes. Depending on the category and depending on the referral reason, yes. We do have psychiatric hospitals [00:34:00] and there are states employed clinical psychologists who work there; clinical psychologists and psychiatrists who are employed there.

There’s a triage system of being able to access those services. So even if you deserve those services, you may not necessarily get them even if you wait for them. It’s the worst cases get access to the services because of a need prioritization.

Dr. Sharp: I see what you mean. Gosh, I’m working through this, do the parents who come see you, do they really have any other option for getting an assessment for their kid? What are the other options for a comprehensive assessment that you might offer?

Michelle: Comprehensive, nothing. The state based assessments are very basic [00:35:00] and like I said, will take between 2 to 3 years, and will be allocated on a needs based. So if you’re on the highest level of need, you will get access to it possibly after 2 to 3 years.

If you have a really good school district and very efficient psychologist in that district, you may be lucky to get an assessment done after a year. So there aren’t options for parents who can’t afford to have their children tested.

Dr. Sharp: I see. Do any psychologists in private practice like yourself “take insurance” or is it all private pay if you’re in private practice for the most part?

Michelle: It depends. There’s probably about 50/50 who will take insurance. How I work is that parents can be reimbursed by their insurance after they have paid my [00:36:00] account.

There are some practitioners who will claim through the medical aid or health insurance so that the client does not have to do any kind of monetary exchange with the professional. I would say probably about 50% of people in private practice would do that.

Dr. Sharp: I see. Okay. Gosh. This health care situation is, it’s always an interesting topic to sort through. I’m curious how people access services, right?

Michelle: Yeah.

Dr. Sharp: Before we totally leave that, being in private practice and being a psychologist, is that a financially viable career for someone there? With [00:37:00] the hierarchy of healthcare professionals, can you charge a rate that affords a decent standard of living?

Michelle: Yeah, I would say so. I would say for the most part. I think it’s like the world over where you need to build up your client base and you need to make sure that you have a fairly reasonable influx of patients.

South Africa is densely populated in some areas and very rural in other areas. And so if you were a psychologist in a rural area, I think it would be exceptionally difficult to make a living wage. I live in a major city and so I am able to access a large client pool and so I feel like I can make decent living.

Dr. Sharp: Yeah. Okay. I’m curious about that. Let’s talk about your actual assessments. You said that a lot of referrals come from schools and it’s a lot of learning issues, [00:38:00] things like that. What kind of measures are you using? Let’s start there.

Michelle: Even in South Africa, that is not a simple question. I personally use predominantly U.S. normed tests like the WISC, the WIAT, BASC, BRIEF, those kinds of tools.

Our local cognitive assessment for children was last normed in 1989 and it was normed on a population of children who were living under apartheid. So I don’t find it especially psychometrically valid and so I don’t like to use it, but it then also comes with a huge complication of using tests that were not normed on the South African population.

Dr. Sharp: How do you work with [00:39:00] that?

Michelle: It’s very difficult. There’s a lot of qualitative interpretation and so statistics are informative rather than used as a decision making tool.

Dr. Sharp: Sorry to interrupt you, I’m really interested in this whole. What does that look like when you administer a WISC, let’s say, when you say there’s a lot of qualitative interpretation? What do you write in the report about that or how do you explain it to parents?

Michelle: That’s an interesting question. For example, the majority of the time I’ll question the validity of the VCI, the Verbal Comprehension Index, because firstly, the majority of children who I work with are not English first language speakers. We have 11 official national [00:40:00] languages and so doing an assessment in a child’s non-native tongue comes with the full gamut of difficulties.

Everywhere around the world that is true. So immediately you’re starting on the back foot with validity questions about mode of instruction and all of those various factors. If your VCI is already compromised before you even begin with anything else, you have to just take the information that you can get.

I do the formal administration and I do a lot of dynamic assessment. For example, in Block Designs, a lot of children become quite overwhelmed by that type of task because they’ve never really experienced something similar to having to [00:41:00] build a model, especially in the resource deprived areas.

I do the full administration of the assessment battery. And then afterwards, I will present the tasks to the child again, and then do some scaffolding techniques of providing two suggestions on how to do and on how to approach problem solving on those tasks, and then evaluate the child’s learning potential in a very qualitative way.

If you’re getting a really low Block Design score but the child is, with very brief suggestions, able to complete all of the designs, then you can see that a child has fair amounts of learning potential rather than a statistical cutoff where a child might fall in a very low range.

Dr. Sharp: Yeah. The VCI makes sense to me that that would [00:42:00] be compromised given the questions, I didn’t even think about visual spatial stuff, but that makes sense.

Michelle: Yeah. When giving instructions and even the word design to a second language learner is really quite a tough vocabulary word so that brings up additional complications.

Dr. Sharp: Sure. So then how does that work with the educational assessment, like with the WIAT and the norms? I’m thinking so much that it’s based on our educational system. I’m guessing, I’m not that person.

Michelle: There’s certain components of the WIAT which are fairly easily generalizable. For example, reading speed, decoding ability, numerical fluency, even numerical operations. Yes, it [00:43:00] is age based, but it’s a fairly broad band, and those concepts are taught at fairly similar ages. I have less difficulty interpreting the WIAT than I do the IQ assessments.

Dr. Sharp: Got you. Oh, that’s interesting.

Michelle: With norms, it is difficult, the comparative analysis is challenging, but you are able to get a very concrete evaluation of what a child knows and what a child does not know and the level that you would be expecting of a child of a certain age band.

Dr. Sharp: Okay. Fair enough. That’s fascinating. Are there any measures that are normed on South African kids in any of the native languages there?

Michelle: There are, but they’re really old and it’s very difficult to find [00:44:00] someone to administer them; to have someone who has that as their own mother tongue or is proficient enough to be able to administer it to a first language child.

There are some, they’re interestingly enough based on the very old Weschler concepts. For example, they will include things like Block Designs and similarities. Those type of subtests are replicated to some extent in those subtests with a lot of cultural references, which are more valid.

Dr. Sharp: Okay. Got you.

Michelle: So for example, on vocabulary, when you ask a child who lives in a country where they frequently travel, what is the definition of a pilot? They will immediately be able to tell you, but if you’re asking a child, what is a coat and they live in very humid hot weather, they will [00:45:00] not know what a coat is because they don’t use coats.

Dr. Sharp: Yeah. Sure.

Michelle: They’re more qualitative valid.

Dr. Sharp: Okay. You said, otherwise, you do the BASC, the BRIEF, for checklists.

Michelle: Yeah.

Dr. Sharp: It’s very similar.

Michelle: Because South Africa is such an unequal society, the children who I work with in private practice are a lot closer to a Western level of standard and so it is easier to interpret those kind of results because the environments that they’re expected to function in are fairly similar to, for example, a U.S. system. And so that does make it a lot easier.

Dr. Sharp: I see what you mean. That’s interesting. I’m just thinking about how you have to be fairly fluid with your [00:46:00] administration and interpretation, working with kids from such different levels of socioeconomic status.

Michelle: Yeah, that’s very much the case.

Dr. Sharp: Sure. What’s your general structure, the battery, for an evaluation? Do you do an interview and then testing on a different day and then report on a different day or how’s that work?

Michelle: That’s interesting that you ask that. If a client is going to claim from their medical insurance, you only are allowed to assess and do interventions or interviews for a certain number of hours per day.

So if a client is going to claim from their medical insurance, then I will do an intake evaluation, interview with parents on one day, and then I will do part of an assessment on one day, usually about 2 [00:47:00] hours, and then the rest of the assessment, however long it takes on the next day. And then usually 2 hours for interpretation on the last day of the testing and then report writing or feedback after the report writing.

Dr. Sharp: I got you. How much time generally passes between seeing the person for the interview and doing feedback?

Michelle: I try not to make it more than 2 weeks.

Dr. Sharp: It’s pretty quick turnaround.

Michelle: Yeah.

Dr. Sharp: Very cool. Would you say, from what you know, are your reports fairly similar to what others of us might write in the U.S. or around the country and around the world?

Michelle: No, I have never seen an equivalent evaluation from the USA. [00:48:00] I have seen one from India, and mine was pretty similar to theirs.

Dr. Sharp: Oh, yeah.

Michelle: I’ve seen one from Australia and New Zealand and mine was pretty similar to theirs. So I’m not entirely sure, but I think that there’s definitely some commonalities.

Dr. Sharp: I would imagine so. Seems like there are pretty similar components.

Michelle: Yeah.

Dr. Sharp: Got you. And then does that typically go back to the school? Then do you interface with the school a good bit or is that left to the parents or what?

Michelle: It depends on the case. A lot of parents will come for an independent opinion if they disagree with their child school’s handling of whatever learning difficulty the child has. So sometimes it will be independent and used to inform parents thinking, but yeah, very often it will be interacting with the school and I’ll give feedback to the [00:49:00] parents and then we’ll usually have a transdisciplinary team meeting at the school and the parents will share the report with the school as well.

Dr. Sharp: Do the school districts have special education services for those kids, then, if you’ve identified them as having a learning disorder or additional concern? Do they provide support?

Michelle: Sometimes, depending on the school. Officially, yes, and so there are supposed to be learning support services allocated but in some cases the demand is much higher than the supply but a lot of schools, if they have additional funding, they will employ learning supports staff independently.

Like I said, the higher brackets of income people that I work with will often have their children at a school that has those kind of services. [00:50:00] So that’s really a blessing for me to work with but huge portion of my job is school training and teacher training so that my report does something and go somewhere and that they can utilize the concepts within the classroom.

Dr. Sharp: Got you. When you say school training or teacher training, what does that look like?

Michelle: Just the basics of how to differentiate, how to support, and even the understanding of the basic concepts of, for example, working memory and processing speed. What does it mean when you get a report where a child has working memory difficulties? And how to apply those recommendations in a practical way.

Dr. Sharp: Oh, I see. Do you like that part of your job?

Michelle: I do.

Dr. Sharp: I think that would be fun. We don’t do a whole lot of [00:51:00] that here, or I don’t, but I’m sure there are other folks here in the U.S. that do more of that. Our school districts are generally on top of things.

Through the evaluation process, are you making diagnoses? And if so, what manual do you use or a standard for that?

Michelle: We were trained in both ICD-10 and DSM-5. I predominantly use DSM-5, just personal preference. I do make diagnoses of specific learning disorder. It’s probably the most common.

We are allowed to diagnose ADHD and certain mood difficulties like the anxiety and OCD type of behaviors specifically only in [00:52:00] children but I infrequently do that because I usually will get a psychiatric consult for that.

Dr. Sharp: Okay. So you, for the most part, stick to learning issues, ADHD.

Michelle: Yeah.

Dr. Sharp: Do you get into brain injury kind of stuff or concussion or genetic medical disorders, things like that or who might handle that kind of evaluation?

Michelle: In South Africa, it usually goes a medical route, so a neurologist but there’s a bit of moving and shaking in the field of neuropsychology and neuropsychiatry. So the five categories that I mentioned of psychologists, neuropsychologists is not one of them, but there is a petition to include that.

There is an organization that has [00:53:00] developed a system of exams and peer-reviewed reports and assessments which gives an extra credential for neuropsychiatric and neuropsychological evaluations. If I were in the field and I had a child or adult who had that type of concern, I would refer probably to someone who had gone through that training process although it’s not officially recognized.

Dr. Sharp: Oh, that’s interesting. Okay.

Michelle: With my current qualifications, I could go through that additional examination process and I could go down that road of that specialization if I wanted to.

Dr. Sharp: I see. So now, at this point, it’s just folks who have gotten extra [00:54:00] random education around neuropsychological assessment or is there anyone who can call themselves a neuropsychologist there?

Is that recognized at all?

Michelle: Legally and officially, no, but in practice, there are people who I would refer to as neuropsychologists.

Dr. Sharp: I see. Okay. So interesting.

Michelle: Complicated.

Dr. Sharp: It’s complicated. On these international interviews, I’m thinking through how I would explain our system as well and it’s complicated.

So you dwell a lot in the DSM, ICD, it’s pretty similar, it sounds like too. I’m trying to think what else feels [00:55:00] important for this conversation here as we’re talking about assessment. Oh, what if a U.S. psychologist wanted to come to South Africa and practice? Is that even a viable option?

Michelle: What do you mean by viable?

Dr. Sharp: Would South Africa recognize our licensure?

Michelle: From my understanding of your licensure, it’s quite varied as well. There’s various training institutions, organizations, levels and specializations. My understanding of the process is that you would submit to our Health Professions Council, your qualifications and training would be evaluated.

An American psychologist would need to write out South African ethical board exams which includes [00:56:00] understanding of relevant legislation specifically about mental health, healthcare, children, justice, those kind of concepts.

They could either immediately be registered after they have gone through the board exam process, or they may have to do a supervised internship program of about 6 months to demonstrate understanding of the South African context.

Dr. Sharp: I see. Do you know any U.S. psychologist who have come over there to start practicing?

Michelle: I know of one U.S. psychologist, but he works for the U.S. State Department and so he does not work with South African clients. I guess, he practices based on his U.S. licensure with U.S. patients.

I don’t know of any [00:57:00] any American psychologist. There are two British psychologists around and they would have gone through similar process.

Dr. Sharp: Yeah. That’s all right. I always ask because I think, for better, for worse, that’s a fantasy of some psychologists here and many people, honestly to move to a different country and be able to work, just have a new life in a way. I’m very curious what that might look like and if it’s even possible.

Michelle: I think it is possible and there might be some hoops that you need to jump through and depending on how motivated you are, it is feasible.

Dr. Sharp: Got you. Okay. Very cool. What have I not asked about? What else feels important about practicing over there that we have not touched on or might need to talk more about before our time runs out?

[00:58:00] Michelle: The one benefit of having grown up in South Africa and having done my training here is that it comes with a really implicit knowledge of the context. So for us, apartheid is really entrenched in our society and in our systems. You take it for granted when you’ve grown up in a system like this.

There were some American students who studied with me in my undergraduate years and if we needed to talk about local issues or even just the application of the theory within a context, not having that understanding was really difficult for people outside of South Africa to really grasp. I feel [00:59:00] really privileged in being able to understand it from a measure of an insider’s view.

I think that’s one of the major factors in it and it influences everything in terms of psychological services, access to services, perceptions of organizations and government institutions, it all becomes closely tied together.

Dr. Sharp: Sure. I’m glad that you are bringing this up because I had that in the back of my mind, but admittedly, I just said, I’m not sure what to ask because I don’t want to sound dumb but knowing that this is a huge deal in political history, I am curious [01:00:00] for a lot of folks out there may be like, can you talk more about that?

When you say apartheid, some people might not know what that is. And then how that does influence things in specific ways and especially for your field and for being a psychologist there. I know that’s a huge question so I’ll just acknowledge that.

Michelle: It is. I’ll touch on what I think is most relevant or what I found to be most relevant. Just as a brief understanding; apartheid was a system of institutionalized and legalized racism where there were absolutely horrific and appalling laws that differentiated people based on race.

In South Africa, there are three main race categories. It becomes quite crass talking about these, but it is a reality in South Africa where [01:01:00] the categories are black, which is a fairly dark skinned person; white, which is a person who is Caucasian and then we have a category that they call colored, which is not the same as the American understanding of colored. It is also not a mixed race person, but it is a person of moderately dark skin.

So you can see how barbaric these concepts were within a South African context but people were differentiated based on those various categories. It was almost as stupid and basic as the darker your skin, the worse the treatment you got was.

There was also a lot of political violence and general [01:02:00] severe poverty and isolation of specific race groups which has not been infrastructurally or however you would say that; in terms of infrastructure, it has not been rectified. It’s also created very specific class divides, which I think are present all over the world, but class is very closely related to race in South Africa.

