Category: Transcripts

[00:00:00] Dr. Sharp: Hey y’all, this is Dr. Jeremy Sharp, and this is The Testing Psychologist podcast, episode 39. Hey, before our episode gets started today, I have two things to share with you. One is that I am so excited to have Practice Solutions on board for one last month of sponsoring here before the year ends.

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The other thing I wanted to share with you is that today I have a fantastic interview with Dr. Cathy Lord, co-author of the ADOS and ADI-R to share with you. It was a great interview, but we had some tech issues. So the audio is a little less clear than usual, but I think you will still be able to get plenty of good information from this interview. With that said, enjoy.

Hey everybody. Welcome to another episode of The Testing Psychologist podcast. Today, I am absolutely [00:02:00] thrilled to be talking with Dr. Cathy Lord. You have likely heard Cathy’s name over the years. She’s a co-author for both the ADI-R and the ADOS, which have come to become some of the gold standards for autism spectrum assessment in our field.

So we’ll talk a lot about that and a number of other topics here as we go along with Cathy. Let me give a brief introduction and then we can jump into our conversation.

Dr. Cathy Lord is Professor of Psychology and Psychiatry and Founding Director of the Center for Autism and the Developing Brain, which is a collaboration between New York Presbyterian Hospital, Weill Cornell Medicine, Columbia University College of Physicians and Surgeons, and in New York Collaborates for Autism. She is a licensed clinical psychologist with obvious specialties in diagnosis and intervention in autism spectrum disorders.

[00:03:00] Like I said, she’s been renowned for her longitudinal work with kids with autism and in her role in developing these diagnostic measures that so many of us have used over the years and continue to use. She got her degrees at UCLA and Harvard. She did her internship at the TEACCH program at the University of North Carolina.

Cathy, I am honored to have you on the podcast. Welcome.

Dr. Cathy: It’s nice to be here.

Dr. Sharp: Thank you so much for taking the time to be here to chat with us. I think like myself, a lot of other folks will be excited to hear this. You’ve been around for a while and you’ve done some important things here in our field. So I am very excited to jump into it and start talking about your work with autism spectrum disorders and diagnostic measures.

Dr. Cathy: Great.

Dr. Sharp: It’s normal for us here on the podcast to check [00:04:00] in here at the beginning. I would love to hear about your training, but really, what you’re currently doing. It sounds like you’re involved with a lot of different agencies and a number of different projects. Can you catch me up on what you’re doing clinically and research-wise right now?

Dr. Cathy: Right now I am the Director of a clinic that sees people with autism from tiny babies all the way up to adults. We provide assessments, intervention and consultation. So we do a little bit of everything and not enough of anything as outpatients.

And then we do clinical research. So we are on the fringes of biological research in that we help the basic scientists describe their patients, but mostly what we do is our clinical things. Mostly our focus right now is on trying to improve the [00:05:00] measures we’ve done.

For example, we’re trying to come up with a better ADI, the parent interview. We’re trying to make it modular, so shorter. We’re trying to make it so that you can do it on an iPad. It’s still an interview, but you can enter it on an iPad. You can pick the kinds of questions you want to ask, you can perhaps ask them over and over again to be follow-up questions but it won’t be quite so onerous as the whole long thing that exists currently.

Our biggest focus is something called the BOSCC, which stands for Brief Observation of Social Communication Behavior, which is a 12-minute videotape observation that can be done by somebody pretty untrained, like a post-baccalaureate research assistant or also a parent interacting with a child. The idea is that you video it with somebody with minimal instructions. And [00:06:00] then you can code this.

Somebody with a minimal amount of training codes the child’s social behavior. The codes are laid out so that they’re much more sensitive to change than an ADOS. They’re more focused on frequency and not diagnostic. This is not a mini ADOS, this is looking for change.

We’re hoping that we’ll be able to get a measure that will be sensitive to things like a child’s change after say, three to six months of early intervention or three to six months of participation in a social group. That’s a big focus of what we’re doing.

We’ve finished the version for minimally verbal kids and are working away on a version for verbal kids. Right now, that’s primarily available for researchers, but we hope we can make it available to clinicians too, and maybe make available a service that would actually code these things so you could just [00:07:00] upload it and have somebody for a minimal cost, not super expensive, give you your codes back so that you can be blinded, because as clinicians, we are biased, we know we are, and so are parents seeing changes because partly we’re hoping to see them, and we’re just so invested, so they give you feedback. So that’s something we’re doing.

We’re also interested in trying to pick apart what changes and why in different interventions. With Sophie Kim, who is one of my colleagues, she just got a big grant to try to use this instrument to look at what changed in early intervention and why, and how that relates to parents’ behaviors. So that’s another project.

And then the last big thing we’re doing is continuing our longitudinal study which has been following about [00:08:00] 200 young people whom we met when they were two years of age, referred for possible autism, who are now in their mid-20s.

Obviously, we have not at all determined these young people’s lives. We’re just watching them, following them, hearing from their families and from them how their lives have gone. It’s been a wonderful way to get a natural history of what happens in the lives of these 200 young individuals and watch them grow up. So that’s the main way I spend my time now.

Dr. Sharp: Okay. It sounds like you’ve got a lot going on. You’re still very much on the front lines doing the research and developing these things.

Dr. Cathy: We are. There’s a lot more to do and we could keep doing. We could make things better. There’s a million ways we could make what we’ve done better. So it never stops.

[00:09:00] Dr. Sharp: Always. I think that’s familiar for anybody in research. You started off with some pretty hot topics right off the bat. When I hear you talk about putting the ADI-R on an iPad and shortening it, the light bulb goes off. I wanted to shout for joy. I feel like I have to ask, is that close at all to be able to roll that out?

Dr. Cathy: Two years, I think.

Dr. Sharp: Oh, okay.

Dr. Cathy: Sorry. It won’t be handing the parent the iPad. It’ll still be an interview because we feel like it’s important that someone asks the questions, but you’ll be able to rule the answers and code it on the iPad so the codes will come right back to you.

We still feel like we need the human clinician. I’m a real believer in human clinician. [00:10:00] It’ll be shorter and more to the point. There’ll be modules, so you’ll be, am I interested in a diagnosis? Do I already have a developmental history so I don’t need to spend a lot of time talking about toilet training? Am I worried about comorbidity, so I need to really talk about behavior problems or is that something someone else is going to do or I’ll do later?

And then the other thing is, is this a follow-up visit? Do I want to go through and talk about things that I’ve talked about before so I’m just focusing on current? And then being able to compare that quickly to what I got before.

We’re hoping that we can do all this with the help of an iPad or putting it right on your Mac or something so that there’s not all the craziness of filling out forms and then doing currents and evers and sorting all that out.

So we [00:11:00] hope quicker, more user-friendly, and more focused.

Dr. Sharp: I think that’s great. It seems like that’s the direction that we’re moving with assessment in general. So that’s great to hear that y’all are trying to move in that direction as well.

I would say for a lot of folks, anecdotally, the ADI-R and the length involved in the minutiae nuances of scoring are sometimes hurdles to administering the whole thing.

Dr. Cathy: Yeah. We know.

Dr. Sharp: I’m sure. You’ve lived it. Gosh, I just had like five thoughts at once from your little introduction, but I’m going to try to stay on script a little bit here. For anybody who doesn’t know, we’re casually throwing out ADOS and ADI-R and that kind of thing. Could you generally talk about what those instruments are [00:12:00] and what they’re trying to assess for anybody who might not know?

Dr. Cathy: Sure. The idea of the ADOS is to use the powers of a human clinician or to observe and interact with a person with autism in order to make a diagnosis, and to try to standardize that in a way that two trained, experienced clinicians who did this twice within a reasonable period of time would come up with the same diagnosis and the same scores so that we’re both having the benefit of both skilled and a human being, but also standards so that if I see scores, I know what they mean. I know [00:13:00] that it has a meaning for me, that it is the same for me and for you and for somebody who is in Sweden or Korea or Thailand or Australia.

And that has to be individualized to some degree because all people with autism are different. Also the context in which we behave. Part of the difficulty with autism is that a person may not be responsive to context. So we’re counting on the clinician to be aware of that.

Essentially, what the ADOS is, is a series of tasks that vary according to the age and the language level of an individual. There were different modules that you select from depending on age and language level. There’s about 10 tasks that you do over the course of about 45 minutes.