The most important aspect of all of that in my field is the compounded intergenerational trauma. South Africa also had institutionalized discrimination in terms of education, where black people were specifically given subpar education so that they were completely disenfranchised. And so the parents of a lot of the kids that I work with [01:03:00] are now children of parents who are predominantly illiterate, so that becomes really complex and compounds the kind of economical cycle.

Dr. Sharp: Of course. I might highlight too, that this is a relatively recent period in your history, we’re not talking like 100 years ago, this is …

Michelle: We were liberated in 1994.

Dr. Sharp: Yeah. My gosh. There have been threads of this throughout our conversation I think when you’re talking about working with kids from different areas; underserved areas and very rural areas and so forth.

Again, this is maybe a hard question, so feel free to ignore it or whatever you want to do appropriately, but how does that show [01:04:00] up specifically in an assessment? How might you handle that or address it or do you address it? That’s a very open ended question.

Michelle: The first thought that came to mind is very early on in the assessment process, it makes things extremely difficult if you have parents who it’s difficult to get basic historical information from them. Also, there’s been a lot of migrants work processes happening in South Africa, where children are very often not with their parents until they’re about 6 or 7 years old.

They generally stay with grandparents in rural areas and then parents will bring them into the city to be educated from when they start school. [01:05:00] So very often, the parents don’t know their children very well. Just doing a basic intake interview can be exceptionally challenging. You can’t ask about developmental milestones and those type of factors makes it really difficult.

The migrant worker process also has huge trauma on a child. And so you’re just trying to unpick and unpack; what is trauma? What is learning difficulty? What is language factor? What is environmental deprivation? It’s so complex. There’s so many extraneous variable that you’re peddling always.

I don’t know if I answered your question there probably in a really roundabout way.

Dr. Sharp: No, I think you nailed it. That was the piece that I was [01:06:00] really curious about is just how do you even start to separate some of these generational experiences and that trauma, like you said, from some just basic learning issues or attention issues or mood when that’s such a part of the fabric of the culture there?

Michelle: There’s also a huge rejection of Western concepts such as psychology and learning diagnoses are very Western concepts. And so for the local population, that can sometimes be conflated with the machine which in South Africa comes with a huge value judgment associated with previous legislature and government systems.

So it’s almost like hospitals are, they’re designed; their architecture, [00:07:00] everything is associated with apartheid. Visibly, they look like apartheid. When you drive past the hospital, you see what apartheid looked like.

And so having a parent coming into that environment can be extremely traumatic but then also acceptance of an engagement with any kind of concepts that come from those kind of organizations or institutions is really hard.

Dr. Sharp: Of course. I think about, in a trauma context, just triggers and if there are these visual triggers all over the place, those does not go away.

Michelle: No.

Dr. Sharp: Gosh, I know we have just touched on this very briefly and there’s so much more that you could say about it, but I appreciate you even being willing to dive into it for a few minutes. It’s clear that that’s such an important [01:08:00] part, just historically, of what you’re doing there.

Michelle: Yeah.

Dr. Sharp: Being mindful of that. I do have one last question with that. Was that addressed in your training at all, in your master’s program?

Michelle: Yeah.

Dr. Sharp: It was.

Michelle: Very strongly. It’s a constant factor and it’s addressed in almost every single professional development program but regardless of how much it is addressed, you never feel fully equipped to deal with it.

Dr. Sharp: Sure. I get that. I’ve really valued everything that you have said here, and this has been a great conversation. I’m still struck by the similarities here between our practices.

When I went into this series, I have [01:09:00] still got two more folks to interview, but so far, I thought it was going to be very different and it’s actually much more similar than I was anticipating in the interviews I’ve done so far.

Michelle: Yeah.

Dr. Sharp: Do you ever come to the U.S. for training or anything like that or is that pretty self-contained in South Africa?

Michelle: I have one trip planned probably in about a year’s time when funding has accumulated. Yeah, there’s great training in the USA, which isn’t always available in South Africa. So I’m looking forward to that. That will be in 2 years’ time. I have visited on vacation, but nothing professional as of yet.

Dr. Sharp: Got you. I didn’t mean to imply that all the good training is here by any means, but I was curious where you might go for continuing education; is that Britain or is it there or Australia or [01:10:00] where’s that?

Michelle: It depends on your area of interest or expertise. There are some local ones but if you’re really specialized or if you’re wanting to look at very specific things, for example, something simple like the ADOS, we don’t have ADOS training, so if I wanted ADOS training, I would go to the USA or the UK.

Dr. Sharp: Got you. Thank you. If anybody wanted to get in touch with you to ask questions of any sort, what’s the best way to find you?

Michelle: Probably email.

Dr. Sharp: Okay, great. I can get that from you. I can put that in the show notes.

Michelle: Sure.

Dr. Sharp: If anyone wants to get in touch, just shoot you a message. Do you have a website or anything?

Michelle: I do. It’s out of date. I do have a website. I also use Skype a lot or equivalents, Zoom, et cetera. [01:11:00] I’m happy to have conversations with interested people.

Dr. Sharp: Okay. All that will be in the show notes if anybody wants to get in touch with Michelle. Thank you very much. Like we talked about before, this is your dinner time and maybe getting into bed time, so I’m going to let you go and get on with your evening, but thank you so much. It was great to talk to you, Michelle.

Michelle: Okay, sure. Thank you so much for having me.

Dr. Sharp: All right, y’all. Thanks so much for listening to that episode with Michelle Ireland. I continue to be intrigued and fascinated by this idea of international assessment. If you’ve enjoyed these past two conversations, I think you will definitely enjoy my conversation next Monday with Dr. Joseph Graybill talking all about assessment at an international school in Moscow, Russia. So stay tuned for that.

If you have not subscribed to the podcast, now’s a great time to do that. We’re pushing out a lot of cool content, clinical episodes on [01:12:00] Monday; business episodes on Thursdays, and it’s been exciting to increase the content and see the response from everyone.

If you have a quick minute and are willing to do me a big favor, I’d love for you to rate the podcast in iTunes, it’s pretty easy if you just go on your phone and give it a quick tap, that helps increase the exposure of the podcast. Thank you to all of you who have jumped in and given ratings over the past few weeks. It’s been super helpful and much appreciated.

All right, take care. We’ll talk to you on Thursday.

The information contained in this podcast and on The Testing Psychologist website are [01:13:00] 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 an expertise that fits your needs.

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[00:00:00] Dr. Sharp: Hello, everyone. Welcome back to The Testing Psychologist podcast. This is 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.

All right. Today is a business. This has been a really nice transition. For those of you who listened to the episode a few weeks ago about taking the podcast in new directions, this has been great. Having one clinical episode each week and one business episode each week, I am feeling much more energized about pushing out podcast content. And it’s been really fun to follow this schedule and be talking about more business topics. So, thanks for listening and hanging with me through this transition. I hope that you’ll take a good bit away from this episode as well.

Today is again another business episode. [00:01:00] The content today is really going to focus on a concept called time blocking. So, this is one of those things that I’ve been doing for a number of years. At first, somewhat intuitively, and then later finding out that there’s some good science behind it, and there is quite a bit of strategy actually to time blocking.

Time blocking, if you don’t know, is the idea of only doing certain things at certain times of the day. This is really a huge reason that I’ve been able to run a group practice, do the podcast, do private practice coaching, maintain a running schedule of 30 to 40 miles a week, and a number of other things all while picking my kids up from school every day and [00:02:00] basically not working weekends.

People are often asking that question here and there, and they’ll say, “Jeremy, how are you doing so much? It seems like you’re doing so much. How are you doing this?” And honestly, a big part of it is just good time management and a big part of that is time blocking. So, that’s what we’re talking about today.

Before I get to the episode, I want to invite any of you advanced practice owners out there to consider jumping into the Advanced Practice Mastermind which will start in September 2020. This is a small group mastermind of no more than 6 psychologists, all in the advanced stages of practice who are really looking to ramp up their practices, take it to the next level. A lot of things we talk about include hiring, time management, efficiency, expanding your practice, [00:03:00] additional streams of income, things like that.

So, if that sounds like you, and you would love to connect with a group of folks who are in the same boat, I would love to have you consider the Advanced Practice Group. This is a group that I facilitate and provide group coaching to the members. So, if that’s interesting to you, you can go to thetestingpsychologist.com/advanced and get a lot more information and schedule a pre-group screen to see if it would be a good fit.

Like I said, this will be launching in September. There are six spots. I imagine that they will fill up quickly. So, I’d love for you to jump in and see if it would be a good fit.

All right, let’s jump to our episode on time blocking.

[00:04:00] Okay, everyone, welcome back. Here we are talking about time-blocking. Many of you may have heard of time blocking or heard of some version of it, maybe it’s hasn’t been called time blocking or that’s not what you know it by, but the general definition of time-blocking is picking specific times of the day to do specific tasks.

Some of you might be listening and saying, that actually sounds very intuitive. Of course, that’s what I do. I do specific tasks at specific times of the day. What I found is that many of us, myself included think that we are managing our time efficiently and basically single-tasking throughout the day when in fact we are not doing that at all. Just being [00:05:00] transparent, I’m recording podcasts right now, but as I look across the tabs on my internet browser, there’s our EHR, there’s my calendar, there is my work email, there’s my work chat, there’s my Google drive and my show notes, my content calendar, there’s a random evaluation intake note up there- who knows what that is, there’s my Asana task list, and then there’s my recording software here. So, even for someone who has practiced this a lot, there you go. I’m not single-tasking at all at least in theory here.

So the idea is that time-blocking is something that is necessary to truly help us hone in and engage in single-tasking rather than multitasking. There is a good deal of [00:06:00] research out there that we are not good at multitasking. And in fact, it’s not a thing that we can do. We might think that we’re doing it well, but we can’t.

What happens is, many of us jump into the day, we open up our internet browser if we closed it in the first place the day before, and we’re immediately drawn to whatever shiny object is presented on our screen. And that’s even if you get to your computer without touching your phone. Maybe you’re looking at Facebook, maybe you’re in your email, maybe you’re on your chat, maybe you’re on Twitter, maybe you’re working on that report that is still open from the night before. So there are any number of things that could pull your attention to them without your explicit decision to work on that thing.

And so, [00:07:00] the idea, again, of time-blocking is that you cut all of that out and you really get down to what you want to be doing at each moment of the day. And during those time blocks, when you’ve decided exactly what you’re going to work on, you only work on that thing. You do not switch your attention to something else even just for a second, because there is again, great research out there around, I’ve heard of called attention residue where even if you just switch over, like, say from writing a report to answering that quick email, you have what’s called attention residue for much longer than the time that it takes to actually complete the task. So it takes a lot longer to get back in the “zone” to be writing your report [00:08:00] than you think it might. So even if an email only takes 15 seconds to shoot off, that task switching in and of itself is very disruptive from a cognitive standpoint and it takes quite a while to get back in the zone for the tasks that you’re actually trying to work on.

So, there are many aspects of time blocking that we could get into. I am going to give you a good solid overview of what time blocking looks like, the different types, and how I implement it in my own schedule. So, let’s dive in.

So again, generally speaking, the concept behind time-blocking is that you just dedicate specific blocks throughout the day to do specific tasks. And during those blocks, you don’t do other things. [00:09:00] For example, for me, whenever I need to work on a report, I know that I have to block out three hours. This is what it takes at this point. Now, there are plenty of tech tools and apps and things like that to make the actual writing more efficient and quicker, that has been covered and will be covered in other podcast episodes. But for now, I’m just talking about the time you need to write your report. Maybe that’s two hours, maybe that’s one hour, maybe that’s five hours, but the idea is that you give yourself a really solid block of time to work on the most important tasks each day.

So that component of picking your most important tasks for the day is crucial. You don’t want to dedicate a three-hour block of time to work on your email unless for some reason that’s the most important thing [00:10:00] that you’re going to do that day. So this really involves stepping back, looking at your week, looking at your clinical load, figuring out really what tasks you really need to be doing throughout the week, and then prioritizing those tasks each day and creating blocks of time to make those happen.

Like I said, if I know that I have to write a report, then I will have a three-hour block of time per report for that week. And those are just set aside and I know that that’s what I’m going to be doing.

So the rest of the day, you might be asking, well, what do I do during the rest of the day? Well, this is again where you can really engage in time blocking to plan out your day in as much detail as you [00:11:00] would like.

Now, the way that I end up doing it is a combination of simple time-blocking, which is just again, just dividing the day into blocks of time with each block specifically being allocated to one particular task, but I’ll combine that with something called a task batching, which some of you have probably heard about, I’ve talked about batching here on the podcast, but it’s this idea that you do similar things all at once so that you aren’t like switching back and forth between disparate tasks.

What this looks like in practice is, for me, for example, I typically come in or start work at the beginning of the day by opening a new internet browser. What that means is [00:12:00] that the day before I have closed my internet browser. So, part of my end of the day ritual is to close out my internet window and make sure that you have that setting on where when you open your internet browser for the first time that day or open a new browser window, that it goes to a blank page, that’s what I found most helpful, or a specific page if you just always know, for example, that you’re going to start your day with email, that’s fine. But I have it open to a blank page because I don’t start with email every day.

So I open the new browser and on, let’s say a typical day, I will spend the first half-hour, so I have a half-hour of time blocked out to jump into the email, answer anything critical, anything urgent. I’ll run through the chat for our [00:13:00] practice and I’ll just make sure that there are… I always take care of the urgent things first, that also involves checking the Facebook group moderation comments and that sort of thing, and then, like I said, I spend about a half-hour on that. So I take care of the urgent things first.

Then I move to just work on my inbox. I do a lot of archiving. There are many things that I do not respond to. We could spend episodes on just email in and of itself, but just as a quick rundown, I don’t respond to everything. Like I said, I do a lot of archiving. I do a lot of forwarding to other people who might be better to answer the question, whether that’s my admin team in the practice or my VA or other clinicians, or whatnot. So I spent about a half-hour on email.

And then for me being a [00:14:00] morning person, if I have to get some crucial work done, I try to have a nice three-hour block in the morning right after email. So let’s say that’s from 9 to 12. So then after I finish my big block of time, then I’ll usually do another 15 minutes to check in on email. And then, in the afternoon, that’s for me, when I try to save work that is less cognitively demanding. For me that might be, I don’t know, researching some new technology for the practice or doing some administrative work or writing up training manuals, things like that.

And then I’ll do, like I said, another hour or two of that, and then I’ll always do a check at the end. So another 30 [00:15:00] minutes to touch base on email or messages. And let’s see, voicemails are the other thing that I’ll typically do at the end of the day. So that’s just a general overview. 

In theory, this sounds really easy. The practice though can be really challenging. The biggest challenge that I found in my work and coaching other practice owners is that we get drawn in during those big blocks of time to do other things. So, even if you sit down and you say, okay, I’ve got a three-hour block. I’m going to work on this report. I’m going to work on this bit of research. I’m going to do some writing, whatever it might be. It’s really easy to get pulled into other things.

So there are a few strategies that I use to keep that block sacred. One of them is, [00:16:00] I only keep internet tabs open that I am working on at that time. So if I’m really sitting down trying to zone in on a report, basically what that means is I have Google drive open with the client file folder and the Google doc is open that has, for example, the evaluation notes, the behavioral observations, and test results, I have a word document open working on the report. And that’s it.

I don’t have my email open. I do not have the chat open. It’s pretty straightforward, but I close out everything else so that I can, like I said, truly focused on the task that I’m working on.

For me, my phone is not a huge distraction, but for some people, it is certainly. So if that means you have to put your phone on airplane [00:17:00] mode or even turn your phone off or just hide your phone, that’s totally fine too. Whatever you have to do to protect that block of time is worth it. But the whole idea is that you are sitting down and you are only working on what you want to work on. You’re not switching your tasks or your attention.

If you have trouble focusing for that long, that’s totally fine. A lot of people do like to take breaks and you can totally do that. A strategy that I’ve used to structure those breaks is the Pomodoro method. The Pomodoro method is the idea that you work for 20 to 25 minutes stretches and then you take a five-minute break. Instead of one huge block of time, you give yourself [00:18:00] miniature deadlines. And there’s something compelling about that to let you know or to keep you focused and keep you motivated for what you’re working on because you know that your timer is going to go off. And at least for me, there’s a psychological effect there that I want to get as much done as possible before the timer goes.

So that is the general idea of time blocking. Now, I have taken it to maybe another level and engaged in a concept called de theming as well. And this is another aspect that I will talk with my coaching clients about that has been really, really helpful especially in clinical practice. So, day theming as you might guess, is where you dedicate specific days to specific tasks or responsibilities that you have.

For example, in a clinical practice, what this might look like [00:19:00] is, Mondays are clinical days. So, on Mondays, you do two interviews and two feedback sessions, and any other clinical contact that you might have. So, for us, interviews are two hours each and feedbacks are one hour each. So, that gets up to about a six-hour day. And that allows for a little bit of time for email at the beginning and end of the day, and maybe a little extra time if you don’t go over your sessions, but the day theme for Monday is clinical.

The day theme for Tuesday and Wednesday, let’s say if you’re doing two evaluations a week, is that you test on Tuesdays and Wednesdays. Now, that could be two full-day sessions or it could be four half-day sessions. However you want to structure it. But [00:20:00] the theme for Tuesday and Wednesday is testing, administration, and scoring.

In a lot of clinical practices then, the theme for Thursday is report writing. So, on a Thursday, if you’re going by this 3 to 4-hour block, most of us will have to two of those blocks to write reports. So, Thursday is all about writing. And you have that time set aside to knock out your reports.

And then, Friday is open. It could be a random kind of follow-up. It could be researching topics you’re interested in. It could be growing your practice. It could be just taking the day off. It could be any number of things.

That’s an example of a typical week and how you might day theme [00:21:00] your weeks in addition to time-blocking each of those days. The combination of those two strategies has been super helpful for me. And again, a set of strategies that I talk with coaching clients about quite frequently.

So, there’s a lot more to be said about both of these things, time-blocking and day theming, but like I said, this is just a little bit of an introduction to get you thinking about how you might do this in your own practice.

My hope is that, by listening to this episode, you might get off of your phone or your computer or wherever you’re listening and go to your calendar and look through your calendar and do some shifting around just to find one three-hour block each week. And you can use that block for whatever you want [00:22:00] to use it for, but just create a three-hour block. It might take a few weeks if you’re booked out, you may have to shift some things around, but just try to create one three-hour block a week that you can dedicate that you know that you’re going to be working on one specific task during that time.

And if you are feeling extra motivated, you can go in and you can tweak some of these settings that I talked about. So, you can do some time blocking for email. You can change your browser settings so that it doesn’t open existing windows every time you open up a new browser window. So, you can take a couple of extra steps as well, but if you do one actionable thing from this episode, the idea is to block out at least one three-hour stretch where you can get some really quality work done.

[00:23:00] And if you’re interested in learning more about this concept and why it’s important and how to do it, I have found two books that have been really helpful. Both will be listed in the show notes. One of those is called Deep Work by Cal Newport. And that book really is entirely about time blocking and managing your attention and how to stay focused when you want to. That’s a really good one.

And then, another one that has a pretty solid section on time-blocking, the whole book is not about time-blocking, but has a good section on it is the 12 Week Year. I’ll list both of those in the show notes. And again, my hope is that you can take some of this information and translate it into your practice so that you can increase your efficiency and really maximize the time that you might have.

[00:24:00] So, thank you for listening to this episode. I love this stuff. I’m a time management and efficiency junkie. So, it’s really fun to talk about, and I hope it’s been helpful for you.

Like I said at the beginning, if you find yourself compelled by this content and interested in really diving in and taking your practice to the next level with this topic and many others, then I would love to have you apply to join the advanced practice mastermind group which will be starting in September 2020. You can go to thetestingpsychologist.com/advanced to learn more and to schedule a pre-group call. I hope to be talking with you soon.

All right. Y’all take care. Continue to enjoy your summer. I hope that everyone is staying safe. We will be back with you on Monday with another clinical episode.

All right. [00:25:00] Bye-bye.

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[00:00:00] Dr. Sharp: Hey everyone, welcome back to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of neuropsychological and psychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach. I’m excited to be here with you.

Today’s episode kicks off a three-episode series on international assessment. During the series, I’m going to be talking with folks from Australia, South Africa, and Russia. It’s been very interesting to talk with these folks and learn about what assessment looks like in different countries. I think that you will at least find this interesting.

I know that there’s been a lot of discussion in the Facebook group recently about practicing overseas, and my hope is that these episodes may give you some insight into what that looks like. My guest today is Debbie [00:01:00] Anderson.

Let me tell you a little bit about Debbie. She is a clinical neuropsychologist. She trained at the University of Melbourne and has practiced in Queensland, Australia since completing her course in 1989. She initially worked in public hospital settings before moving into full-time private practice work.

She evaluates clients both at the referral of treating physicians and she does a lot of independent expert work in what she calls medicolegal cases like personal injury matters and competency to stand trial and so forth. She enjoys the challenge of complex cases and has done quite a bit of testimony in legal proceedings.

Debbie has several publications and conference presentations related to this work. She’s very active in the Australian Psychological Society, and most recently chaired the College of [00:02:00] Clinical Neuropsychologists annual conference in 2018.

Debbie’s passionate about training the next generation of professionals and supervises new graduates which are called registrars and retains casual appointments at two universities in Brisbane where she lectures on clinical neuropsychology and assessment skills. Her most recent project combines self-care for clinicians and professional education, and organizing overseas retreats for neuropsychologists.

I was really fortunate, Debbie and I had our interview way back in February, 2019. And then I had the great privilege to meet her in person at the AACN conference later that summer. Debbie’s full of energy. She has a great personality and she’s clearly very knowledgeable about the assessment world. So I hope you enjoy this.

We [00:03:00] dig into the nuances of assessment in Australia and cover a wide range of topics; what assessment looks like, what private practice looks like, the healthcare system, those are just a few things that we touch on in this episode. So I hope you enjoy it.

Here’s my conversation with Debbie Anderson.

Hello all, welcome back to The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. Today, I am speaking with Debbie Anderson. Debbie is a neuropsychologist in Australia and this is part of our international series of assessment podcasts. So I’m really excited to be talking with Debbie.

Debbie, welcome to the podcast.

[00:04:00] Debbie: Gooday from Down Under. I’m very glad to be here.

Dr. Sharp: Oh, nice. I’m glad you led off with that. It’s funny, Debbie and I were rehearsing a little bit before we started recording, she came out that, and I had to ask, do people actually say that? Debbie, of course, your answer’s what.

Debbie: Not usually people that work in urban or professional areas, but ordinarily, more the people who live in rural areas might say that. It’s not a phrase I use every day. I’m sorry, everyone.

Dr. Sharp: That’s totally okay. I’m glad that we got the truth here from you. Welcome to the podcast. Like I said, I’m thankful that we were able to make this work. It is 7:00 AM, your time. You are up bright and early, which I appreciate. [00:05:00] I think we’re all set for a good conversation. So thanks.

Debbie: Thank you for inviting me.

Dr. Sharp: Of course. Let’s start out, I would love to hear and I think other folks would like to hear where you’re practicing in Australia and what your day-to-day looks like, a little bit about your training and how you got where you are.

Debbie: I’m in Brisbane in Queensland in Australia. Australia overall has a population of about 24 million. So it’s a very large place with not many people. Queensland itself has around 4.5 million, Brisbane, 2 million people.

I did a little bit of research to say, what parts of America our weather would be most similar to, and I think it would be Florida, possibly New Orleans. So that’s [00:06:00] subtropical area. We’re in the northern part of the country that, so there are other parts of Australia that are not like this.

I was not born in Queensland, but I love living here, and the weather is one of the reasons. It has a really relaxed holiday like atmosphere in some ways in either direction from Brisbane; both the Gold and Sunshine Coasts. So if you’ve seen tourism, you would have seen a lot about probably the Gold Coast which are beautiful beaches, that sort of thing but Brisbane is more of the commercial center, if you like, of Queensland.

I personally I am in private practice full-time. I do a little bit of very occasional lecturing at universities, but full-time private practice. I’ve been doing it for a large number of years that it gets embarrassing every time I say the number. [00:07:00] I try not to say it out loud on the public record too often, but more than 20 years.

I like the flexibility that private practice gives me and the opportunity to do the kinds of work that I like to do. I basically assess all day, every day apart from report writing days because that’s what I like. I don’t do any therapy. I’m not endorsed to do any true therapy in the clinical psychology way.

I very much was very excited when I found your podcast, because I was like, there’s someone else in the world that does what I do every day.

Dr. Sharp: Wow. Yeah. Is there, we’re jumping into it already, but I would think in a city of 2 million people, there might be a lot of folks doing testing. Is that not true?

Debbie: [00:08:00] I looked up the figures yesterday and the number, in Australia, we have the use of titles, so the name psychologist is heavily regulated by one national body. So we have rules about who can say they’re a psychologist and the specialist titles, like neuropsychology, you have to do additional training to be able to use that title.

So in Queensland overall, we have just over 100 neuropsychologists, so it’s not that many really. A lot of those work in the public system, so there’s not all that many in private practice.

Dr. Sharp: Okay.

Debbie: Other psychologists that would do testing would probably be very similar to a large number of people in your group. We call them educational and developmental psychologists. They tend to do more of [00:09:00] the academic testing and that type of thing, working more closely with the schools.

While some neuropsychologists specialized in pediatric neuropsychology, so they’re also doing the assessment of learning disorders and similar things, the educational and developmental group, they tend to work a little more closely with the schools, often are employed by schools.

Dr. Sharp: Okay. That’s fascinating. So you said that there are about 100 in all of Queensland.

Debbie: Yes, 100 neuropsychologists.

Dr. Sharp: 100 neuropsychologists. Sure.

Debbie: There are other kinds of psychologists. There are a lot of clinical psychologists; they can give a WAIS, it’s required that they’re able to do that and general psychologists, but not the true, it [00:10:00] won’t be endorsed neuropsychologists.

Dr. Sharp: Yeah, sure. Maybe we could talk through the different levels of meaning. We spoke briefly before we started recording about that. Walk us through where do you go schooling wise to what’s that look like to get to being an endorsed neuropsychologist in Australia.

Debbie: Sure. After school we go to university and we would do an undergraduate degree, a three-year degree usually with an emphasis on psychology and then an honours year, a fourth year in psychology. So that fourth year has a small thesis, so it’s an honours year. That is the very most basic amount of training before university years of psychology that are required to be a [00:11:00] psychologist.

Dr. Sharp: Oh wow.

Debbie: That’s the academic training. Some people branch off there. They do a program that we call the 4+2 program, which means they’ve done four years of university, and then they do two years of supervised experience. So they don’t do further academic training; they just get workplace supervision, if you like.

They do sit an exam. Part of the national requirements are that they have to demonstrate their knowledge and sit an exam and submit cases and the like. They become general psychologists so they don’t have any specialty area, they’re endorsed as a general psychologist.

If you want to be more specialized, however, you obviously go on to do further academic training. So the minimum requirement [00:12:00] for the specialist training is master’s level. So we can do master’s level training in neuropsychology, clinical psychology, some forensic educational and developmental and so on.

So the minimum is the two years, the master’s level. Some people do a side day; that additional third year. Some people do it as a PhD, but in Australia, PhDs tend to be more research than coursework, and so you have to have done the master’s level coursework somewhere, somehow, to be applying for registration to use the specialist title.

So then when you come out from that, you’ve got your academic qualification, there are a large number of people like me that have stopped at the end of the [00:13:00] masters level. And then you have to work then for another two years in a supervised environment, which is called the registrar program. Those people are referred to as registrars. At the end of that is when they then can say, I’m a clinical neuropsychologist or I’m a clinical psychologist. So it’s at the end of that registrar program.

Dr. Sharp: I appreciate you walking through that a little bit. I want to make sure that I’m following. It sounds like, that may be a difference here, maybe in terminology, where after folks do a bachelor’s degree, do you call it a bachelor’s?

Debbie: Yes.

Dr. Sharp: So that four-year university degree, they can call themselves a psychologist and go into practice as a general psychologist.

Debbie: [00:14:00] Okay.

Dr. Sharp: Is that right?

Debbie: Yes, they still have to do the two years of supervised work after, they can’t just open up their shop at the end of four years.

Dr. Sharp: Okay. Got you. Interesting. So that’s almost like an applied masters or something where you just do two extra years of. But for y’all, it’s almost like your master’s degree is like our doctoral degree. You do two years of course work, but then you have to have two additional years of supervision and work.

Debbie: Yes.

Dr. Sharp: Got you. I’m just getting it all straight trying to wrap my mind around all of this. That’s interesting. So people will go and get the masters and then is that where you choose after that, which specialty you want to go into? Like you could do neuropsychology or forensic or clinical or?

[00:15:00] Debbie: When you’re accepted into the masters, that’s the specialty you’re in. So the masters is specifically to do with that specialty or that area. So yes, you make a choice. You might apply to lots of them, but you might get accepted into one. So whatever is the name or the content of that training is the area for which you can obtain the endorsement.

Dr. Sharp: Okay. That’s interesting to me. So when you applied, you knew ahead of time, I’m applying for neuropsychological programs. Was it totally focused on assessment then for the what ended up being four years or did you do therapy training or how does that work?

Debbie: I trained a few years ago and at that time, it was [00:16:00] very assessment focused, there was no therapy. I understand things have changed over time, that people do learn a little bit more about the interventions, but yes, when I did it, it was all assessment.

Dr. Sharp: Got you. I’m just thinking through, that for folks who, if you know what you want to do, that’s a cool way to do it. I can say there were many parts of graduate school that for me felt useless to be honest. Especially, they felt useless at the time, they feel incredibly useful now, but I’ve honed in on only doing testing with kids, it’s a niche.

So that’s interesting to me to think that you could choose that ahead of time and just know this is what I’m committing to, and that’s all my graduate education is going to be.

Debbie: Absolutely.

Dr. Sharp: That’s cool. So you have the specialist designation neuropsychologist and that you get to [00:17:00] practice that way.

Debbie: Exactly. Yes.

Dr. Sharp: Can you talk a little bit about how is a neuropsychologist different from a clinical psychologist and is there any overlap? Are neuropsychologists the only ones that can do assessment or not? All those things.

Debbie: There’s an added level of controversy around some of these things. I should clarify to say, I incorrectly used the word specialist, the word we’re meant to use to describe us is endorsed whatever title. We’re not supposed to imply to the public that we’re special but anyway that’s just the government.

The differences of these, and this has an impact on the funding, so I’ll come to the funding in a second. [00:18:00] Clinical psychologists primarily engage in treatment. They see people for one hour sessions and engaged in some kind of treatment program. As part of their training, the clinical psychologists and all psychologists are trained to administer at least the WAIS, WISC, and possibly the WMS and some personality measures.

If it is within their purview, if they decide that they would like to assess somebody, they’re allowed to do it. There’s no reason that they couldn’t. A lot of people are very glad to say goodbye to the WAIS the moment they leave university, and who are clinical psychologists, so they’re often happy to refer their cases along for assessment to someone who likes to actually do that.