You have to learn to do [00:14:00] this and you have to practice. You present these tasks to a person that you think might have autism. As you present them, in a particular way, you are watching how the person with autism responds to you and also how they initiate with the materials. The materials are deliberately selected to provoke or evoke certain kinds of behaviors.

And then when you’re finished, you code what the person does, and this gives you a diagnostic algorithm that can be rated on severity. It’s not severity for life, it’s severity compared to other people of the same age and the same language level, how severe are that person’s symptoms in terms of social communication and repetitive behaviors in that 45 minutes? That’s what the ADOS does.

I think that the other main value of the ADOS is that for young children, the parents or caregivers are expected to be there. You can use them to participate. This is not why it was created, but I think that a tremendous value is parents can actually see what it is that you’re doing and understand what it is that you’re looking for in making a diagnosis, and be part of this in a positive way, because we’ve put positive experiences, pleasant experiences in there.

For older kids, I think the value is that there are deliberately situations that we hope aren’t misery creating, but are hard for many people with autism that they may be able to avoid often in other [00:16:00] circumstances, and that it does make you think about things that might be hard for somebody that you might not see otherwise. So it does give you these standardized scores for difficulty.

What the ADI-R is a very lengthy caregiver interview that a clinician gives. What’s different about it than other things is it’s relatively open-ended. It’s a semi-structured interview, which means that the clinician has a certain question that’s open-ended, but then you have codes and it’s up to the clinician to get enough information to answer that code.

Once you’ve asked the first question, it’s up to the clinician to keep probing till you can honestly check off one of the codes. So you can ask any other question that you need to [00:17:00] ask or get the person talking about, whatever you need to in order to reach those codes. So it’s very different than something like an SRS or a CBCL where you’re just filling out a form.

I think for me, the primary value for us in our clinic, we always try to get away from an ADI-R and then we end up coming back to it, is it gives parents a chance to tell us about their children. It gives us a chance to see the child through their parents’ eyes.

There are other ways to do that. I think people work out all kinds of ways of getting that information, but for us, especially in a training clinic, it’s been very helpful to start with that, particularly for families who are fairly well-informed and seeking a diagnosis.

It can be a great entry point for a clinician to get a sense of what is the family thinking about? What do they know about their child? What are they [00:18:00] worried about? And then go from there. It’s way too long and there’s a lot of things in it that don’t need to be there.

Dr. Sharp: That’s interesting to hear you say that. It sounds like y’all are working on that for sure. It’s a very useful tool either way.

I think over the years, between those two tools that you’ve helped develop, the ADI-R and ADOS, that term, gold standard for autism assessment really became commonplace, especially with the ADOS. It seemed like for a while, there was a lot of emphasis put on ADOS as the deciding factor in a diagnosis.

And now it seems like we’re going back the other direction. You’ve been an author on some of those papers to say, hey, this is maybe not the only thing to use, there are other tools. Am I right with that?

Dr. Cathy: I think there isn’t one answer [00:19:00] ever. What we’ve tried to do with the calibrated severity scores is say, there is a continuum and it’s important to use these scores like a blood pressure metric. You should compute it and say, where does this child fall and what does this mean? And then take that into account with other things.

At least in our clinic, and obviously we are so biased, because we talk about this all the time and we all do it. We trust our own judgment more than we trust almost anything else, which maybe we shouldn’t. I think that you’ve got to know what the child is like in other circumstances, you’ve got to know what they’re like at school and other circumstances. You also need to know from the parents and the [00:20:00] teachers.

We know that autism diagnoses that take into account information from a teacher or a parent and a clinician using something like an ADOS and an ADI-R or an SCQ or an SRS are going to be more diagnosis of stable and reliable than a diagnosis made just on one source. So that we know. Those probably make less difference.

Dr. Sharp: Oh, that’s interesting. I was going to ask, maybe you’ve already answered this but in your mind, what is the ideal suite of assessment tools when you’re looking at autism in kids? I know it varies depending on age and things like that, but in a kid, what else would you [00:21:00] recommend?

Dr. Cathy: I think you want something from a parent. Ideally, I would like something from a teacher, maybe not so much diagnostic but I would want to know from a teacher how they think the child is doing. I would want to know either the equivalent of the CBCL or a Vineland or something or input from the teacher. And then I probably would do an ADOS, but partly it’s because I’ve done so many ADOSes, they’re second nature to me, so it’s easy for me to slot in an individual child compared to other kids.

I think that for young kids, the STAT is very good. It’s just much more limited in terms of the age of the kids and you do get bigger age effects and language effects. The problem with these [00:22:00] instruments that are specific to particular ages is that if you have a very bright child or a child who has very minimal skills, you’re going to lose them either end.

And that’s been the value of the ADOS is it covers such a broad range by the time you have all the modules that you can move up and down easier. I think the STAT is also very good. So that’s another instrument that involves clinician observation.

The CFBS for the little kids is probably over-diagnostic of communication problems, but also a place where you observe the child. It’s focusing on communication. You can look at repetitive behaviors during it. It’s for very young kids as well.

Basically, though, you want an observation and then you want some kind of way of reporting from kids. The SRS people use it a lot. It makes me [00:23:00] nervous because the SRS is far more correlated with the CBCL and behavior problems than it is with social deficits. So you’ve got to be really careful. I think it means something’s wrong when you get a high on SRS, but it certainly doesn’t mean autism.

Dr. Sharp: I see what you mean. I think it’s a dilemma we get in.

Dr. Cathy: That’s the problem. People use it, but who knows. There’s a variety of other autism measures that I’m less familiar with, that a lot of people like a lot. I just shouldn’t comment because I don’t know.

Dr. Sharp: Sure. I think that’s the dilemma with the behavior checklist is that, at least in my experience with some colleagues, it’s been hard to find the right one. I’ve settled on the SRS in conjunction with these other methods we’re talking about, [00:24:00] but it’s tough, like the GARS and the CARS I’m a huge fan of, this has been tough to find the right checklist. It sounds like that’s not just me, maybe.

Dr. Cathy: Right.

Dr. Sharp: So an observation, an ADOS and certainly getting information from multiple sources, those are pretty important. And then you just have to be careful with the behavior checklist that you’re using and integrate that appropriately. Is that about right?

Dr. Cathy: Right. With the behavior checklist, so when you have like a CBCL, you’ve got to remember that the SRS and the CBCL are going to be more correlated with each other than they are with anything else because you have method variants that’s stronger than the kid. That’s where you have to be careful but it’s still better than not doing it.

[00:25:00] So get that and get an ADOS alongside of the not doing it, but it’s not the same thing as getting separate autism information. Just because it’s called the Social Responsiveness Scale does not mean it measures social responsiveness. It means that we didn’t want to call it the Autism Responsiveness Scale because that upsets parents. So you’ve got to be really careful.

I think that’s where you’ve got to be careful. The CARS was the original autism measure. It was the best thing around for a lot of people and it still works most of the time just because most of the kids who have the things on the CARS have autism, but it doesn’t really match up with what is in DSM-5 or what will be in ICD-11 at all.

It’s just fortuitous that it [00:26:00] describes autism symptoms. It just includes a lot of other things in there, like low IQ which many kids with autism but not most by any means, have.

Dr. Sharp: It is hard to separate and hard to find the one that is exactly right. I think that speaks to the variance in presentation with folks on the spectrum. That’s a good segue, I did want to ask you about how you see the ADOS fitting in with, and assessing that variation, particularly there’s the girl versus boy or male versus female question, and then there’s the higher functioning versus more lower functioning on the spectrum question.

I wonder if we could tackle that a little bit and how you see the ADOS, [00:27:00] particularly for higher functioning females, but it seems to maybe miss some folks on the spectrum. How do you work with that or do you have thoughts on that?

Dr. Cathy: I think that the role of sex differences in girls with autism is a real question that we just don’t understand. When you look at the data, they’re all over the place. There’s some data that suggests that we really are missing a lot of girls and other data that suggests that we aren’t.

I think part of the problem is that girls, like the boys, are so variable, and we all remember the girl that we missed. On a gut level, I do believe that girls are different than the boys.