[00:19:00] But then some of the other groups, so the forensic groups often do intellectual assessments. They, as I said, educational, developmental, they do quite a lot of assessment. They’re very practiced at it.

The neuropsychologists tend to do a little more differential diagnosis in a much more medical setting; does this person have dementia? If so, what type? That kind of thing, or what is the impact of this brain injury on the ability to return to work? They are more the kinds of questions I would get asked rather than just what’s this person’s intellectual level? That sort of thing.

So I guess the idea is that the more complex assessments do tend to come to neuropsychologists, but all other psychologists are allowed to do assessments, but they often choose not to.

Dr. Sharp: Okay. It sounds like there’s less overlap than there is [00:20:00] here, maybe, or more distinction between clinical psychologist and neuropsychologist than there is here.

Debbie: Possibly, but that might just reflect the way that I work and who I associate with, because I know in the past, there has been a lot of angst around who should be doing assessments and who can be giving expert opinions to the court, that’s usually where it really fires up around and particularly around the assessment stuff.

There have been people in the past who are clinical psychologists who prepare essentially neuropsychological assessments for court, and then there’s a bit of debate around should they be doing that? So there is debate and there is definitely overlap [00:21:00] but the funding, in recent years, some of the things that changed with the funding have made it a little more divided, if you like.

Dr. Sharp: Okay, before we totally dive into that, can I ask one clarifying question around the different endorsements? As an endorsed neuropsychologist, could you do a forensic evaluation and have that be credible?

Debbie: I’m giving my best. I’m in court and thinking about my answer carefully.

Dr. Sharp: That’s was the thing. That’s exactly what it was.

Debbie: Consumers of our skills don’t really distinguish. If you do a good report, they’re happy it’s a good report. [00:22:00] It might be raised, I have certainly been in cases where the forensic people have said, oh no, it should be a forensic person giving this report. I say, I’m just reporting on this bit here that I know and understand, and if you want to put that in the forensic context, then good luck.

There is a little bit of that debate, but at the end of the day, the marketplace just worries about whether it’s a good report. So the consumers are more concerned with the quality of what they’re getting. Legally, as long as I’m not calling myself a forensic psychologist, I can do any kind of psychology work.

Dr. Sharp: I see. Okay. Good answer. Nice. I’ll let you off the stand now.

Debbie: Thank you.

Dr. Sharp: You were talking about the funding piece, which I’m guessing, does that mean insurance [00:23:00] versus private pay, that kind of thing?

Debbie: Yes. I’ll step back, Australia has quite a big difference in its philosophy around health funding than I understand America has, although I may have that wrong. We have universal health care in the public system, so if you fall over and break your leg, they take you to the local hospital, you get treated and that’s for free under your, everybody pays a little bit in their taxes to fund the health system and that’s free.

That then extends out into the public sphere, where if you want to just go and see your local GP for your antibiotics, there is some element of that is paid for by the Medicare system, and you might pay a little bit of additional fee on top of that to keep their practice running.

[00:24:00] Most neuropsychologists work in the public health system so they’re funded by the state government to work full-time in the hospitals. So then the biggest change in funding in Australia happened a few years ago, I failed to look up what year it was because it didn’t apply to me because what happened was we got funding for psychological treatment under the Medicare program.

So that means that you can go and see your local psychologist and a portion of that fee will be paid by the public health system, even if they’re in private practice. Some or all of the fee, it depends on what they charge. They can charge an additional payment.

But there’s a distinction; so this whole business about endorsed and not endorsed is quite important now [00:25:00] because the people that have general registration get one kind of rebate, the people who have clinical psychology endorsement only get a much higher rebate per session. So that means they can either charge more or the patients pay less of a gap.

There is this enormous thing around if you’re a clinical psychologist and we have very large numbers of clinical psychologists, but the Medicare funding only covers treatment, so it doesn’t cover assessment. So we’re left out. We don’t get any Medicare funding.

And so that also becomes a driver in the marketplace though, because the clinical psychologists, if they can get funding per hour to be treating people, then it’s not really worth them spending their time on non-funded hours [00:26:00] where the person has to pay fully out of pocket to them for them to do assessment. So that kind of changed the marketplace a little bit in that respect.

Dr. Sharp: I can see that. Do you have any idea why assessment is not included in those public funds?

Debbie: Oh, I shall put away my cynicism and paranoia and say the following; the funding was essentially, it’s to do with funding buckets, the way that the government thinks of where the money comes from. The original funding was under mental health, and so cognitive assessment was not seen by the government as being part of mental health. They were thinking anxiety and depression, that sort of thing.

And so even though what people actually go to the psychologist for is much more than what was perhaps originally [00:27:00] intended, assessments still excluded. So that’s changed the landscape of the way that psychology has operated in the last few years.

Dr. Sharp: Oh yeah. So prior to that change, were all psychologists just private pay?

Debbie: Yes. Even though we’ve got the free public hospitals, we’re encouraged by the government to have some private health insurance as well so that if we wanted to have some elective surgery and go to a nice private hospital, that’s what that insurance pays for. It also pays a small amount for other types of things like your glasses and your physiotherapy and psychology.

[00:28:00] Some people were using their private health funding to get some rebate on their psychology sessions prior to Medicare coming in, but they also still do now because if they don’t want it on their records and those sorts of things, they might not go through the Medicare system.

Dr. Sharp: Okay. I see. So zooming out a little bit and maybe to help me understand the whole haelthcare system; it sounds like over there everyone basically has what older adults have in the U.S. like Medicare plus maybe a supplementary policy if they want it.

Debbie: Pretty much, yes. So the supplementary policy, the government has been creating incentives or penalties if you don’t take it out by a certain age. So they’re trying to move people into that idea of having some private health insurance as [00:29:00] well, but it is not mandatory and you still can get treatment if you need it.

Dr. Sharp: Okay. I see what you mean. That’s interesting. So you then, I’m gathering, have never really dealt with insurance in your practice?

Debbie: Primarily not in the way that it sounds like you guys do. I’ve been reading all your posts about the changes and it sounds awful.

Dr. Sharp: Oh my gosh.

Debbie: No. With neuropsychologists, certain bodies will fund an assessment, so they are sometimes insurance companies but insurance companies where someone’s had an injury rather than a health insurance company. So it’s a little bit different here.

Dr. Sharp: Okay. This is what our brains do, we’re to [00:30:00] categorize and organize things according to existing heuristics. So is this like a worker’s compensation kind of thing where if they get injured on the job, then that would pay for their evaluation, that kind of insurance.

Debbie: That’s one very good example. Yes. Certainly, I provide for workers’ compensation, which is good because they will pay for the person’s, say someone has an injury, they get treated at the public hospital and then workers take over, so then they fund all of their rehabilitation; so their physiotherapy, their occupational therapy, and their neuropsychological assessment. If they need some psychological intervention, they will also fund that.

That’s quite comprehensive funding, because the goal is to get people back to work. They are usually generous in the beginning. So I do that. The other insurers are motor vehicle accident insurers. If you had a [00:31:00] car accident and the other person was at fault and the insurance company said, look, we accept that this driver was at fault so we’ll pay for your treatment.

Dr. Sharp: Yes.

Debbie: So again, thinking in the same way as the worker’s compensation, they do the same thing to get people back to work and so on. In one of our states, Victoria, they have a very large system where all the insurance for the motor vehicle accidents is all pulled together and they actually fund rehabilitation hospitals.

And so if you have a car accident, you go from your initial treatment into a rehabilitation hospital, which is multidisciplinary, does include neuropsychology, includes lots of other disciplines. The treatment is all managed there.

In the state that I work in, we don’t have [00:32:00] that. That’s why there’s opportunities for private practice because people have to get those treatments outside in the private sphere.

Dr. Sharp: Got you. That might be a nice segue to my next question, which is, where do your referrals come from? How do you get folks in your private practice?

Debbie: There are three main areas. The first one is medical referrals. So because I primarily work with adults, they may be seeing their urologist or a geriatrician, and there might be questions about cognitive function, MS query, dementia, that kind of thing. So the neurologist would send them.

Those people are 100% private pay. They have to pay that out of their own pocket unless the [00:33:00] health fund will give them money, but it will be a very small percentage. It will be like 10% of what the cost is. It’s not generous at all. That’s the first group. That’s classically what you would think of as neuropsychology and what we do.

The second group is the insurers. So the workers’ other insurance companies. Also we have a system for our veterans, so department of veterans’ affairs. So a little bit like your VA. They also, regardless of their age, it’s to do with their accepted level of compensation. If their doctor wants it, they can be sent for a neuropsychological assessment as well, fully funded. That’s the only public money we get.

And then the next group [00:34:00] as I’ve become more experienced I’ve moved into is the personal injuries cases; the legal cases. They are very exciting. In Queensland, if you have a motor vehicle accident, you can sue the other party who was responsible and their insurance company then answers that legal claim. And so the plaintiff will need to prove that they’ve been injured or damaged by the accident and how it’s affected them.

So the neuropsychology becomes quite important. I tend to be quite comprehensive looking at both the cognitive and the mood elements to that. So even though I don’t treat like a clinical psychologist, I certainly assess the issues that will be relevant to a clinical psychologist. So those are probably the top end of paying cases. [00:35:00] So I do those as well.

Dr. Sharp: Nice. Do those rates from the insurances and those different sources, are they comparable to your out-of-pocket rate? I know here, there’s a pretty big difference between what insurance reimburses and what our out-of-pocket rate typically is. Is that the case there as well?

Debbie: We set our out-of-pocket rate to be around about the same as the work cover rate so that they’re all about the same amount. It’s all worked on X number of hours at X rate, which is below the recommended rates.

Our provisional society says you should get this much per hour but the rates that the insurers are paying are lower than that. I personally set them at about the same because it’s just too [00:36:00] hard to deal with the differences otherwise, because sometimes people will ring up and say, what’s the fee and you tell them, and then they say, oh, but we’re on work cover, and the fact that it’s a different fee ends up being just problematic.

Dr. Sharp: Who’s that term that you used just a minute ago, your provisional society.

Debbie: Oh, our professional society.

Dr. Sharp: Professional society. Would that be like the APA for us?

Debbie: Yes.

Dr. Sharp: They put forth a recommended rate for you?

Debbie: They sure do.

Dr. Sharp: Okay. That’s interesting.

Debbie: It is interesting. It’s their way of helping us to argue our worth, if you like. When we say this person needs treatment, then they need 10 sessions at the APS rate and that’s far higher than the Medicare rate or the insurance rate.

[00:37:00] They’ve got some kind of algorithm that is to do with what it would cost to have an office, to work there 40 hours a week, and do all the things you’ve got to do. It’s based on more therapy work, though. It’s worked out in a therapy hours model.

Dr. Sharp: Okay. I see. That’s fascinating. Without getting into specifics, you don’t have to go into detail with the numbers, but I know over here, being a psychologist, you can make a pretty good living. We could get into all sorts of arguments about that but if you charge a reasonable rate, that’s market rate, you can do pretty well. Is that the case over there too or is it upper, lower?

Debbie: Oh, look, it’s partly way about how you manage it and how much bulk billing work you do.

[00:38:00] If you’re the kind of psychologist that’s working in an area that people can’t pay extra, can’t pay out-of-pocket fees, then you’re not going to be making a lot of money because it’s a pretty basic sort of amount that Medicare would give you. So it would be like if you only took the insurance without a copay.

In my case, because the personal injuries cases we charge more than double what the other ones are, we charge more than the recommended rate, that creates a good income. My observation is people who have that mix of cases in all different kinds of psychology do tend to be doing reasonably well.

Dr. Sharp: Sure. Is it feasible at all for a neuropsychologist there to only [00:39:00] do private pay where maybe they don’t have these work cover contracts or the personal injury stuff? I’m thinking maybe, if you can’t answer this, that’s totally fine, but maybe pediatric neuropsychologist where it’s not coming from a neurologist or an accident or something but people walking in off the street, so to speak.

Debbie: Oh, absolutely. Yes, I have several friends that are pediatric neuropsychologists who that’s all they do. And it’s pretty much private pay all the time.

Dr. Sharp: Oh, okay.

Debbie: It’s probably not an enormous income, but it’s certainly doable. So once people are in with the right guidance officers, the guidance officers tend to be at the schools and then they request this information. They can have quite a busy assessment practice [00:40:00] and as I understand it, they do reasonably well.

Dr. Sharp: Okay, that sounds good. Nice. Let’s talk about your practice. What does that look like? Is the evaluation structure similar or different? There’s a huge variation, maybe I’ll back up and just ask what do your evaluations look like? How many might you do a month? We’ll just go from there.

Debbie: Okay, of all the people in Australia, you’ve probably chosen one of the small number who have adopted what would probably be a very American model. There’ll probably be a lot of similarities in the sense that I like to come to the American conferences and read a lot of the American literature so I’m quite influenced by that.

The structure is that; it’s me, I have a psychometrician some days; a technician, [00:41:00] is the word you might use. I have some registrars, so I have two, but one does more work than the other, two are casual. So if we get extra cases that don’t need super specialty work done on them, the registrars do them and I supervise them so that counts as part of their training, they’re moving towards endorsement.

We try to have a mix of cases per week. We might have three assessment days in a week and two report writing days. The cases that take the most time and energy to write the reports are the medicolegal ones, because they’re very long and detailed.

Having listened to the podcast about time blocking and things, I’m trying to keep days free to work on those, to give [00:42:00] myself the psychological space to actually think about the problems. With the assessment days, they’re quite full. We do very full batteries, so full WAIS, WMS. I personally don’t like the D-KEFS so I use more of the Rey figures and RAVLT and what’s called the Halstead category test, those types of things.

Depending on people’s reading level, the PAI or the MMPI-2. We try to do a comprehensive, my philosophy is most of the basics and several effort measures, of course, most of the basics are the same for all assessments. So I choose to do a full WAIS, a full WMS every time, unless there’s something really outstanding about why the person can’t cooperate to do [00:43:00] that.

We are a very assessment-based practice. People are here anything from five hours to eight hours, depending on the complexity of the case and the history and so on. We do it as a one-off. So they come in one day. Ordinarily, we asked them to bring a partner or family member to interview. So I interviewed them and all of that happens on the one day. So everybody’s exhausted at the end of that day.

Dr. Sharp: Yeah, I’m sure. I worked for a clinical neuropsychologist in graduate school and that’s what they did as well.

Debbie: The advantage of this for me, because of where we are, is it means that it’s [00:44:00] only so people cities, Queensland’s very large and popular, the idea of getting it all into that one day is quite important so it’s a long assessment day and then we keep all the report writing and so on for the other days.

Dr. Sharp: I see. So then you said the medicolegal reports end up fairly lengthy, what does that mean when you say lengthy?

Debbie: Probably about 12 to 15 pages, which to you guys, I hear people talking on your podcast or in your group, and they seem to talk about that as an average report. An average report for me, so if I was reporting back to a doctor or an insurer, would be no more than [00:45:00] 4 or 5 pages.

Dr. Sharp: I see.

Debbie: There’s data in there, we do data tables, but only the summary indexes and focus on what the conclusion is; what does this data mean? Because we found that people just were, it was doubling up information. So all of that longer-term history, we just found it was doubling up and the referrers just didn’t want to read it all again. They already knew it and it was just pointless paying us to do it again.

I’d spoken directly to workers’ conference, for example, about that. They were like, oh, we just want the news. What’s the news? So that’s what we do. The legal ones; they are a bit longer. They could be up to 20 [00:46:00] pages because the lawyers have always gotten millions of questions.

Some people like to explain every test and stuff like that, I write it as if the person reading it knows what the tests are. I explain what they mean rather than what they are and that seems to go down reasonably well.