One of the things I keep reminding myself is that at one point when I was younger, I was in [00:28:00] London, I was going through the records at the Institute of Psychiatry with Michael Rutter, 90% of the kids there had atypical autism diagnoses. Only 10% got regular autism diagnoses. Everybody that came to their clinic, they would say atypical autism.

My point is that it’s very seldom do we see a classically autistic child. We’re always saying, oh yeah, not quite classically autistic. I think we’ve got to remember that because when you get the idea in your head that somebody is going to be atypical, which is going around right now with the girls, you’re going to see that.

On the other hand, I think that the experience that girls have is different than boys. We know that girls are less hyperactive, girls are less aggressive, girls are less disruptive [00:29:00] and girls are less likely to be language-delayed than ordinary girls. All of those factors probably contribute to looking less autistic as an adjective, not as a diagnosis.

And then I think girls are socialized to be better behaved and so I think that contributes probably; both biological differences and social differences to being different. We have to be careful. I think that one of the things to try to remind people with the ADOS and ADI-R is there is flexibility in there. There’s a lot of stuff in the ADOS and you can also choose your examples, so don’t be rigid, choose your examples so they’re appropriate [00:30:00] to a girl.

Sometimes people say, oh this stuff is so geared toward boys, but it’s not, there is stuff in there for girls. Use it for goodness sake.

Dr. Sharp: Can I jump in and ask that?

Dr. Cathy: Do not do the same thing that you’ve just done with all those boys. Try to find the stuff in there that you think will appeal if you think this girl wants to do it. Not all the girls are dying to do girl stuff, but I think that you do have to remember that.

It’s certainly on the ADI-R, you can think of examples that might be more appropriate if you think that you’re pulling the wrong example because at this point, there isn’t evidence that we’re actually looking for something different in the girls. It’s just [00:31:00] that we may need to shift our expectations a little bit and provide different examples.

I do think the threshold may be different. I just saw a 13-and-a-half-year-old girl, she had a diagnosis of pretty much everything else under the sun than ASD. I think she has ASD and nobody saw it.

Dr. Sharp: What things did you see that others maybe didn’t catch or how did you pull those things out through the assessment?

Dr. Cathy: This is a young girl who is very nice-looking. She has a beautiful smile and otherwise, no facial expression, but she does have a beautiful smile. I think people saw that smile. She has pretty good eye contact, but she also has a visual problem so she doesn’t quite look at you right. She also has a [00:32:00] astigmatism so that’s part of it.

So I think people didn’t put that together. I think they didn’t catch that it’s actually quite hard to catch her eye. They always thought it’s because of the astigmatism. And then they didn’t even notice that with this lovely smile, otherwise, there’s nothing there.

She’s a very fine actress. When she is animated, she can she can re-enact Frozen for you. And then she gestures, she sings, but otherwise, she does not move her body, she does not gesture. In that sense, she does look classically autistic in terms of her nonverbal behavior.

I think people were so surprised, at a very early age, she started singing. That so [00:33:00] much overwhelmed people. Also, the fact that she had delayed motor skills, which is perhaps maybe more common in girls with autism than boys. We don’t know. And the visual problem, and her verbal skills, she’s always been very verbal. That’s not necessarily typical of girls with autism, so they just didn’t even think of autism.

And then when she started having terrible temper tantrums, everyone got so obsessed with that, they went off onto a whole other diagnostic route. And then I think what she’s rigid about is mental health. She’s obsessed about her own mental health and everyone else’s mental health, and then a little bit about social justice and various other issues which are not the [00:34:00] same as like being obsessed about flags or subways or ceiling fans.

Dr. Sharp: Sure, but still a restricted interest as far as you can tell.

Dr. Cathy: Yeah. If you counted up her references to social justice and the unfairness of buying $700 shoes, which is specific to Manhattan, that may be female in the sense that I don’t know how many boys would even know who bought $700 shoes.

Dr. Sharp: Sure. That’s a good question. That’s an interesting case that touches on the sex differences, but it also raises a question for me that during the ADOS, I often have a hard time picking up those repetitive behaviors, restricted [00:35:00] interests, particularly if they’re not obvious. I often end up with a bunch of zeros on that bottom half of the scoring rubric. I wonder, do you have thoughts on things to look for in that regard or ways to pick up more nuanced, repetitive behavior, particularly during the ADOS that people might be missing?

Dr. Cathy: That’s a really good question. She was a good example where I debated what to score there and ended up finally scoring that because I thought, in the end, there were just so many references. I had such a hard time getting her off that topic. I had to define it as a topic, which seemed a bit odd to me for me to define that as a topic.

I think that sometimes you are going to have zeros. We have to admit sometimes we [00:36:00] don’t know. I think that we are basically going back and forth realizing that in some cases, for example, in research, we’ve had young research assistants trained to do ADOSes, they come back, and every 10-year-old boy that they assess, whether they have autism or they’re typically developing, comes back and they say they have repetitive interests in video games.

You have to be careful to define what a repetitive interest is. On the other hand, here I am giving you an example where I’m struggling whether to call something a repetitive interest. It is pretty nuanced.

With odd behaviors, what we’ve ended up saying to people is if [00:37:00] you see something that looks odd, go ahead and score it because you’re not going to make someone autistic by having one odd behavior. They’ve got to have other things as well.

It should be odd in a way that’s clearly autistic. It shouldn’t be picking your fingernails or rubbing a table. It should be smelling something that no one else would smell or something very clearly autistic. Otherwise, we have to live with the fact that we can’t always catch things.

Sometimes we don’t see it and then literally, you’re walking someone to the waiting room, and out comes some clear example of something that you were trying desperately to get someone to tell you during an ADOS and they’re not doing it.

[00:38:00] Dr. Sharp: So what do you do with that situation? I’m curious because I think we’ve all had that, like the ADOS goes pretty well, but then there’s something in the waiting room or something during the other portions of testing, and you’re like, oh, if I could just score that as part of the ADOS, how do you work into that?

Dr. Cathy: I don’t score it in the ADOS but I still trust my judgment. I would just overrule the ADOS. What I do is write up the ADOS, I say what I saw but I’m wishy-washy about what it means. And then I say what I really think.

I would write up the ADOS probably emphasizing the aspects that made me suspicious but you can’t put it in the ADOS, because the ADOS is a measurement. You can’t put it in that [00:39:00] measurement. You’re stuck but you can in your clinical formulation. You can say, the ADOS gave me this information and then you don’t have to put the negative information.

The ADOS gave me this information, my clinical observation gave me this information, this is my decision. Ultimately, it is your decision. One caveat I would stick in here is that we have seen a number of very small kids who’ve had high ADOS scores where clinicians could not bring themselves, I’m talking about two year olds, to say they had ASD. There I would be really careful not to rule it out.

I would be careful because those kids often get in the denied services, and when we see them often they do have ASD because they get worse. So there are lots of groups where [00:40:00] if you get a middling high ADOS score, I would be tempted to be really careful not to deny a kid services if it’s going to be dependent on an ADOS.

Dr. Sharp: Can I put you on the spot a little bit? I agree with that, absolutely. I wonder about the wording and how you might phrase that to parents because I feel like parents come in for these evaluations and I hope that they are conclusive to some degree. Do you have a sense of how you would present that to parents to leave it open so they would still get services but not be definitive in the diagnosis?

Dr. Cathy: I have an easier life because I work at an autism center, so I realize that it’s different for me than someone who works in a more general place, because families have bitten the bullet by [00:41:00] walking in here. What we do say here is we say, look, your child barely met criteria for ASD on the ADOS. I don’t know if he has ASD. That’s what I would say.

I don’t know. He’s little, he’s got everything going for him. I don’t know, but I think we’ve got to get to work and make sure that this doesn’t get worse. I am going to give you this diagnosis, but I don’t know if it’s going to last. Let’s assume this is a working diagnosis but I honestly don’t know if it’s really going to hang on.

Dr. Sharp: Okay. That’s good to hear.

Dr. Cathy: That’s what I would say. I would say, if you don’t want to think of this as a diagnosis, it’s fine. If you want to leave this [00:42:00] up in the air, it’s okay.

Dr. Sharp: Okay. And giving them permission to embrace it however they’d like.

Dr. Cathy: If families say, I don’t think so, I would say, you know what, I am with you. I don’t want you to walk away from this and not do the things that I think he needs now because there’s enough going on here that you came and then I see. That’s what I would say. And then we know that many kids at this age get worse, so we don’t want that to happen. So that’s what I would say.