Dr. Sharp: Got you. You said that you’re maybe in the minority, that this is more of an American model. So what’s the typical Australian model?

Debbie: There are plenty of people that do quite a bit of assessment, but not quite as much as I do. There is also a history in Australia of a more, people would call it a hypothesis testing approach. So they would do a bit of this and a bit of that, Paired [00:47:00] Associates, but not the other things or similarities and Block Design and so not the full batteries of things.

When I trained many years ago, that was the prevailing model and over time, there has been increased influence of a much more psychometric model. So it probably is the case that the majority of people do use a more psychometric approach now. I was probably wrong in saying I was a minority, but there are certainly some people who do not do full batteries at all, particularly in the public space. They feel like that the pressure to see lots of people is such that it’s hard to justify the time that a full battery would take.

Dr. Sharp: Yes. That makes sense. Nice. You said you have technicians or psychometricians; [00:48:00] what level of training do folks have to have to be a technician over there?

Debbie: It’s not a full-time job, it’s a casual job. I ordinarily employ them whilst they’re studying their masters. So they are already done the four years. They’re provisionally registered, all they have to be is provisionally registered and I have to be their supervisor. That’s all they need.

Dr. Sharp: I see. Nice. I like that model as well; employing graduate students, that makes a lot of sense.

Debbie: Exactly.

Dr. Sharp: Do you have any idea how U.S. training might translate to Australia? So let’s just say I wanted to leave the U.S. and move to Australia, would I be able to find a job or open a practice [00:49:00] as an assessment psychologist or neuropsychologist or not?

Debbie: I couldn’t see why not because the APRA; the regulation body would, I’m quite sure, see the training as equivalent and that’s the first hurdle. So as long as you’re registered, you can do whatever you like. I don’t know a lot of people that have come from the U.S. to Australia. The main people I know people that have perhaps trained in the U.S. but had originally come from Australia and come back for more academic roles, lecturing and the like. I can’t say I know of any clinicians that have made the move, maybe there’s a place for you.

Dr. Sharp: Hey, I’m going to take that and run with it. Australia would be a great place. [00:50:00] It sounds fantastic, aside from that whole meme about millions of predatory creatures out to kill you everywhere you turn. I don’t know if I can get over that.

Debbie: Our houses are just like everybody’s houses. There’s no crocodiles.

Dr. Sharp: That’s good to hear. That gives me some hope. One thing that I did not really touch on was just the role of diagnosis. Do you all use the DSM? Do you use something else? Do you care about diagnosis? How does that work?

Debbie: In my view, diagnosis is really important and it’s a crucial part of what we do. I know in the pediatric area, there is a greater emphasis on the DSM diagnosis around some learning disorders and stuff like that.

It depends on what people are being assessed for. [00:51:00] With the more medical assessments, if it’s coming from a neurologist, they don’t care what the DSM says. So if I write back to them, this person’s got major neurocognitive disorder, they’re like, what are you talking about? So I don’t worry about that. But if I was writing to a psychiatrist, then that would be helpful to them because they would know what the DSM says.

From a statutory point of view, some of the medicolegal cases that we do, some of the ratings, when you do medicolegal case, you’ve often got to distill your results down to a rating; this person has X% impairment in relation to whatever.

Some of those are medically based on the medical diagnosis, so brain injury and its cognitive effects would fall under there but if you want to say, and they’ve got an adjustment [00:52:00] disorder or they’ve got PTSD, you have to show that meets the DSM requirements. To use that rating, you do need the DSM. We do use the DSM, but for the less neurological things.

Dr. Sharp: Yeah, I see what you mean, but it is the DSM, there’s no other manual.

Debbie: Oh, no. DSM, that’s it.

Dr. Sharp: Got you. That makes sense. You write for your audience.

Debbie: Yeah.

Dr. Sharp: Got you. Very cool. My gosh, I feel like I’ve learned a lot about practicing in Australia. What else is out there? What have I not asked about? Anything that is unique or interesting about practicing there that might be different from what we do or any other points of interest you might think of?

[00:53:00] Debbie: Two things; I wanted to say that I have enjoyed your stuff on technology and I’ve been an early adopter as well. So all good. It’s available in Australia. You’d be pleased to know.

Dr. Sharp: Oh, great.

Debbie: Probably the thing that’s a little unique about the size of Australia is it makes the whole provision of healthcare to everybody very difficult because of the amount of travel and the outback and those sorts of things. The majority of us are localized in quite urban areas, particularly in New South Wales and Victoria. That’s where everybody is.

In some of the other states, one of my friends in Western Australia runs a clinic where they fly to another part of the state and run a clinic because they [00:54:00] don’t have access to neuropsychology or psychology otherwise. And so that kind of adds a dimension.

I have a forensic person in my office who every week flies to another part of our state and provides services because they can’t get the services locally. I get to fly around occasionally with my tests and people. I realized it’s a reflection of the size and shape of the land, but we do a little bit of travel sometimes which is interesting and fun.

Dr. Sharp: Yeah, that is really interesting. It sounds like there’s maybe more of a norm for that than there is here certainly where you have to. Oh, that’s great. It does sound exciting. It makes our job sound a little more exotic than just hanging out.

Debbie: That’s what I tell myself when I have to get up very early to catch the only plane [00:55:00] that’s going to that location that day.

Dr. Sharp: I bet. Whatever it takes, those cognitive tricks.

Debbie: Exactly.

Dr. Sharp: Wow. This has been informative, interesting and fun too. Like I said, I really appreciate that you were willing to make the time to talk with me about these things and listen to some of my dumb questions as we’re just figuring it out.

I know there are a lot of folks around the world who are listening to the podcast and practicing in different settings in other countries, I’m curious about all of that. So I appreciate what you’re willing to talk with us about.

Debbie: Thank you very much. I’ve certainly enjoyed it.

Dr. Sharp: Oh, good. If people have questions either about Australia or Queensland or Brisbane or neuropsychology or really anything down there, what’s the best way to get in [00:56:00] touch with you?

Debbie: Probably best to email me. I’m happy for you to put my email in the notes.

Dr. Sharp: Okay. Yeah, we can do that.

Debbie: Yeah.

Dr. Sharp: Great. Debbie, this has been great. I really appreciate it. I know our paths will cross in the Facebook group but until then, take care.

Debbie: Thank you. Bye bye.

Dr. Sharp: All right y’all, thanks as always for listening to this episode with Debbie Anderson, all about testing in Australia. I was struck by how similar the practice is. There’s certainly some differences in the healthcare system and some of the environmental factors, but sounds like the practice is largely similar.

I know for myself, I’m always at least a little bit in the back of my mind, thinking about practicing internationally and maybe moving our family, and this was a really cool conversation to have [00:57:00] to add some more information to that decision-making process.

We will continue with the international assessment series over the next two Mondays. Next time I will be talking with Michelle Ireland about assessment in South Africa and following that, I’ll be talking with Joseph Graybill about assessment at an international school in Russia. So both of those were just equally fascinating conversations. My hope is that you’ll stick around and tune into those as well.

If you have not subscribed to the podcast, now’s a great time to do it so that you don’t miss any episodes coming up. If you have a moment to do me a huge favor and rate the podcast, I love those 5-star ratings. It helps to spread the word and increase exposure for the podcast. And like I always say, if you are tempted at all to leave a less than 5-star rating, please shoot me an email [00:58:00] and let me know what could be better and what you’d like to see different here on the podcast, always open to feedback.

Okay, y’all, take care. We’ll catch you on Thursday with another business episode all about time blocking and streamlining your schedule to be most efficient with your time. All right, take care.

Click here to listen instead!

Dr. Sharp: Hey everyone. Welcome back to another episode of 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.

All right, y’all. Today is a solo business episode where I am going to be talking with you all about Designing and Implementing a Think Week as Bill Gates, many other CEOs, and high-performing individuals. 

A Think Week is basically the time that you step away from your daily life, whatever that looks like, and you take some time to regroup, reflect, vision, and plan for your business. I think that these Think Weeks or retreats as I’ve called them, have been completely integral to some of the most successful changes in my practice and my coaching, and the podcast. And I’d like to share some of those ideas with you today.

So without further ado, let’s get into it.

Hey y’all, welcome back. Like I said, we are talking all about the idea of a Think Week or a retreat as I’ve called them over the years. I want to dive right into it. And full disclosure, this is actually the second time that I’m recording this podcast. I recorded the whole thing. And then reflected back on it and thought, you know that wasn’t quite good enough. This topic is so important. And the practice of doing retreats each year has helped me so much that I wanted to go back and really nail this one. That’s what I’m doing.

As we dive into it, I want to give just a little historical context for why this is important. So, folks over the years, and when I say years, I mean, centuries have found that solitude and time to reflect is crucial for creativity, wellbeing, planning, and visioning. This is not a new concept necessarily, but it has gained popularity, I think, over the last 2 to 3 decades.

Bill Gates popularized the idea of a Think Week. It’s what he called it. I think he first spoke of it around 1995. Since then, I’ve read many accounts of authors, CEOs, and other high-performing individuals taking deliberate time off from their day-to-day work, family, responsibilities to sit with themselves, have a little time to regroup, and really think through some of the big questions that they may be dealing with in life. 

I didn’t know this at the time, but probably four years ago, I started this practice of doing twice yearly retreats where I would get out of town and use that time just to decompress. And again, just take time away from working in the business so that I could work on the business. So, you can frame your retreats however you’d like.

I’m going to be talking about them in the context of your business, but there are certainly personal impacts as well. The most obvious one is that when things are going well in my business, things typically go well in my personal life. Doing these retreats even though they’re business-focused, they always have the outcome of streamlining my schedule, optimizing the services in our practice or in my coaching business, or making things really just easier on the business side so that that flows through to the home environment as well. And just my well-being in general.

So again, just a little historical context. This is not a new concept, but it is something that I’ve seen many, many times as being beneficial and talked about as being very important for folks who are trying to do big things.

Now, you may be saying to yourself, oh, I’m just a solo practitioner or I don’t have big things on the horizon, or I’m not important enough to need to do this sort of thing, but I will immediately challenge that and encourage you to really, I think this is part of the transition, to stop thinking small. So, stop thinking like a one-person business or like a solo practitioner and really start to make that transition to a CEO mindset because whether we like it or not, or whether we conceptualize ourselves this way or not, we are business owners and that role is just as important, if not more important than our clinician role in our practices.

So this is not just for large group practice owners or having multiple streams of income or anything like that. This can be super useful just from the standpoint of dialing in your business, whether it’s just you or not. We always need time to reflect on what we’re doing and be deliberate about what we want to do moving forward. So with that, I’m going to dive in and walk you through exactly how I plan and design my retreats. I’m going to use those terms interchangeably, Think Week and retreat, but I typically call them retreats. I think Bill Gates uses the term, Think Week. So, that feels like I should give it some credit as well.

All right. Spoiler with the Think Week. There is a good bit of planning involved, but the planning and the details and nailing those right from the start so that you can enter your think week and hit the ground running are going to make or break your experience. So I’m going to talk a lot about the planning, exactly what I do, and then also talk about the execution of the Think Week and what actually happens when I’m out of town.

All right. So the first major thing is that you have to actually get these on your calendar. So I am going to push you to right at this moment if you’re in front of a computer, or you’ve got your calendar right there on your phone where you can do this, pause the podcast and look ahead on your schedule to the first time that you can legitimately take let’s shoot for three days off. So three full days off where you can get away from your business, preferably get out of town and have that time to yourself.

Now, I’m guessing some of you are going to say that’s not going to happen for years. And that’s really the challenge here is that you have to make time to do this kind of thing. So look ahead, find the first three open days or days where you could feasibly reschedule a couple of things, and try to find a three-day gap in your schedule. Immediately reserve that gap for your retreat.

Once you do that, I’m going to ask you to look six months ahead of that and book a five-day retreat. So for most of us, this is going to get us at least 8 to 12 months down the road for these two separate retreats. I don’t know many people these days who are booking 9 to 12 months out. So, just do it. So again, shoot for three days for the first one. If you can’t find three days, go for two. If you can’t do two, do one. But the important thing is just to book this time on your calendar and make sure that it’s reserved so that you can do that.

Now, that also for many of us means checking with a partner, checking our kids’ school schedules, other commitments, your other job if you have one. So, do all of those things, clear your calendar and put these retreats on the calendar. So you’ll at least be set for next year. Okay. If you’re not able to do that right now, then I’m going to ask you to set a reminder on your phone to do it at your next open interval today. Getting it on your calendar is absolutely crucial. Once things are on our calendar, there’s good research that it greatly increases the likelihood that we’re going to do them. So let’s do that.

Now that you either have it on your calendar or have planned to put it on your calendar, let’s talk about what actually happens before and during these retreats. So for me, the location is really important. I have gotten in the habit over the last few years of doing my retreats solely in the Los Angeles area.

Now, why do I choose Los Angeles? Well, I have a number of friends there. So, a small part of my retreat is always checking in with those friends. These are very old friends that I’d love to connect with. So I always set aside part of the retreat for some socializing. The other part, though, is that a component that we will discuss is simplicity and exercise during your retreats.

So for me, LA satisfies both of those things. The weather’s warm enough that I can go any time of the year and can count on being able to get outside to exercise and walk as much as I want without having to worry about the weather. LA or certain parts, and the parts that I like to stay in are also very walkable. And that to me is crucial. So I don’t like to worry about a car or driving or directions.

Now for you, you can pick the location that fits best for you. It might vary depending on what time of year. But I think that it is crucial to get out of town somehow. Once we’re away from our businesses and our families and our daily lives, that’s when your brain is really able to open up and work through the bigger problems that you just don’t have time to think about. So I’m a big fan of truly getting out of town.

In the worst-case scenario, if you can’t get out of town for whatever reason, I do think it’s important to step away, whatever you have to do to step completely away from your daily responsibilities. So if you can do that being in a hotel or Airbnb in your own town, that’s great. I can not do that, but what I know about my brain is that the moment I drive out of town to an airport, to a different town, wherever, anywhere out of my local area, my brain shuts off from day-to-day work mode and really starts to embrace all the other ideas that are out there. So location and getting out of town are pretty important.

The other piece that I do ahead of time is I work really hard to plan my retreat so that I eliminate all non-essential decisions. So what do I mean by that? Well, like I said, I pick someplace that is completely walkable. I do not like to drive, especially in cities, especially in unfamiliar places. Parking is a hassle, finding directions, being unfamiliar, traffic, all those things. So that is one huge non-essential decision that is just eliminated right off the bat. So, when I can walk everywhere, that helps greatly.

The other piece that I do that eliminates a ton of non-essential decisions is essentially planning out all of my meals and coffee ahead of time so that I’m not spending time. Once I’m on the retreat, I do not want to spend time just on Google reading reviews, mapping locations, wondering if this place has vegan food or whatever, that’s the last thing that I want to do when I’ve taken this huge break from my family and my work. The last thing I want to do is spend time thinking about where I’m going to eat and how much it’s going to cost and are they going to have what I want and that sort of thing.

So, in choosing your location, a big part of it for me is or was, at this point, I stay basically in the same neighborhood every time that I go. So as you’re getting started, you can get familiar with a place, but over time it becomes familiar and that’s just one fewer decision even you have to make when you’re planning your retreat. But as you can tell, that’s related to the location. So do your research and check out the restaurants in the area. Make sure if you’re a big coffee drinker or a tea drinker or a kombucha person, or whatever your morning ritual is, make sure that there’s a coffee shop right nearby or that breakfast place that you need to eat at, or a smoothie location, whatever it might be. And the same for the other meals.