I would also say, look, this is so in that mild range that I’m not saying to you, this is forever. I’m not saying this is a lifelong diagnosis, I’m just saying, let’s get going.

Dr. Sharp: Okay. [00:43:00] That’s really helpful. I want to be respectful of your time. It seems like these interviews go by so fast, this one particularly. Can I ask one last question that’s related to that and your thoughts on the idea of someone growing out of autism?

Dr. Cathy: Sure. I think it happens. I didn’t used to think it happens, but I think that partly it’s that we are diagnosing autism in smarter kids. I think both formal early intervention makes a difference. The key in early intervention is both direct services, but also parents realizing they’ve got to keep kids engaged and that sometimes they have to change their behavior, that it is different having a [00:44:00] child with ASD, or a child who may have ASD.

In our longitudinal study, we have a significant minority of the people who have average intelligence do seem to be moving out of the spectrum. It’s not the majority. It’s also important to point out that there also are people who clearly still have ASD as adults who are doing okay. So it’s not whether moving out of the spectrum is any better than staying in the spectrum, but having a job and being happy in your life, it’s not better, probably.

It’s quite amazing to see somebody that you knew when they were two who had pretty classic autism who doesn’t anymore. I think that it can happen. [00:45:00] Mostly, it doesn’t happen early. It can but it mostly doesn’t. It’s a long process.

Dr. Sharp: Okay. Thank you. I appreciate all your thoughts and the time. This has been a pleasant conversation. I’m aware there’s so much more we could talk about, but maybe there’s a round two somewhere down the road here on the podcast.

Dr. Cathy: Good question.

Dr. Sharp: Thank you. This has been great. Could we maybe end with any resources on training in the ADOS or ASD assessment in general that you might recommend to folks or ways to get better?

Dr. Cathy: WPS, which is the Western Psychological Services, which is the publisher keeps updates of ADOS trainings, which are now all over the place. I’m [00:46:00] sorry, I don’t keep track of them.

Dr. Sharp: I’m sorry.

Dr. Cathy: We do training and UCSF does training twice a year here. They’re also pretty much all over the U.S. and pretty much all over the world now. If you’re interested in particular places, you can email me and I’ll pass you on to our coordinator and they can let you know for specifics. I don’t know books and stuff.

The good news about the ADOS is we have an adapted ADOS now, which I don’t know if WPS is going to sell, but there is an adapted ADOS for less able adults that is available. You probably know there’s a toddler version. So we are continuing to try to expand it to make it more [00:47:00] appropriate for more people. So we’ll keep working on that.

Dr. Sharp: That sounds great. I’m going to keep close tabs on all these projects. You’ve got some cool stuff going on. It sounds like you’re working so hard to develop these measures, use them in your clinic and then use that feedback to tweak the measures. Just going through that whole process where you’re incorporating all these sources of information in the real world and research, that’s fantastic.

Dr. Cathy: Thanks, Jeremy.

Dr. Sharp: Sure. Cathy, it’s been an honor to be able to spend some time with you. I appreciate it. Hopefully, our paths will cross in the future again.

Dr. Cathy: Thank you very much.

Dr. Sharp: All right, take care.

Dr. Cathy: Bye bye.

Dr. Sharp: All right, y’all. Thanks again for listening to that interview with Dr. Cathy Lord. She’s clearly done a ton over the years and continues to do pretty [00:48:00] incredible clinical and research work in the field of autism spectrum assessment.

Thanks again to our episode sponsor, Practice Solutions, a full-service billing company. They do a fantastic job. They are incredible. If you are interested in billing services, give them a call. You can get a discount off your first-month services if you use The Testing Psychologist or my name, where you can go to practicesol.com/jeremy and sign up that way. They’re happy to answer any questions too. It’s a no-pressure initial consultation for sure. So check it out if you’re looking for a billing service.

As always, if you have not checked out our Facebook group, I would invite you to do that. We have nearly 500 members strong, at least at the time that I am recording this podcast, likely to be over 500 by the time it’s released. We talk about testing. We [00:49:00] talk about the business of testing, case consultation here and there. It’s really a cool group that’s got a lot going on. We do consulting giveaways and all sorts of things. So check that out if you are interested in finding more community around testing.

If you’re interested in learning more about consulting or building your practice in testing or tweaking it or taking it in the direction you want to take it, I’m happy to talk with you as well. You can sign up for a complimentary pre-consulting phone call on the website, which is thetestingpsychologist.com. You can also get a lot of information there about consulting services and whether that’s right for you. So if that is interesting at all to you, give me a shout, I’d love to talk with you and see if consulting could be helpful.

So y’all take care. I should have two more episodes coming out here before the Christmas season. In the meantime, I hope everyone is enjoying the holiday season and staying warm or staying cool, depending on where you’re [00:50:00] at, and having a good year. We’ll talk to you later. Thanks for listening. Bye bye.

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[00:00:00] Dr. Sharp: Hey y’all, this is Dr. Jeremy Sharp. This is The Testing Psychologist podcast, episode 38. Hey, before we get into today’s episode, I want to give another shout-out to our podcast sponsor, Practice Solutions. Practice Solutions is a full-service billing company for mental health professionals so that you don’t have to spend your valuable time working on mundane tasks like billing.

They do everything from benefits checks, to entering payments and ERAs, to collecting on balances. They do it all. They’re super responsive. They specialize in mental health and they have helped our practice increase our collections. It keeps going up. I think we’re at 20 to 30% more than we have typically been collecting since we transitioned over to them.

So if you need a billing service or you just have questions, you can go to practicesol.com/jeremy and shoot them a message, and they will get you hooked up with whatever you might need. [00:01:00] If you use that link, you’ll also get discounted services for your first month. Now on to the episode.

Hey everybody. Welcome to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. We are back today with our first interview in several weeks. We just wrapped up our 5 quick tips series and I am thrilled to jump back into the interview game with someone that many of you have probably heard of or read some books or read some articles. I’m here today with Jacobus Donders.

Dr. Donders is the Chief Psychologist at Mary Free Bed Rehabilitation Hospital in Grand Rapids, Michigan. He is board-certified in [00:02:00] Clinical Neuropsychology, Pediatric Clinical Neuropsychology, and Rehabilitation Psychology through the American Board of Professional Neuropsychology.

In addition to being an active clinical practitioner, he has served on multiple editorial and executive boards, has authored or co-authored more than 100 publications in peer-reviewed journals, and has edited or co-edited 5 textbooks. Dr. Donders is a current associate editor of the journal Child Neuropsychology and Archives of Clinical Neuropsychology.

He’s a Fellow of the American Psychological Association and of the National Academy of Neuropsychology. His main interests, at this point, include validity of neuropsychological tests and prediction of outcome after brain injury.

Dr. Donders or Jacobus, welcome to the podcast.

Dr. Donders: Nice to be here.

Dr. Sharp: Thank you so much for taking the time to come on and talk with us. That’s a heck of a bio. You have a lot [00:03:00] of very esteemed titles and designations in there. I’d like to maybe start a little bit with where you’re at right now with your career and what you’re doing day to day in your work, and we can take it from there.

I know people are really excited to get into some discussion about feedback and reports and report writing but tell us a little bit about what you’re doing these days and what your work situation looks like.

Dr. Donders: Sure. Being 58 years old, I’m supposed to call myself late career, my job at the hospital is about half-time clinical and half-time administrative research in nature. Most of my work involves outpatient neuropsychological evaluations of persons who have either suspected, confirmed [00:04:00] or disputed acquired or congenital brain injuries.

I see a lot of head trauma in the adult population. I see a lot of mild cognitive impairment on the pediatric side, anything from spina bifida to cerebral palsy, you name it. I’ve always adhered to a lifespan approach.

I was initially trained to deal primarily with pediatrics. I later did some adult training. So I feel comfortable at both ends of the age spectrum. I enjoy children a little bit more but I see individuals across the age span, really.

My practice involves about, it varies on the year, but about between 12 and 14% forensic work as well. Forensic I mean personal injury, medical, legal. Besides the clinical work, I’m involved with some training. We have an APA-approved residency in clinical neuropsychology and [00:05:00] I have about a half a day a week to do research.