Now I am a person much to my wife’s dismay who can basically eat the same thing day after day. So I can have the same thing for lunch and basically the same thing for dinner several days in a row before I get tired of it. If you were curious for whatever reason, I’m a salad for lunch, a Mexican for dinner kind of guy. So, I’m always looking for a place that has, let’s say a Whole Foods nearby. And I’m totally happy with a Chipotle or something like that. So the idea is that you map out the area and almost plan your meals for the time that you’re going to be there. And if you have to write this down, if you want to eat something different every night, that’s totally cool. You can do that.

But the trick is that you plan it out ahead of time so that when you get there, you are there to totally zero in and drill down on the work that you’re trying to do, and the ideas you’re trying to sort through, like the big ideas, rather than spinning your wheels and wasting time like I said, looking at Google reviews or mapping out restaurants or figuring out how to drive there and get there and all those kinds of things.

Another piece of eliminating non-essential decisions is just generally planning the time. So like I said, I always spend some of my time socializing. So, months ahead of time, I’ve contacted these friends and I’m like, “Hey, y’all, I’m going to be there this night and this night, can we get together?” So that I’m not tempted while I’m there to call them or do random things, spontaneous things that might come up. So that’s one piece of it.

The other component of scheduling is that I generally map out the retreats where I will schedule time for a consultation or bounce ideas off of some friends and other colleagues or coaches about halfway through my retreat. I scheduled it halfway through so that I have some time on the front end to really sort through my ideas and work on a few things and get the ball, moving on a few things. Then I have the consultation period, and then I have some time afterward to implement whatever tweaks or changes that consultation yielded.

So mapping that out and being able to schedule those meetings ahead of time. So this could be like a conversation with your spouse or partner, it could be a conversation with a good friend, another practice owner, your peer support group, your coach, or a number of those folks. Many times I’ll have 2 to 3 half-hour to hour-long meetings set up with trusted friends and colleagues and coaches on that day, typically in the morning so that I can get a variety of opinions and really cover all the bases. So again, I have all that planned ahead of time so that I don’t have to worry about it. I just know what to expect when I get there.

Another part of eliminating non-essential decisions is making a pact with yourself and with your employees if you have them that you are completely off the grid, essentially, as far as working in the business. So I am not writing reports, I’m not responding to emails, my staff knows that there’s basically one way to contact me if it’s urgent. For me, that’s chat. We use Google chat, so I know if I get a message from them, it is truly urgent. Otherwise, I’m not working in the business. I’m not doing those small things. I’m not wasting my time with issues that aren’t moving the needle quite a bit. You get the idea.

Definitely planning. You can get us as nuanced as you want, planning your leisure time, planning, of course, what you’re going to wear each day. The idea is that you wake up and your brain is dedicated to the work, the creativity, the brainstorming, and the problem solving that you want to do for your practice. And you are not busying yourself with these other items that eat at your cognitive resources. So that accounts for a lot of the planning involved.

The one component that I will mention is that I always build in time at the end of my retreat. It’s usually the last half-day that I’m going to be there. So the last, let’s say four hours of whatever day I might be working. I save that time because I know that I am not going to likely finish everything that I want to on the retreat. So I save that time to go look at my calendar and tie up any loose ends and schedule more time in the future to work on the things that I didn’t finish or set up meetings with folks at my practice that I need to set up to keep moving forward. So I save that last afternoon basically to tie up any remaining items and really plan for the future.

Okay, you get the idea. Eliminate all the non-essential decisions. Plan your agenda and make sure that you’re in a place that feels comfortable and allows you to do the work that you need to do.

Let me tell you a little bit more about my schedule when I do these Think Weeks. So my biggest thing is when I go into the Think Week, I don’t always know what I’m going to work on. Now, I tend to fly to Los Angeles. So my routine that I’ve gotten into, I know that this is a two and a half hour flight. So the first hour is largely spent talking myself down out of my flight anxiety which won’t seem to go away. After that is done, then I use the remaining time in that first hour to just do a complete brain dump. So get my computer out and just make a huge list of things that are running through my mind.

Now I’m not talking about like, respond to that email or mail that letter or order that basket or whatever. It’s not the little stuff. I do a brain dump of all the bigger ideas that I’ve been thinking about. So things that I’d like to tweak in the report template. Measures that might be getting old. Topics I need to research. Redoing our recommendation bank. Podcast content to some degree. Coaching offerings. Do we need a new staff member? How can I tweak the training process for my psychometrists? So, just like bigger picture ideas and things that I’ve been wrestling with.

This has often involved refining my schedule too. So I always do an overview of my own schedule and I look at it and say, what’s working and what’s not working. And almost always, I have found something that’s not working and something that I want to change for the coming months. So reviewing your schedule, thinking about what’s really working in your practice, what’s not, what’s eating up a lot of time where it doesn’t need to, things you could delegate, things you can get better at, ways you can get better, topics you want to learn about, that sort of thing. So I just do a big brain dump for the first hour of that flight.

And then the second hour, I am basically culling that list and rank ordering all of the pieces that I’ve dumped on the page. After that process is done, I usually have come up with 2 to 3 big ideas that I want to work through. So at that point, I’m about to land and I have a pretty good idea of what I want to work on over the time in my retreat. Once I have those 2 to 3 big ideas, then I kind of map them on to the time that I have.

So at this point, I typically do five-day retreats. If you’re doing three days or even just one day, you can scale it back and map your time out accordingly, but once you rank that list and distill your ideas down to 1,2 or 3 main ideas that you really want to work on or things you want to accomplish, then certainly you try to map it to the time that you have.

So, the way that I, and this is getting very nuanced, but again, this is my process and this is what works. So I always have a flight that lands in the early afternoon. I don’t want to feel rushed. I don’t want to get in late. I don’t want to get a poor night’s sleep before the first real day of the retreat. I want to have some time to get to the place I’m staying. I already had my dinner mapped out like I’ve talked about. And I’ll use that afternoon/evening after I get there to continue to refine those ideas and get prepared to wake up and work on what I need to work on.

So once I get all that settled and I have a good idea of what I’m going to do, if there’s any time that evening left, I’ll use that to take care of any random things that I need to close the loop on to make sure that my mind is totally fresh and ready to jump into the big stuff the next day.

So then, like I said, I do a five-day retreat. Exercise is a huge component of these retreats for me. My preferred means of exercise is running. So I’m going to be running 3 or 4 of those mornings. I run first thing in the morning and if possible, I stay at a place with a pool. So I do a run, then I get in the pool and then I am ready to roll. On the days that I don’t run, I am walking everywhere. If you can find a place that has a nice mix of nature and walkability, that’s fantastic. So I do a nice walk kind of out in nature and then I walk everywhere else throughout the day, like walking to get lunch or dinner if I don’t have them delivered and walking anywhere else that I might want to go.

During some of that time, I might listen to a podcast or an audiobook if it’s relevant to what I’m working on. And sometimes it’s silent, but exercise is a big part. So I exercise in the morning and then I have basically two work periods. I work from about 8:00 AM to 12:00 AM, then I have lunch, and I work from about 1:00 PM to 5:00 PM.

And then that’s it. And then for me in the evening time, again, my meals are planned out. I have dinner pretty early. I’m an early dinner person. So, I’ll do dinner around 5:30 PM, maybe 6:00 PM, and then I’ll relax.

So I kind of unplugged and or at least unplugged from the work. And for me, I watch movies because I never get to watch movies otherwise. So I’ll watch movies or go to the movie theater, which I never do these days. So that’s my sort of unplugging at night. And then I am in bed pretty early, I’m again, an early to bed person so that I can wake up and do it again in the morning. Now you can obviously adapt this to fit your circadian rhythms if you’re more of a night person, but the idea is that you do have a rhythm to the day and a start and a stopping point. If you don’t have a stopping point, then I’ve found at least that it is harder to be motivated and to work hard when I feel like I can just go forever. So I like to have these stopping points and breaks.

Let’s see. In terms of other details, this may go without saying, but I’m not drinking a lot, partying, or anything like that. Sometimes there’s a temptation to do that when you’re on your own, but I don’t because it wrecks my sleep and I don’t want to ruin the next day.

So, that’s pretty much the schedule every day that I’m on retreat. Again, with that last half-day being reserved to tie up any loose ends and plan for the future and make sure that I can implement the things that I want to implement because that’s always an outcome of these retreats is that I have ideas that I need to continue to work on, and it always requires some implementation. So that’s why you save that last a half-day or so to make sure that you can implement and you have time to do that.

Okay, so that’s that. Again, just little details. I keep all my notes in Google drive. I keep track of everything that I’m thinking about and doing during that time so that I can refer back. I still have notes from retreats from years ago, and it’s really been helpful to reflect back on my process and what I’m thinking about, and ideas that I’ve had. Some of them I don’t work on, but then they marinate and come back a couple of years later.

So that’s an overview of how I do retreats. And like I said, these have been crucial for both of my businesses, the practice and The Testing Psychologist. So I, again, highly, highly encourage you to find the time and plan your first and second retreats over the next year. My guess is that it may feel strange. You may have questions, like, can I really do this? Or is this worth it? How do I spend my time? And that’s okay. That’s totally okay. The key is just to make time and get the ball rolling. And once you get there, I think you will find that it is infinitely helpful. And you dial on your process the more you practice.

All right. Thanks for hanging with me and thinking through, through the idea of a think week or a retreat for your practice. I hope that I’ve got a lot of you thinking about how to do this and maybe even excited about how to do that. I’m going to put a few resources in the show notes, books that have helped me with how to structure a retreat, and how to structure my time. Check those out.

Now going forward, let’s see, this is a concept that I found is particularly helpful for folks who are running growing practices. The more that we expand our practices, the more time we need to get away and reflect on our role as being as a leader. So to that end, if you’d like a group of other practice owners who are in a similar place, our advanced practice mastermind will be starting up again in September. I’m recruiting members for that. And it’s a group of 6 psychologists all in the more advanced stages of practice. You can learn more about that at thetestingpsychologist.com/advanced and book a call there to determine if this is a good fit for you.

Okay, y’all. I hope you are doing well, hanging in there. Things are going a little nuts these days with the virus, but I hope you’re staying safe and staying sane. I will be back with you on Monday with the clinical episode. Take care in the meantime.

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

Today’s guest is a special one for me. Dr. Katie Scott is a former practicum student of mine. She was one of my very first graduate student psychometrists in my private practice probably 10 years ago. She has circled back and is now a neuropsychologist. She is here to talk with all about concussions and TBI.

We get into many dimensions of this area. It’s a very nuanced area and we really just do a nice overview of what I would think are the essentials of TBI. So we define some terms. [00:01:00] We talk about assessment of head injuries: when it’s necessary, when it’s not, what can we gain from it. And then we spend most of the second half of the interview talking about managing post-concussion symptoms or lack thereof and supporting folks as they return to school or whatever the “real world” might look like.

So it’s a great episode with lots of fantastic information, some great show notes, and resources that Katie provided. I think you’ll take a lot away from this one.

Before we jump to the conversation, let me tell you a little bit more about Katie, which I am very happy to do. It’s great to see where she has ended up and the career that she is building for herself.

Dr. Katie Scott is a licensed psychologist and clinical neuropsychologist at the University of Michigan’s Mary A. Rackham Institute. She is also a clinical partner with the University of Michigan’s Concussion Center, a multidisciplinary center with research, clinical, and outreach cores that are committed to concussion prevention, identification, management, and outcomes.  

Katie earned her doctorate in Counseling Psychology at Colorado State University. She completed her internship at the Denver VA, and that led to her post-doctoral fellowship in clinical neuropsychology at Mary Free Bed Rehabilitation Hospital where she worked with a well-known podcast guest, Jacobus Donders. Many of you have read his book on report writing. So, Katie had the good fortune to train with him for a number of years.

She has experience in a variety of settings, including inpatient acute rehab, outpatient interdisciplinary clinics, and outpatient neuropsychological assessment. She has also served in educational and supervisory roles within an APPCN-affiliated fellowship program.

Let’s see. What else? Specific to concussion, she’s worked in a variety of settings including sideline assessment of acute concussion in sports, assessment and intervention within both sport-related and non-sport-related concussion clinics, and evaluation of individuals experiencing prolonged recovery of symptoms after a concussion. She has worked with athletes across varying levels of competition including youth sports programs, high school and collegiate athletics, and professional teams. Her current research interests include return-to-learn and psychological intervention following concussion.

As you can see, Katie’s been doing this work for quite some time and is well involved in this concussion world.[00:04:00] She has a lot of knowledge to share with us, and I will not keep that from you any longer. So here you have my conversation with Dr. Katie Scott.

Hey everyone. Welcome back to another episode of The Testing Psychologist podcast. Glad to be with you. Also glad to have my guests here today. Dr. Katie Scott is going to be talking with us all about concussion, TBI, assessment, treatment, management, all of those kinds of things. I’m really excited to have Katie here.

Katie, welcome to the podcast.

Dr. Scott: Thanks for having me. It’s good to be here.

Dr. Sharp: A lot of people know I don’t record the introductions until after the interview. So I don’t know what I’m going to say in the [00:05:00] introduction as far as our relationship, but it’s been cool to touch base with you. The last time I saw you was 10 years ago when you were a practicum student in my practice doing psychometrist work. And now here we are like, you’re a podcast interviewee, which is awesome.

Dr. Scott: Yeah. It’s crazy to think about the last 10 years, and where that’s brought us in training and experiences and all of that.

Dr. Sharp: Yeah. Well, I’m really glad that we’re able to connect. I’m excited to talk with you. This is a topic that it’s hard to believe that I have not really tackled concussion/TBI on the podcast before. But here we are. And I’m ready to dive in. So, thanks for being here.

As usual, I’d love to hear, especially, having a prior relationship, why this is important to you and your journey to get here as a specialty.

[00:06:00] Dr. Scott: Thinking back on my experience with concussion brain injury, I had some exposure, I would say, like in graduate school and in that practicum training and things like that. And then really on internship when I was at the VA in Denver, just a lot of exposure to patients who had a history of brain injury. We saw or had psychoeducational groups around concussions, things like that.

And I think that’s really where my first step into how important education around concussion can be, obviously for providers and clinicians who work within the population, but also for patients as well. I think talking about concussions with other clinicians and practitioners who maybe don’t find that to [00:07:00] be their specialty or an area that they practice in a lot, but who do on occasion will see patients who have that history, I think it’s really important to have a good primer education about what brain injury is, what recovery looks like because especially with a concussion, we know that that education piece is so important to a patient’s recovery trajectory.

If we look back on the work from Dr. Grant Iverso back in the 90s looking at the provision of education to patients early on in their concussion recovery really did seem to have a positive impact on prognosis and recovery timelines. And we still see that today obviously. And so, I think it’s important to really equip clinicians with good information to be able to provide that to their patients.

I also find concussion work just to be really great. It sits at a [00:08:00] great intersection for psychologists and neuropsychologists in particular because it really leans on our background in psychotherapeutic work and being able to be an empathic presence for patients and have that counseling or clinical psychology background. But then also, obviously it’s important to have an understanding of the neurologic basis of concussion, how to appropriately assess and understand cognitive functioning within the context of income concussion is important. So it really draws on and challenges those pillars of who we are as neuropsychologists and psychologists

Dr. Sharp: I like the way that you phrased that. And it will become evident very quickly, I’m not an expert on concussions, but from what I know, the whole process, [00:09:00] I guess counseling and management piece is huge. It’s huge maybe as important or more important than the actual assessment, right? Being able to balance those is crucial.

Dr. Scott: Yeah. I think in the work that I’ve done, I’ve done concussion work I think in almost all settings. I’ve been present on the sidelines for NCAA DII Football games, soccer games,acute concussion clinics, all the way to seeing patients who’ve had a history of a concussion from decades ago. And I think all of those time points for patients, it’s really being able to recognize symptoms, but also all of the factors that can be driving those symptoms as well. Those are really important [00:10:00] to understand that symptoms present themselves for a variety of reasons. And so, being able to recognize that is a really important piece of assessment within the context of concussion.

Dr. Sharp: Absolutely. I’m so excited to get into this. I already have a ton of questions.

Dr. Scott: I’m excited too. Being able to talk about concussions is… When you’re passionate about something, it’s exciting to be able to talk about it.

Dr. Sharp: Absolutely. Let’s lay some groundwork just right off the bat. So talk me through the terms, concussion versus TBI versus brain injury, and any other terms that feel important to really nail down for our discussion.

Dr. Scott: TBI or traumatic brain injury is the umbrella under which [00:11:00] we see different categories of severity of the injury. Starting on the mild, so a mild TBI is really synonymous with what we call a concussion. If it’s helpful, I can get into the injury parameters around how we category is that is.

Dr. Sharp: Yeah, I think that would be helpful if you could lay that out.

Dr. Scott: When we talk about a mild TBI or concussion, we’re talking about an injury that results from a force to the head where we don’t see any kind of abnormalities or changes on neuroimaging like CT or MRI. Typically, we see a brief loss of consciousness if any. And when I say brief, I mean most commonly we hear people say maybe they went black or were unconscious for two seconds anywhere up to about [00:12:00] 30 minutes.

And then post-traumatic amnesia is another one of those injury parameters that we consider. So that means a loss of memory for events that occurred after the injury. We measure that by asking patients what’s the first thing they remember after the injury. And then we also look at retrograde amnesia. So the loss of memory for things that happen before the injury.

Typically, when we’re talking about categorizing TBI, specifically that mild categorization, we’re talking about a PTA or loss of memory after the injury for less than a day or less than 24 hours. I would say from clinical experience and what we know from the research when we see concussion patients, it’s usually, if [00:13:00] they talk about PTA, it’s a duration of a few minutes to maybe a few hours, much more rare to see a PTA that extends to upwards of that 24 hours period of time.

And then when we’re categorizing TBI, the lapse injury parameter we consider is GCS- the Glasgow Coma Scale, which is a scale that looks at essentially a patient’s functioning directly after that injury. So taking into consideration things like eye movement response, verbal responses. So is the patient-oriented motor response. Are they able to follow simple commands. And for a mild TBI, that’s typically a GCS of 13 to 15. 

Dr. Sharp: Do you find that a lot of folks [00:14:00] have that number available? I’m thinking outpatient private practice or a school setting, like any non-hospital setting, parents usually have no idea what I’m talking about when I ask about that.

Dr. Scott: That’s a great question because that’s the number that we see if somebody is evaluated in the emergency room typically and what we recommend right now is that acutely that typically the emergency room is not necessary for a concussion. And in some ways, going to the emergency room following the concussion might contribute to some prolonging of symptoms, just because of so much activity in the ER when really a patient is needing rest primarily again, in that acute phase after an injury.

To [00:15:00] give a simple answer to your question, I think most patients who are presenting with a concussion history probably do not have that specific GCS number. And they may have vague responses to questions about, what’s the last thing you remember? What’s the first thing you remembered after the injury, given that there’s a lot going on if maybe the injury happened and there aren’t good markers during the day of something that might’ve been occurring. And the work I’ve done in sports concussion, and sometimes the sporting event itself is helpful to anchor those events, but not all of these injuries are occurring in contexts like that too.

Dr. Sharp: Sure. So I noticed that you didn’t mention nausea. There was one other that I commonly hear about being associated with concussion. So I just wanted to ask about that if that’s if that is truly a [00:16:00] factor we need to be concerned about when we’re…?

Dr. Scott: Nausea is certainly one of the common symptoms that we hear about following a concussion. I would say it’s pretty common acutely to hear people say that they felt nauseous, less common to hear people that they actually had an episode of MS or were throwing up. I will say, I think it’s important to note that repeated vomiting after hits of the head is an instance where we certainly recommend a visit to the emergency room. 

Dr. Sharp: So, we were talking about the mild categorization, what would need to be happening to jump up to moderate and then a severe concussion.

Dr. Scott: For both moderate and severe TBI, that’s when we typically will see findings on CT or MRI, so bleeding [00:17:00] edema or swelling, things like that on neuroimaging study. We typically then see longer periods of time of loss of consciousness. So in the moderate range, we’ll see periods of loss of consciousness of 30 minutes up to one day. For severe categorization, it’s loss of consciousness beyond that 24-hour mark. And then with regard to PTA, it will be loss of memory following the injury for one day to one week in that moderate category. And then beyond a week for patients who fall in the severe category.

We know though that patients don’t always fit into neat categories. I’ve seen lots of patients in acute settings or acute inpatient rehab settings where what we end up categorizing their injuries moderate to severe based on variability. So maybe [00:18:00] they had positive neuroimaging and a PTA of a day, but a loss of … Well, that wouldn’t quite make sense. I was about to say a loss of consciousness is longer, but so maybe flip those. So, they had a period of time that falls in one or both categories that doesn’t neatly really fit under the label that we’re providing.

I think what’s important to keep in mind is that those moderate and severe injuries do come with evidence on neuroimaging. So CT or MRI, which we do not see when we’re talking about concussion.

Dr. Sharp: Sure. I appreciate you making that distinction. It seems rare at least again, an outpatient private practice where we actually see moderate to severe concussions, at least in my experience. I get a lot of parents reporting [00:19:00] a skull fracture. So I’m just curious, that’s an offhand question, but how that fits in? I assume it’s possible to fracture your skull but not necessarily generate anything that’s going to show up on the imaging of soft tissue.

Dr. Scott: Yeah. It’s certainly possible. There are a lot of people out there trying to look into what force is needed to sustain the severity of these injuries. And so, certainly, I would say as possible that you could sustain a force that would result in fracture, but not necessarily bleeding of the brain or other kinds of intracranial injuries.

I think this is maybe a moment to say what really can be helpful in assessment where we’re looking at concussion and brain injury [00:20:00] is a really good review of medical records, which I know is in a very ideal situation available, and in less ideal situations, not always available. For instance, you’ll see patients who will report things like, well, I had bruising and it’s helpful to be able to look into the medical record to see if that’s extracranial bruising or was that really an intracranial injury, if that makes sense?

Dr. Sharp: It certainly does. And I think you’re right. That’s probably a nice segue just to talk about the assessment component. Starting at the beginning, what should we even be asking about? What are those questions that we need to ask? I’m just going with pediatrics here because I feel like that’s a more limited area to tackle. It limits our scope. I [00:21:00] don’t know that it’s more limited than adults, but it limits our scope.

Dr. Scott: For sure. You bring up a good point and we could talk about concussions for hours on end. If we’re talking about assessment in the less acute phase, so just a hypothetical situation, you have a patient who presents for assessment and they report a history of concussion 6 to 9 months ago.

I think again, really just important to gather as much information as possible about what that injury looked like. So information like, do they remember if they had any loss of consciousness? Do they feel like their memory around that injury was fuzzy at all or does it all seem pretty clear? And then what their symptoms looked like immediately after the injury [00:22:00] is really helpful.

There is evidence to suggest that the severity of those acute and subacute symptoms on a concussion are strongly related to prognosis following concussion. So, it’s just helpful to understand what their symptom history looked like after the injury. And then I think trying to gather, are there other available data points? Is it possible to get medical records if they did happen to present to the emergency room can be really helpful as well?

Dr. Sharp: Right. So just to lay it out and be super concrete when we’re, again, I’ll just think about parents in the office. So we’re asking about symptoms within that first. 24 hours, a week, what’s the guideline in terms of what we ask them?

Dr. Scott: I think it’s really important in that first [00:23:00] 24 to 48 hours to understand what symptoms looked like and how those were managed. So for instance, I hear a lot of parents who will tell me, well, I woke them up every 2 to 3 hours because that’s what you’re supposed to do, right? And actually, we know that that’s not what we’re supposed to do anymore. That’s an artifact of times past, but it’s helpful to know. For a child, if their sleep was pretty heavily disrupted like that most first 24 to 48 hours, it might make sense that they have a little bit or they’re experiencing prolonged symptoms.

And then, really understanding or getting a good picture of what the symptom resolution is, if we’re talking about symptoms that have resolved by the point that you’re seeing them, what that looked like, and if those symptoms haven’t resolved, what that trajectory has looked like.

We know of concussion [00:24:00] that symptoms should be worst first. There really isn’t a good reason to expect that after that acute phase, those first 24 to 48 hours that symptoms are going to evolve to be worse. And so, if you have somebody in front of you, a pediatric patient or an adult who is reporting that those symptoms worsened after that acute period, that’s a really good important data point to keep in mind because it’s not consistent with what we know about the neurologic trajectory of this type of injury.

Dr. Sharp: That’s such a good point. I think a lot of us have had that experience where… I mean, you’re describing that, of all the people who report a concussion, this is probably 90% of those cases, where it was like 6 to 12 months ago, maybe two years and they’re wondering if the memory problems [00:25:00] and the attention issues and whatever are attributable to the concussion. Parents swear that things got worse in the months following the concussion, they started tanking at school.

So not to say those things didn’t happen, but it seems safe to say that the research would suggest that it’s not due to the concussion directly or the injury that may have happened.

Dr. Scott: Yeah. I think this is a point where it’s really helpful to bring out those skills around empathy because just as I think you just said, it’s not that those things didn’t happen or aren’t occurring, but that they’re very, very unlikely to be related to any true neurologic change in the brain after a concussion, but there are lots of things that can happen after a concussion that certainly are influential to thinking abilities.

And so, I think in a good assessment, it’s [00:26:00] then gathering the data that helps us to understand what else might be happening that’s causing any difficulties or reported subjective concerns with an individual’s thinking.

Dr. Sharp: Yeah. Before we move to, I would say, beyond that initial assessment phase, are there other things that we should be asking about or tracking with parents just in terms of that acute injury period and then what happened afterward?

Dr. Scott: Yeah. I always want to know who they saw. Oftentimes, they may not have gone to the emergency department, but maybe they went to see their pediatrician or they had some established relationship with a chiropractor or physical therapist or whatever the case may be. It’s really helpful to understand.[00:27:00]

I think another really important data point is what other education they’ve received around concussion particularly from other providers, but also, have they been doing a lot of Googling and trying to figure out in that way what’s going on with their kiddo or for themselves? Again, not to sound like a broken record, but it is very important, I think to know what kind of education they’ve had just because we know how important that education is to prognosis and recovery trajectories.

And then I want to know what they’ve been doing. So how have they been managing symptoms if they are still reporting symptoms? I would say with a fair degree of frequency, we see [00:28:00] children that 9 months to 1 year mark, who did miss a significant amount of school and that may have been recommended to them by their pediatrician or another provider. And so, understanding, were their attempts to go back to school, what did those look like? And then what other activities they’ve been involved in. Were they taken out of sports? Were they taken out of other kinds of choir, do they play instruments, things like that too, just other hobbies. What they’ve been doing or haven’t been doing is really, really important to understand too.

Dr. Sharp: Yeah. Can you speak to how much that limiting of activity is necessary because I know people are asking are thinking like, should kids be out of school? Sports feels a little different because of the risk of re-injury, but [00:29:00] I’m curious about these different activities and whether we should be limiting and in mild cases.

Dr. Scott: We’re talking about concussion. So that mild TBI. We used to tell people to go sit in a dark room and sleep for a month and let us know how they feel. And when I say we used to, I mean years ago. We’ve known for a while that that’s not useful.

But there’s a lot of really interesting research coming out about graded return to activity pretty soon after a concussion. For instance, John Leddy’s group out in Buffalo has been doing a lot of research around graded return to physical exercise and how that does seem to be useful and beneficial to prognosis and timeline soloing recovery. The research on…

[00:30:00] Dr. Sharp: And when you say, pretty soon.

Dr. Scott: Yeah, thank you for it. Yeah. So what does pretty soon mean? So we know that probably for the first 48 to 72 hours, a lot of really good rest. So that’s why we don’t recommend any longer waking up kids. If they’ve had a hit to their head every few hours, they really should get some good sleep. And again, for those first 2 to 3days, a lot of limiting of physical activity, mental activity. But after that time point, it does seem like, again, graded return to some activity is beneficial.

The research and empirical evidence on cognitive activity is, and that’s a really newer area of research. It’s a little bit easier to get people on a treadmill and say like, okay, how does this affect your symptoms? It’s a little bit harder to figure out how do we grade cognitive [00:31:00] activity? And so, I think similar though to physical activity, really the kind of current recommendations that we’re seeing reflect the similar time period that maybe 2 to 3 days of time away from school can be beneficial, but beyond that point, it’s really just time to start getting back to some graded activity.

And so, in acute concussion clinic where I will see patients who have had a concussion within the last week, we’ll talk about, let’s try to get back to school for a half-day on your first day and see how that goes, see how long you can tolerate that. And then if you have an increase in symptoms, we want to know when that happens, what activities you’ve been doing in school that seemed to [00:32:00] reflect or cause that increase in symptoms. But we want you to keep going back to school. So Again, grading that return to activity.

There does not seem to be any evidence to support removing kids from school for longer again, than a few days to potentially a week depending on the severity of those acute symptoms, but really beyond that point. So sometimes I’ll see kids who’ve been out of school for 1 to 2 months. And at that point, how do you get kids back to school?

Dr. Sharp: Great question. I’ve had those cases for sure. Also, I want to table that just for a second because I think that totally plays into that education piece and expectation management and our role in that. I do want to ask though, [00:33:00] and this is maybe going back to maybe a more, I don’t know, during the more acute period following the injury, but when is testing actually warranted in the case of a concussion? Let’s just say that’s the only “concern.” When should we actually be testing a kid?

Dr. Scott: That’s a great question. I don’t think that a standard comprehensive cognitive battery is necessary even most of the time. I would say that’s a more rare occurrence where that eventually will be needed in those acute phases. So when I see the kids in an acute concussion clinic and they’ve recently had an injury, we’re really not typically doing a whole lot of cognitive assessment.

[00:34:00] I have in the past used IMPACT because it is the piece of the overall puzzle of understanding the recovery trajectory, but I would not say that it is something that is always necessary to have. Sometimes, I’ll see questions from people who will say, well, they’ve had a concussion, so I have to do IMPACT, right? I would not say that that’s a necessity, but it is one tool that we have in a really large toolbag to understand or toolkit, I should say, to understand when people are fully recovered. But I would not say that routinely, again, a long battery of cognitive assessment is this something that is needed.

Dr. Sharp: Yeah. So then the follow-up question to that I suppose, is, in these cases that I tend to see a lot [00:35:00] nonsphere, what we would call mild cases where kids are presenting several months down the road, and parents. It may not be the main referral question, but it’s a subtext, like, oh, and we want to know if that head injury maybe has anything to do with what we’re seeing right now. A question I guess right off the bat is, can our assessment even answer that question?

Dr. Scott: I think an assessment can. I think that’s a case where a case can be made to do a good, comprehensive cognitive assessment where you are looking at different cognitive domains. And I think really making sure to emphasize and include areas of thinking that have been shown in the empirical research to have some sensitivity to brain injury. So [00:36:00] things like processing speed, basic attention, and then including executive functioning measures and some verbal memory measures as well.

But again, that’s in the context of a really good comprehensive evaluation that also looks at mood and takes into consideration things like sleep. Are there other symptoms? I’m thinking of things like headaches or other kinds of physical symptoms that can contribute to overall cognitive efficiency. And I think with a good assessment like that and using those good tools or data points, you can get to see the whole picture and put together that puzzle of everything that is contributing to a kid’s presentation [00:37:00] when they’re in front of you. Does that make sense?