Dr. Sharp: Okay. What’s your research looking like these days?

Dr. Donders: There’s two things we’re looking at, right now we’re looking at subtypes of MMPI-2-RF profiles in individuals who have sustained a traumatic brain injury and see whether the different profiles are related to either demographic variables or injury variables or comorbid psychosocial factors or financial compensation seeking or any combination of the above.

We’re also looking into the concept of what’s called sluggish tempo in children with brain injuries that’s becoming a more hot topic in general cognitive psychology, but neuropsychology has not looked into that very much.

Dr. Sharp: Both of those sound relevant and super interesting. Am I remembering right that I see an article [00:06:00] you are part of that was a review of neurofeedback as well. Is that …?

Dr. Donders: I don’t think so.

Dr. Sharp: No. Okay. That might just be me. There’s a lot out there. Just from this little brief introduction, you’re involved in a lot of things that I think would be incredibly interesting to our listeners. What we are going to focus on today is a lot around report writing.

This is something that you’ve been involved with for a long time, at least as far as I know. I remember that 1999 article that you wrote about reports being too long. I don’t know if you were doing research or looking into it before that, but it’s been at least 18 to nearly 20 years. And you just, within the last few years, wrote another book Neuropsychological Report Writing. Is that right?

Dr. Donders: Yeah. [00:07:00] I edited it. I had some of my colleagues be generous enough to donate their time and treasure to write chapters in it.

Dr. Sharp: Sure. I found that book very valuable and I think there are a lot of great chapters in there. I am curious how you decided to go down that route. You’ve written or edited several books, but why a book about reports? What led you down that path?

Dr. Donders: This is the one I actually always wanted to do. I wasn’t always sure whether it had merit to the book or yet another article in the peer-reviewed journal. When I wrote that original article in Child Neuropsychology in the mid to late 1990s, it was more out of frustration with what I saw coming across my desk in terms of reports from other psychologists and [00:08:00] neuropsychologists that would go on for 12, 18 or more pages and basically said very little.

The tipping point for me came when, and that was actually included in that article that I wrote, there was a principal from a high school who had paid out of his own budget to get a neuropsychological evaluation of a young adolescent girl who had sustained a stroke. At that time, keep in mind, this was mid to late 1990s, so they spent more than $1,000 for that out of a rural school budget, and got a long report back that said, yes, she has brain damage. It’s on the left side of the brain. You need to work with visual methods and instruction.

That’s pretty much all it said. The rest was very detailed description of test results, scores, and everything. The man called me [00:09:00] and said, I already know she had brain damage. I’ve seen her hospital discharge summary. I know she had a stroke. I also know it’s on the left side of the brain. Look at her, she can’t even move her right side. This doesn’t help me. What does that mean, visual methods?

So I did that. That’s why I decided, okay, let’s write an article encouraging people to cut down on the unnecessary detail and focus more on what the reader is actually looking for. Doesn’t mean you have to tell them what they want to hear, but answer a question in a way that gives people new insights that tells them something they didn’t know before. And that then results in some practical recommendations that people can actually implement in a feasible or practical manner.

And then two years later, I did a nationwide [00:10:00] survey about report writing because I wanted to know why do people write the way they do because one psychologist or one neuropsychologist spreads differently in another way. I wanted to figure out what do people do and why do they do it?

It turned out there was no consensus in the field about how you should write a report. A lot of it differed with the practice setting. If you are in a medical setting and you write for a neurosurgeon as part of an epilepsy team and neurosurgeons, they’re very good at their job but with regard to reading reports, their attention spans probably 5 minutes at tops. So you need to get very concise information to them.

There’s very specific information that they’re looking for, such as, is this patient going to or not going to be at increased risk for cognitive decline after surgery? They don’t care about all this other stuff [00:11:00] about on this test and that test, they’d want that question answered.

On the other hand, if you are doing a child custody evaluation and you have to explain to a judge why parent A might be a better custodian of the person than parent B, you’re going to have to give some more information.

If I see a young adolescent who has a history of brain injury who is now approaching the age of majority and I’m asked to determine if this person has the mental capacity to function as his or her guardian, I need to answer very specific questions and using very specific terminology that are dictated essentially by the probate court.

I found out it depends a lot on who you’re writing with, what you’re comfortable with yourself. People doing pediatrics write different reports than people doing older adults. So it was a hodgepodge, [00:12:00] but there were several things that a lot of people agreed on what should be in the report.

I’ve seen reports where it was not at all clear who referred the patient. It’s important to know, is this a referral from a physician or from an attorney? I’ve seen reports where the date of the individual was not even mentioned. A person’s referred as a child, but I don’t know if I’m dealing with a 6-year-old or 12-year-old or anything in between.

What I wanted to write eventually, so we did that originally before a paper in the 1990s. It’s a survey published in early 2000, 2001, I think it was. What I wanted to write is one book that gave examples of if you write in this situation, be that a school, be that a court system, be that a medical system, here are some things that you need to know, here are some things that will be helpful in terms of serving your clientele. And the [00:13:00] clientele would be both the patient and the referring physician most of the time.

I wanted to do it in a format that eschewed the traditional cut-and-paste options that you get from some of these books. Okay, if you want to write a report here, just put this boilerplate in there, because that’s what I wanted to stay away from.

I wanted it to be meaningful and I wanted it to be individualized, but I wanted a format that in each chapter had, okay, here’s a good example of how to address this, and here’s a not-so-good example of how to address this. Here’s why example A is better than example B. That’s what I always wanted to do. It just took a long time to put it out here.

Dr. Sharp: Sure. I think that’s something that I appreciated about that book is that:

1. That it addressed writing reports for different audiences.

2. That you did give examples of [00:14:00] here’s a good way to do this and here’s a not-so-good way to do this. It’s nice to have really clear examples like that.

I would imagine I’m not the only one that found myself doing some things that were not so great but it’s nice to be able to change that up and have some examples from the field.

I think that we could certainly delve into the process of writing that book, I’m personally curious about that, but I know that a discussion that’s come up a lot in the podcast community and the Facebook group for testing psychologists is reports are just, they’re the bane of our existence in a lot of ways; the time involved and not getting reimbursed and things like that.

And so a lot of people are really excited to hear [00:15:00] about specific ideas about writing quality reports, but also balancing that with efficiency and making sure we’re not wasting time. At this point, I know it’s hard to cut across audiences, but do you have any general tips or thoughts on what are the core elements of a good report that should always be there?

Dr. Donders: What always should be there is who referred to patient and why, and what was the referral question? If I get a referral, it says, please evaluate, I typically send it back or I pull back and say, evaluate for what? Because I can throw a ton of tests at this individual, I don’t mind making the money. Tell me how I can best help you.

So if there’s a question about, does this patient have depression or dementia or does this child have a learning disability or attention deficit, is that what you’re worrying about? Okay, [00:16:00] that gives me an idea of what you’re struggling with.

That does not mean I cannot address anything else in my report or in my evaluation. If that child comes in and has a big bruise on their cheek, then I want to know where that bruise comes from. If that person comes in as an adult and looks very depressed, yes, then I will address their emotional adjustment, but who referred a patient? What was the referral question?

I am not in favor of regurgitating everything else that is already in a medical or in the school record that is already known to the reader. I might reference it very briefly but I’m going to assume that if a pediatrician sent that child to me, that pediatrician will know that child’s birth weight, her Apgar scores, the developmental milestones, and blah, blah. I don’t need to investigate all of that in the report.

Dr. Sharp: That’s interesting. Can I jump in real quick and ask how you handle that then? How would you [00:17:00] write the, let’s say, medical history then if you don’t regurgitate that stuff?

Dr. Donders: I had available to me the office notes from Dr. so and so, they revealed that Johnny’s medical history, language and motor development prior to the car accident in question were entirely unremarkable. Hearing it.

Dr. Sharp: Okay.

Dr. Donders: Sometimes I do that and if I don’t have that information, I will do an interview with the parent.

I will get all those milestones. I will know when that child started sitting up. I will know when they started crawling. I will know that when they said that first word. I will know when they got potty trained and all that. If I don’t find anything of significance, then I can say there was nothing unusual about this child’s development prior to the age of whatever we’re talking about.

And the people that I have worked with will know that I have asked, that is not boilerplate, that I’ve asked all those questions. [00:18:00] What I do feel strongly about, if you uncover something that people don’t know or have not appreciated, you need to draw attention to that in the report, whether that’s something about the history of observation it.

I have a patient here who supposedly was in a car accident and I read the emergency room report. There was nothing wrong, but now this patient’s sitting across from me at the table and I see a distinct nystagmus. I’m not an ENT, I’m not a neurologist, but I can’t ignore this nystagmus. So I will document that’s present.

Or if the person tells, my doctor has recommended this medication for me, this antidepressant and I told him I will think about it, but I don’t want to do that because I’ve tried that before and I had bad side effects, but there’s nothing in the doctor’s notes that the person has been tried on [00:19:00] psychotropic medication before, then I want to draw attention to that. Not to call the patient an evader or a liar, but that’s something that the referring physician should know that there’s a prior psychiatric history.

So tell the reader anything about the background that the reader doesn’t know yet. In your test results, focus on, and that includes also the behavioral observations, focus on what really makes a difference. If all the scores look normal, I’m not going to belabor them all of them.

I have a habit of attaching to my report a brief summary of all the standard scores, let’s say, a summary of the formal psychometric data is attached. The vast majority of these are within normal limits, specifically with no deficits in attention, language, perceptual skills, or memory. Only area where we find some difficulty is whatever x, y, and z, [00:20:00] and the nature of that difficulty appears to be a, b, and c, as evidenced by performance on these and these tests.

And that’s all I say if it’s a very uncomplicated situation. If it’s a very complicated situation, I will still say, I’m not going to go through every single test or every score, but let me highlight the most significant findings. This child has two problems:

1. This child can only pay attention to one thing at a time. You give him more than one thing to do, he gets lost, he starts missing things, starts making mistakes.

2. The second thing that’s going on with this child, he’s very critical of himself, any negative feedback, he panics, he has a catastrophic reaction, and that anxiety or that frustration associated with that will make him look more impaired than is in fact the [00:21:00] case. Here are some examples of how that played in the test.

I try to highlight what are the main findings and what are the main red threads throughout the report. When I come to the end, I am not in favor of appending a summary because I just went through a short report that should be one or two pages at most, why do I need a summary?

I’ve seen summaries that were a page and a half long. That’s not a summary. That’s basically saying the same thing. In the conclusions and recommendations, I basically say, listen, I do not think that this person has a learning disability. I do believe that they have post-traumatic stress disorder associated with the car accident in question.

I don’t believe that they need special education services because of head trauma because that head trauma is very minor. I am concerned about the way this person’s emotional status may negatively affect their educational success, so I’m going to ask for consideration of special education support [00:22:00] under the emotional impairment qualification. Here’s what I would do in a school setting. Beside that, this child needs individual psychotherapy or we should try a medication of Prozac or whatever.

I try to keep to the point very specific and then have some directions for follow-up. That’s pretty much what needs to be in the report; who referred? What was the question? What new information did I uncover? What does the balance of the interview, background, behavioral observations, and test results really tell me? What does that imply for this individual’s treatment and what’s the follow-up?

Dr. Sharp: Got you. I have a lot of questions about that. When you think about the history, I totally get doing a short medical history, getting really comfortable with the phrase within normal limits or unremarkable or whatever you might use.

How do you handle the, [00:23:00] let’s say, the presenting problem? How do you document that? Because that ends up being, for me, just being honest, probably at least a page where I’m talking about the parents or adults presenting concern; the history of that, the way it manifests. How do you handle that?

Dr. Donders: I focus on the highlights. A person comes in and says, I have memory problems, but then the more I talk to that person, they’re not talking about memory problems, but talking about the word-finding difficult.

I may, for example, say, even though the primary subjective complaint pertained to a memory problem, I got the distinct impression that there were more word retrieval issues, whereas this person did not indicate any problems with leaving the stove on, paying his bills, taking his medications or with a child doing his homework, remembering to turn in the homework, doing his chores, [00:24:00] whatever.

If the timeline is important, then I will elaborate on that. For example, if it’s an older adult who has a question about Lewy body disease, and according to the criteria, the emergence of cognitive and motor symptoms should be within approximately one year or less of each other, well, I will comment on that because that’s important for the diagnostic criteria. If it’s not all that important, I will not elaborate on it.

What I try to focus on is what is really important for the reader to understand in the conceptualization of this patient versus what might be interesting tidbits, but in the larger scheme of things really don’t matter all that much.

Dr. Sharp: I think that gets maybe a bigger question of or maybe logistics of when do you write the history in relation to the rest of the report? [00:25:00] Are you writing the history to fit the diagnosis or vice versa? Does that make sense?

Dr. Donders: I think the history is important regardless of the diagnosis. I may end up with a final diagnosis that this young boy indeed suffered a significant traumatic brain injury in the accident in question and that this child doesn’t need special education support and also needs outpatient occupational physical speech therapy services.

If I also uncover a history that this child has been sexually abused in the past on more than one occasion by close male relatives, I will probably put something in the recommendations that the therapy, particularly if it’s going to be physical therapy, should probably be done by a female, and that it’s very important if you’re going to touch that child, you’re going to [00:26:00] tell him in advance why you’re going to touch him, where you’re going to touch him, and you do it while you’re making eye contact with him instead of approaching him from behind.

I may not go into great detail about why that’s necessary because I consider that confidential, but I will put that in. So that’s where the history still becomes an issue even though it’s not necessarily germane to the final diagnosis.

Dr. Sharp: Right. That’s a great example. And so thinking about moving through the rest of the report, I think a lot of us separate into, there’s a section for test results and we go through each domain maybe or some people probably list out specific tests. And then there’s the section; interpretation or summary or conclusions, however you might phrase that.

Could you break that out a little bit more and say [00:27:00] what you would include in the test results versus the summary/interpretation and how those breakdown?

Dr. Donders: The test results should focus on exactly what it is. What tests did you give? What are the results? Again, I’m favoring of attaching a list of the standardized scores, and those should basically focus on what do those scores tell you sometimes with caveats based on behavioral observations like it might seem that this child is very poorly on block design, but you need to keep in mind this child has motor limitations as a result of his cerebral palsy.

Every time we gave him extended time or 10 or 15% extended time, he got them. There were several items, if the time limit was 60 seconds, he got it in 68 or 72 seconds. That should be in the test results.

The [00:28:00] interpretation/recommendation section should focus on how do I integrate those test results with what I’ve known from the medical records that I reviewed, sometimes academic records of this child, with the interview that I conducted, and the behavioral observations that I did.

So here I have all these test results that seem to suggest that this child has difficulty with word finding. There is some indication for relatively greater motor impairment on the right side of the body. I have a history from the hospital that this child had a tumor on the right side of the brain. And so my God, what’s going on here?

This doesn’t seem to fit, but then I need to keep in mind that this child is left-handed. Therefore, probably has atypical lateralization. So it still fits with the overall idea of some cognitive [00:29:00] impairment, language impairment, motor impairment, as a result of acquired neurological history, and therefore, I am recommending special education support.

So the integration part, and that’s what we’re getting paid to do for as neuropsychologists, anybody can give tests, it’s really not that hard to do. I prefer to use masters-level clinicians to do the testing for me because they’re also my eyes and ears. So the guy getting very good behavioral observations.

What you need a doctoral-level psychologist or neuropsychologist for is the integration of those test data with the history, with the interview, with the observations, and other information that you need to know. Like if you do evaluation for a probate court, there’s certain rules, certain criteria you need to follow. If you do an educational evaluation, you need to have some understanding of what special education law is in your state. So you need to integrate all of that.

[00:30:00] Dr. Sharp: Sure. You said you do append the scores at some point, at the end of the report, do you …?

Dr. Donders: It’s a one-page thing that lists, in a normal battery, it would list the IQ scores. If it’s a child and I could get achieved scores, main results from tests of memory or problems or whatever tests were given with a caveat on the top of that page that those scores are for professional use only and they should never be interpreted without consultation of the accompanying report because scores are just scores. They need to be integrated with something else.

Dr. Sharp: Of course. Yes. I got you. Let me ask then, how long do your reports end up being generally, because there is variation?