Dr. Sharp: It does. Yeah, certainly. I think it just speaks to how, I don’t know how much longer we can delay this, but I really like that whole post-injury scenario: what they were told, how they were treated and how providers interacted with them in school and so forth, all those things. And I hope… Go ahead.

Dr. Scott: I’m sorry to interrupt. The one, I think additional piece that as you were talking that I did not mention was, this is a case where I think having performance validity testing included in your battery is really important. And that is not because I’m here to suggest that if you have something in front of you suggesting that their concussion is still impacting them a year later, that that’s all in their head or anything like that, [00:38:00] or that every patient who presents in that way is going to display poor effort. I certainly don’t think that that’s the case, but I think that those measures, so having some performance validity tests that are embedded, but also standalone can be helpful to understand if there are any non-neurologic factors present in their presentation.

Dr. Sharp: Sure. Let me ask you just briefly about your preferred measures. Maybe we could work backward and go performance validity testing, verbal memory, executive functioning, processing speed. 

Dr. Scott: Particularly in the case of concussion, I will use TOMM and, or one of Green’s measures- MSVT or a Word Memory Test [00:39:00] more frequently MSVT but Word Memory Test as well can be useful. I think you just mentioned executive functioning and we’re in verbal memory. So trail making whether the standard Trail Making A&B, or if you have access to D-KEFS Trail Making could be helpful too.

With verbal memory, I use the CVLT probably 90% of the time when I’m wanting to look at verbal memory. The other thing that CVLT gives you is that embedded measure of effort and performance validity, which I think is again, trying to gather as many points of data related to that can be really useful.

I think it’s important to again, provide that empathy and understand what the patient is [00:40:00] presenting with and what that’s in the context of. For instance, I’ll see plenty of patients who are still reporting concussion symptoms a year later. And in that year, they really have not had good sleep. And so, you can make the argument, certainly, their sleep got disturbed after they have the concussion and they’ve gone now a year without a good quality of sleep. And so, let’s figure out how we’re going to get you sleeping well again. And that will likely translate into some good resolution of other symptoms.

I think one thing that we have not really touched on yet is how premorbid and comorbid mood symptoms really play a role in presentations following concussion. We’ve known for a long time that the history of depression, anxiety whether that was significant at the time of the [00:41:00] concussion or if there’s really just a history thereof mood symptoms that, that certainly plays a role in prognosis and recovery trajectory after a concussion.

I think one of the things I talk most frequently with patients about is the overlap of symptoms between, let’s say depression and concussion, how strongly that overlap is. If you had a Venn diagram there are almost pretty much two circles on top of each other in a lot of ways. I will say I have had the experience quite often of sitting with a patient and explaining the overlap of those symptoms and you see a little bit of relief kind of like a weight off of their shoulders when they begin to understand [00:42:00] just how closely those symptoms overlap.

Dr. Sharp: Yeah. I could see that. Well, I’ve seen it go both ways, honestly. There are some folks who really seem to cling to the concussion as a driver, and then there are some folks who seem very relieved. It’s not a permanent change that they had previously thought it was.

What you’re saying though really speaks to, I think that maybe the clinical interview and trying to gather that pre and post data that if someone is reporting a concussion and symptoms that have continued after whatever context, that’s a trigger to immediately go into asking about what was this like beforehand, how much did things really change or is this familiar from earlier in life, those sorts of questions [00:43:00] especially around like ADHD comes to mind immediately, and like you said, depression, anxiety sort of thing. 

Dr. Scott: I think in all of the conference talks that I’ve seen over the years related to concussion, the one clinical Pearl that has always stuck out the most to me was I think actually from Micky Collins at UPMC. He said something like, talking about all the factors related to concussion recovery and the quote that always sticks in my mind is “concussion plays dirty.”

And so, if you have a history of symptoms or difficulties with things that also look like concussion symptoms, those are often things that can get exacerbated or sometimes present as more [00:44:00] problematic after you’ve had a concussion. You brought up ADHD. That’s certainly something that we can see some exacerbation of as well as just some prolonging of symptoms as well. And it’s likely related to, again, there’s just such a strong overlap there with what we know of concussion symptoms.

Dr. Sharp: Right. Could I back way up? You mentioned the term post-concussion syndrome. Can you just define that real quick- what that even means, and what we were looking for over there?

Dr. Scott: Yeah. Post-concussion syndrome is really a label that we use when individuals are experiencing concussion symptoms one month after their injury or longer. There’s a lot of discussions around whether that label is useful. It’s again, a syndrome [00:45:00] by definition. And I think there’s a good argument to be made that the focus being more so on symptoms and how can we treat each symptom appropriately, I think can be more useful for patients.

But I think we probably all have had the experience of seeing a person who was seen acutely in the ER and they’re diagnosed immediately with post-concussion syndrome. And so, I think just being aware of the flimsy accuracy of that diagnosis sometimes if you see it in medical records or things like that.

Dr. Sharp: I see. It seems like wrapped up even in that definition, I guess. So symptoms more than one month after an injury is the idea that those symptoms theoretically shouldn’t be there. Is that [00:46:00] a fair characterization? I mean, if we’re saying that symptoms typically resolve from a mild concussion pretty quickly after the injury?

Dr. Scott: Yeah. That’s a good question point. I think where it is useful for consideration is that patients who are presenting with symptoms beyond that one month/several weeks point, there’s probably something that’s driving the experience of symptoms that deserves to be addressed, if that makes sense.

There’s a wide variety of possibilities of what that could be. And again, that’s why I think a good assessment, particularly with somebody who specializes in concussion at that point can [00:47:00] be really useful. It could be something as simple as, yeah, you had a concussion, but you also had an injury to the musculature in your neck and we need to get you to see a PT who’s going to help you resolve those headaches.

It might be something more complex like, for the last month, you’ve had some worsening of your mood symptoms and we’ve taken you out of a lot of activity and we need to help work through the process of getting you back to regular activity and also addressing those mood concerns. I think there’s obviously a wide spectrum of what that could look like.

Dr. Sharp: Certainly, there’s a continuum and cases are all different, right? So when you run into folks maybe in that period, a few months after they’re still struggling, and [00:48:00] we’ll take kids again, what are some of those things or ways that you might approach them to start to introduce the idea that they could possibly return to activity or to school or more of a normal life again?

Dr. Scott: I think it’s having a really good conversation again, around what concussion is, what we know of typical recovery, and then what we know those factors are that can influence recovery. And then, I think it’s moving into making some really concrete goals about a return to activity and what that again, concretely looks like. It’s easy to say, yes, we’re going to get you back to school, but [00:49:00] what does that actually mean, and how are we going to take those steps to get back there?

And really making sure that we’re putting in the effort to set kids up for success with that return to school as well? If I see a kid who’s been out of school for a month, I don’t want to just plop them right back into 110% activity like a lot of kids are functioning at a baseline. And so, talking through what they’ve been missing, maybe where we can prioritize things.

And then, are there structures that we can lean on within their school system to really help to support that return? Obviously, there can be some variability in how schools respond to that, but I think it’s important to try to work as closely with the school as [00:50:00] possible particularly if the kid’s been out of school for a while.

And then setting goals that seem a little bit, I mean, lots of kids find school fun, but some kids don’t. So are there other things that we can get them to really engage with? Maybe they are a kid who played soccer six nights a week and they haven’t been able to do that. So, how are we going to set goals to get them to get back to that level of activity?

And then also making sure that where the restrictions or limitations that maybe are in place, are they sound? I think for lots of good reasons, what parents want to do immediately is take away any kind of screen time or cell phones, limit those kinds of things. I don’t think we [00:51:00] always need to take screen time away 100% in the presence of concussion symptoms. And so, how do we set good boundaries around that but still allow kids to have what their social outlook is and connection in that way?

Dr. Sharp: That’s important. I hear that a lot. After a concussion, parents were told, no screen time for a month, go into the brain rest, and don’t access your cell.

Dr. Scott: The reality is that screen time is how a lot of kids interact socially. It is for better or for worse really built into the social structure currently. And so, you can certainly see how if you take a kid away from sports since school and being able to talk with their friends through whatever means they have on their cell phone or [00:52:00] things like that, that can lead to some real complications related to mood and then how that drives concussion symptoms as well.

So not to suggest there shouldn’t be any restriction around that, but being mindful of, is this something that’s actually causing any kind of worsening of symptoms, or is it manageable to allow them maybe 10 minutes of screen time or 20 minutes of watching television, things like that and see how that impacts symptoms.

Dr. Sharp: Right. What else feels important at least in that post-concussion treatment, education realm for us to cover before we wrap up?

Dr. Scott:  I think we’ve touched on sleep a bit, but supporting, I think kids [00:53:00] getting good quality sleep across the board is important, but particularly in the context of concussion, making sure they’re still getting adequate nutrition and hydration are really important.

And those may seem like really common sense things, but sometimes, and the chaos that can ensue after concussion and whatever else has come from that, those things can get lost sometimes. So making sure to understand how kids are functioning I think in those realms too.

And then, are they getting any kind of physical activity? We know that that’s important to support mood functioning, cognitive functioning, just in general. But I think the research is really telling us that that graded return to some level of physical activity fairly early on is really important to helping people to [00:54:00] recover.

Dr. Sharp: Sure. Yeah, just more evidence that seems like exercise is the closest we get to a cure for anything.

Dr. Scott: Exercise is medicine, right?

Dr. Sharp: Exercise is great. Yes. Now, are there any… oh, go ahead.

Dr. Scott: I’m just going to bring up return to learn as an area that I think we’re only really beginning to understand if there should be specific protocol around that. Obviously, there’s been a lot of talk and activity around return to play. I think we’ve been touching on there. I’ve said several times in different ways that I think getting kids back to school is really important. And I think for kids in structured school environment that re return to learn process can look[00:55:00] varied just because we don’t necessarily have a strict protocol around that at this point.

Dr. Sharp: And is that just because the research hasn’t really caught up yet to define a protocol or are there a bunch of different protocols or where are we at with that?

Dr. Scott: I would say, and this is I think based more so on experience in high school and college settings, but I think there’s a variety of protocols that all look fairly similar. I think the research is a little bit behind where we are with again, return to play and return to sport. But it is in some ways a more difficult phenomenon to measure. I think any one kid’s school day looks very different from any other kid’s school day. So how do we [00:56:00] measure that appropriately?

Dr. Sharp: So, it sounds like we feel like a graded return is probably helpful and relatively quickly after the injury, but the actual schedule and the nuances of it are what we’re still figuring that out.

Dr. Scott: Yeah. And we’re hoping to. I think that’s one of the things our group here at Michigan would really like to explore further. We’re hoping to do some of that work with our school partners here in the area which I think will be of good benefit to our kids.

Dr. Sharp: Yeah. It certainly seems like it. Oh my gosh. So I’m going to ask a question or close with a question maybe that I should’ve asked in the very beginning. Are there any myths around concussions or concussion treatment that we haven’t addressed yet that you want to put [00:57:00] out there for us as clinicians?

Dr. Scott: Lots of them. I think we’ve touched on a lot of them. I’m trying to think through where our conversation has gone. I think the biggest one that really has the most impact on recovery is just, we don’t need you to sleep in a dark room for a month after injury. And that’s probably actually going to hurt you in some ways.

And then getting back to normal activities should be a very realistic goal that I think is emphasized with patients that these are injuries that people recover from. I know there’s a lot in the media around the long-term effect of concussions, and I think it’s [00:58:00] important to note that what we’re talking about here really your uncomplicated concussion outside of the context of multiple concussion history, things like that.

And I think in those cases, it’s certainly really important to have people evaluated by concussion specialists who really understand what the research tells us about that. But I think in almost every especially concussion clinic visit that I have, the thing that I say is, this is an injury you’re going to get better from. And it might take a little bit longer than we’d like, but we’re going to get you back to where you were functioning before this happened.

Dr. Sharp: I like that. Okay. I’m going to throw another question in there since you reminded me. We didn’t touch at all on multiple [00:59:00] concussions. And the last time I dove into the research just briefly, it seemed like we don’t know a lot about what happens with multiple mild concussions in kids. Has that changed at all? Where are we at?

Dr. Scott: I would say that’s a really good summary I think of where we are still. What we know with some good degree of certainty is that when we talk about kids and adults who have sustained concussions, some more than three concussions, we see that 4, 5, 6, what we know is that the duration of symptoms seems to last a bit longer with subsequent injuries. I would not say in every single case that that’s what we see, but I think that the [01:00:00] research supports that.

I think it’s just important to know that the research, I think is still evolving in that area and to be transparent with kids and their parents about that, that this is what we know. And there’s still an area that we’re trying to get a better understanding of. And I think parents can appreciate and kids can appreciate that we may not have all of the answers, but that we’re well versed on where the research is currently. 

Dr. Sharp: That makes sense. Great. Are there, just to close, any resources that you might point us toward as clinicians that can help understand this whole realm [01:01:00] research or books, or really anything that can help in

Dr. Scott: There are lots of good websites out there. Some of the institutions where a lot of this good research is happening like the University of Pittsburgh, which is where Micky Collins and his group are at. The Medical College of Wisconsin, which is where Michael McCray and his group are. They do a lot of great research specifically related to some of what we’ve been talking about related to return to activity. I think both groups have put out some really good available resources on their websites and things like that.

Dr. McCray, certainly, I believe is that the AACN [01:02:00] library of books, he has great really digestible primer on mild TBI and recovery that I think if this is something that you do see with some frequency in your practice, it can be really helpful to get a good grip on the state of the research as well.

Dr. Sharp: Great. I’ll list all of those in the show notes. If you happen to think of others, send them my direction.

Dr. Scott: I can do that for sure.

Dr. Sharp: Well, Katie, I will say thank you again for all your time and expertise to talk through admittedly very nuanced and complicated topics. To address all of these pieces in an hour is tough, but I think this is a great overview and people will take [01:03:00] a lot away from it. So thank you so much for being here.

Dr. Scott: Thank you.

Dr. Sharp: Okay. Thanks a lot for listening to this conversation with Dr. Katie Scott as we navigated through a multi-layered complex realm of neuropsychology. There’s a lot more to be said about this, obviously, but this is a topic that has not come up on the podcast before somehow. So I wanted to do a nice introduction and overview. The hope is that we’ll dive more into specific areas related to concussion and TBI as time goes on.

Thanks as always for listening. I have not rated the podcast, I’d love it if you just did me a huge favor and jumped into iTunes or wherever you might listen and take a quick second to rate the podcast. That helps spread the word about the podcast and give it a little more [01:04:00] exposure so that more people can find it, which is a good thing. And if you have any temptation to rate it less than five stars, please reach out to me directly. I would love to hear suggestions for improvement, different ideas. The idea is that it’s helpful and if it is not helpful for you, then please let me know jeremy@thetestingpsychologist.com.

All right y’all, I hope that your summers are going well. And if nothing else, you’re getting a little bit of a reprieve from some of the demands of day-to-day life. At least for me, the summer tends to be a little more relaxing just inherently. And there’s that leftover from going to school for so long. Getting a break in the summer, even if I’m working just as hard, it feels a little bit like a break. Even though we have a crazy situation here in our country as the virus [01:05:00] continues to ramp up in some areas, I hope you’re at least getting a little bit of relaxation and able to step away from the daily grind.

Okay, y’all. I’ll be back with you on Thursday with another business episode coincidentally about stepping away from the daily grind and designing a think week for yourself to reflect and plan for your business.

All right. I hope to catch you next time. Take care in the meantime.

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