Dr. Donders: If I had to write them on a normal letterhead, they would probably be two [00:31:00] to three pages plus that addendum of the test scores. Some of my reports are very brief. There’s a lot of physicians in my hospital I know that they actually never read my full report because what I do when I’m done with a patient, I’ll send that physician an email that basically says, listen, this is Mr. Jones or child’s name, whatever, who you saw on clinical, that date, who has a history of fill in the blanks.

We will policy to multi-branch or whatever like that. You had a question about this, here’s what I think; A, B, C. I do it in bullet point. I recommend X, Y, and Z. There’ll be a full report to follow next week. I know they never read that full report. They want that email with those bullet points [00:32:00] that’s probably less than 500 characters total.

Dr. Sharp: That makes sense in the hospital.

Dr. Donders: The other day I called a physician from the outside and said, I know you’re concerned about the differentiation between mild cognitive impairment versus depression. I think it’s depression, but what I’m even more concerned about is that this person is self-medicating with alcohol. You should know about that because you’re also treating this person with pain with a narcotic.

This physician had absolutely no clue that this person was self-medicating with alcohol. In fact, he was washing his if I get in down with the alcohol. Then I said, you need to know this, you probably want to follow up right away.

The length of [00:33:00] report; I’d like it to be concise, I’d like it to be brief, I’d like it to the point, but length is not as much as important as content. What matters to me in terms of content is what does it tell the reader that the reader doesn’t know yet that helps the reader change or improve care for this particular patient.

My pet peeve about many neuropsychological or psychological reports is they go on and on, it becomes verbal diarrhea. It really doesn’t give the reader, whether that’s a teacher or an attorney or a physician, any new insights, anything new that they can actually work with and do something with.

As long as we focus on that, I don’t mind the report being a little bit longer, even though I prefer it concise, if it really accomplishes that. My concern is that many individuals seem to confuse quantity with quality. [00:34:00] If you just focus on, let’s put out a quality report that helps whoever sent this patient to me and in the end, my report will help improve care for this patient, that’s all that matters.

Dr. Sharp: I think a lot of people are probably out there thinking, oh my gosh, how do you get reports down to three pages? So I want to ask you about that but before we get to that kind of stuff, I am curious, the quality is so important, where do you find you spend the most energy or have the most focus? What section of the report is taking up the bulk of your time or your energy?

Dr. Donders: The bulk of my time probably is the interpretation and then subsequent recommendation section because that’s where the integration of everything is. It’s going to be lots of fun for a nerdy psychologist [00:35:00] to calculate where the score A is statistically significant different from score B and whether that meets the criteria for minimally clinically important difference.

The history might be juicy and all that, but what it boils down to is how do I integrate all this and how do I integrate this in a way that I can explain this to whoever reads this report, referred this patient to me in a succinct, intelligible manner that is going to ensure the best follow up?

The way I’ve taught myself to do this and the way I teach my residents to do it is, there’s two tricks that we use. One is, okay, the big news on when I was watching CNN this morning is that Twitter is going to go to 280 characters. All right, Twitter is just [00:36:00] 280 characters.

Let’s say you need to send out a tweet, and let’s say this tweet only goes to the referring physician, what can you say in 280 characters about this patient? I may change it to 280 words because 280 characters is a little bit too short, but let’s say 280 words. Or let’s say you need to leave a voicemail on this person’s voicemail machine, and you only have 100 seconds, what are you going to put in that voicemail?

That’s how you get to the point. In order to do that, in order to get to the point where I can say, okay, I can say in 280 words or in a little bit over 1.5 minutes, what I think is going on with this individual and what should happen to them, I need to do that integration.

I need to cut out the irrelevant details. I need to focus on the nitty gritty. I [00:37:00] need to keep in mind what the physician or the referring party already knows. I need to keep in mind all those external contingencies such as in the court or in special education law and say here is the bottom line.

If there’s anything I want you to know about this individual, if there’s anything I want you to do about him, here it is. If you train yourself to complete that task before you start writing or dictating anything, then your time to actually do the report is going to become very brief. I dictate most of my reports in less than 20 minutes.

Dr. Sharp: Less than 20 minutes, oh my goodness. I know there are people out there just crying right now.

Dr. Donders: I’m not trying to make anybody uncomfortable. I may spend more time than 20 minutes with the integration. I’m [00:38:00] thinking for a long period of time to how do these test data fit with this history. If I want to make a case for this child to get these kinds of services, what I’s do I need to dot, what T’s do I need to cross?

The way I try to think about it and the way I explain it to my residents is it’s an inverted pyramid. The top of the pyramid is where you want to be, you want to climb to the top of the pyramid. That’s where the golden ball is. And that’s my conclusion/recommendation.

And then I go back down and say, what are the foundations of that pyramid that allow me to say, yes, this is my conclusion, I need to address. A, B, C, and D. Another level down is here are some specifics if people need to get convinced or I need to put a little bit more meat on that bone that will support that I actually have looked at all those pillars for all those foundations.

So I begin with [00:39:00] what’s my top ideal, where do I want to go? In order to make that case, what issues do I need to address and what sprinkling of details do I need to put in there? So if I’m ultimate conclusion after doing all that integration is, yes, this person does have cognitive difficulties that are a direct consequence of his traumatic brain injury, and they cannot be solely attributed to his premorbid history, then what do I need to say?

I want to say something about test results that are selectively impaired in areas that are typically affected by traumatic brain injury, such as processing speed. I also need to make a comparison between this child’s premorbid test scores and his post-morbid test scores, because I have a WISC from two years ago, where they fortunately gave the processing speed of this, and there’s a decline of 14 points that exceeds the minimally clinically, that’s a reliable change, [00:40:00] exceeds the criteria for minimally important.

I have been able to rule out that this child has a complicating anxiety or depression as has been suggested by some of the other providers. The child is frustrated. Here’s how I can tell because I did a PHQ-A, I did a GAD-7, I had the parents fill out a PIC and none of it suggested a complicating disorder.

Those are my three pillars. I can show that this child has impairments selectively on tests that are known to be sensitive to brain injury. I have compared this child’s test performance pre and post morbid, and I’ve ruled out other complicating factors. I sprinkled in there some details because I had processing speech scores, I had formal standardized ratings of mood and behavior. Now my inverted pyramid is essentially done.

Dr. Sharp: And that’s your interpretation section, huh? [00:41:00] That’s fantastic. What do you think about the, I’ve heard people call it the inverted pyramid of report writing, where you put the interpretation and maybe even the recommendations first and foremost at the front of the report and then follow with everything else. What do you think about that?

Dr. Donders: That’s personal preference. I know that if I write a report where I put in interpretation and the recommendation at the end, more than 90% of physicians really flipped to the last page.

They will not always tell you that. They say, oh, yeah, you’re right. I read your whole report. I know they’re lying but that doesn’t bother me. I’m more concerned about that they read that section that really bothers where I do the integration, where I pretty much advise them what to do, that I’m pretty confident for.

To me, it doesn’t matter upfront or in the back as long as it’s evidence-based, as long as it achieves [00:42:00] that objective of telling the reader something they don’t know and eventually helping the patient.

Dr. Sharp: I got you. I think listeners are probably dying to hear a little bit about how you get down to the point where you’re writing two or three page reports and dictating in 20 minutes. Did you start at that point or have you worked down to that point? And if so, how did you do that? What helps you with that? Tools, tricks, anything.

Dr. Donders: When I first started out, particularly during my internship and postdoctoral residency, of course, I took a lot more time. At that time, I was hand typing my report. I’ve been doing this for 29 years as an independent practice now, not counting my training, you get more [00:43:00] experience, you get more efficient.

There’s two things that I found helpful to do. One thing, for example, and some things are extremely simple. One thing is that my psychometrist, when she hands me the test data, the protocols, they’re always in the same order and always keep them in the same order because so if I know that I’m going to look for a certain test result, I don’t have to wade through all kinds of, oh, where is the test? Oh, where is this? I just saw it. No, it’s always in the same order. That sounds very little, but that saves a lot of time.

I’ve learned to, when the test results come back and the psychometrist gives me that summary sheet with all the test data on it, I eventually will append to the report. I will try to do a very [00:44:00] quick masked, we used to say blind, but you’re supposed to say masked.

We review those test results first because I’m involved with at least 6, sometimes 8 or 10 evaluations per week, and sometimes these test results come to me later in the day or the next day so it’s just, okay, let’s just look at this blindly and say, okay, I’ve got a 50-year-old man with 12 years of education who’s right handed or a 7-year-old girl who’s left handed. I look at these test results, what do I make of that provisionally? And just as an academic exercise. It takes me about 5 minutes.

Then I go back to my notes from the interview, I say, oh, okay. I need to keep in mind that this child is left handed or I need to keep in mind that this child has a history of foster placements, has been bounced around a number of times. Now it’s time to take a look at the behavioral observations from the psychometrist and the child was very anxious, withdrawn. Okay, [00:45:00] let’s now go back to the test results.

Yeah, no wonder that there’s some inconsistencies in these test results, because she’s anxious. She’s typically anxious when she’s being timed. Yeah, that appears to be a pretty consistent pattern. Her feeling being watched, judged, such as being timed, or only getting very succinct feedback, like on the Wisconsin Card Sorting Test, or a similar test where you don’t read, don’t write, or wrong, without an explanation why, we get more anxiety.

So I see a pattern here. This is a child with a lot of anxiety. You learn to do that in that fashion where you basically say okay, I’ve got all the test results on the same mark. I’m not wasting time waiting to see that. I can give a brief general conceptualization.

I’m going to check how that holds together with my history. I see a pattern emerge, but it’s okay. Let’s hold on to that pattern. Anxiety is one of the things I need to address in my report. That will be one of my pillars. [00:46:00] What’s another pillar? What’s another issue? And then I can put it all together and say, okay, here’s the final interpretation.

I think that the main keys is being organized. When I do reports, my door is closed. I typically have open door policy. Everybody in my department means that if my door is closed, I’m either with somebody discussing something confidential or I’m dictating, please do not interrupt me.

And since my dictations do not take all that long because I don’t close that door until I’m ready to start dictating and not ready to start dictating until I’ve actually already done my integration, that door is only closed for 20 minutes and people will respect that. So I don’t get interrupted, and I’m organized before I start dictating.

I spend more time on integration of findings than I do on dictating the report. People often make the mistake and say, I’m going to [00:47:00] start writing and I’m going to start dictating and somehow magically God’s greatest insight into the nature of mankind will come to me while I’m doing that, and then they find themselves on page 11 or 12 or 13 while they’re still trying to figure it out. And then it takes so long.

I think if you do the integration beforehand, before you either even write or dictate a single word, then your work is already half done.

Dr. Sharp: So do you actually, I know I’m getting into the nitty gritty here, but do you physically write out these pillars in that pyramid model, or are you just thinking of it in your mind or how do you do that?

Dr. Donders: I do it now in my mind. When I first started doing this, I would sketch them out and I might sketch out a pyramid that says here’s the top and says, so conclusion child has PTSD, not both concussion syndrome.

[00:48:00] What are the pillars? I have a history here that the child has nightmares with accident-related content, is still very uncomfortable being a passenger in cars. Doesn’t appear to be generalized anxiety because there’s no anxiety about playing soccer with his friends.

Why is not post-concussion syndrome? Because I don’t see any indication on any of the tests for cognitive difficulties, particularly not in areas of novel learning or speed of processing that I know are relatively sensitive to brain injury. I also know from the history there’s nothing in the pediatrician’s notes for this child prior difficulties with anxiety. So I know this is not a pre-existing condition.

So now I know I have the symptoms that fit with the diagnosis. I can rule out another diagnosis, potion question, because I have the data to do that. I can also say it’s causally related to this accident, not only because of the nature of the nightmares, but because also there’s nothing used in this child’s medical records. [00:49:00] This is just a prior interview or a prior problem with anxiety.

I used to sketch that out. I would have a triangle at the top with three or four columns at the bottom. And then under each column, I might write down, okay, make sure you discuss the Achenbach with regard to the anxiety or make sure you discuss Dr. Jones’s office notes or a few key words.

Having done this for more than 24 years, I can now do this in my head. I usually recommend to my residences sketch it out first, but don’t make it an art project.

Dr. Sharp: That’s a good way to put it. Sure, I like that. I think that’s something that over time I’ve probably been doing in my mind, but even to hear it articulated like that helps, it gives a little more organization and structure to [00:50:00] it. I know there are probably folks out there who are thinking, okay, this is good. I’m going to start literally sketching it out before doing the interpretation. I like that visual. That’s very cool.

Do you use any, aside from dictation, any sort of technology or apps or anything like that to keep you on track or stay efficient in your report writing?

Dr. Donders: I use a transcription service, so I think they can send back to me, I typically always review them to make sure that there’s no mistakes. The mistakes are usually mine that I mumbled too much and insignificant might come out as a significant.

As an interesting tidbit, my main transcriptionist is blind. [00:51:00] She transcribes in the most accurate manner, I watched her do it once. She has the option of playing back what she just wrote. Of course, she can’t see anything. She rarely makes mistakes.

She will email me, say, hey, you forgot to put a section on the CPT codes or whatever, very accurate. I use a transcription services, how we got on this topic. I know some of individuals like to use dictation software like Dragon or one of the other ones, either way, the necessity of being organized and doing the integration so forth, it will be the same.

One of the things that I’ve found just being organized, as I said, get all your ducks in a row before you start what you’re doing. While I’m dictating, I can see how much time has elapsed [00:52:00] since I started. It keeps track for me on the phone.

So if I’m only halfway down what I want to say and I’ve already 20 minutes in the same, then I probably pause the whole dang thing, I said, what am I really doing? Why am I getting off track? What do I need to do?

As I said, I avoid interruptions. Somebody has a patient on across the hall holding a gun to his head or somebody else’s head, yes, I will deal with that but otherwise, please do not interrupt me while I’m dictating, because I need to get this done in one session, if at all possible, because else I’ll lose that train of thought.

I do at least one and most often two neuropsychological evaluations per week. If I get distracted and I start breaking up in different time slots, I lose track of what I wanted to say because I do all the integration in my head. So making sure that I have the time to do that, it’s now almost [00:53:00] 11:30 AM, I can do this report in 20 minutes, but I need to do the integration. So let me do the integration between 11:30 AM and 12:00, let me dictate between 12:00 and 12:30 PM.

Do I have that on my calendar? No, because I already have a new meeting. Okay, then I’m going to set this report aside. I’ll do that later this afternoon when I have the time for it, and between now and twelve o’clock, I’m going to do something different. Those basic time management issues help me out quite a bit.

Dr. Sharp: Yeah. I think that’s what is really standing out. There’s a lot of maybe self-awareness or self-monitoring in this process. I hear you also talking about batching your time which I’ve talked about a lot on the podcast in terms of being efficient.

So it’s like you know exactly how long a report should take you and then you just match that to your schedule. And if it doesn’t match, then you wait till you have the time, that sounds like.

Dr. Donders: Yeah. That works for me because I know what my schedule is, the [00:54:00] people around me know about my open-door policy and there’s a good reason for me to have the door closed. I know some people don’t have offices, they have cubicles or they may have more chaotic lifestyles, but try to make it easy for yourself. If at all possible, try to do that integration before you dictate so that way your dictation time will be actually be very brief and try to get it all done in one sitting.

Dr. Sharp: Yeah, that’s fantastic. Goodness, an hour has gone by really quickly. I feel like I’m looking at this long list of questions that we didn’t even really touch on, but this has been super valuable. I want to be respectful of your time.

Anything else, any kind of parting thoughts or strategies or anything like that, or even resources for folks who are trying to really tighten up their reports and make sure they’re doing a good job and not spending their lives [00:55:00] writing reports?

Dr. Donders: You mentioned my book. I don’t want to oversell it or anything like that, but I’ve pretty much put in a book on Neuropsychological Report Writing; what I think needs to be in there in terms of general guidelines and specific illustrations.

One thing that we haven’t touched on a lot is forensics or any other arena where you might beg to differ with another psychologist. What I have learned is I sleep much better and in the long run, I have much better relationships with my colleagues if I take the high road. I mean that the report is not a place to make snide remarks about another psychologist. It’s not a place to go into a micturition match. It’s not a place to be [00:56:00] passive-aggressive.

So even if I think that other psychologist is an idiot in terms that he can’t tell a cucumber from a frontal lobe, I’m not going to say that. I’m going to say, I’m a little bit puzzled by Dr. So and So’s conclusions because I don’t see a clear foundation for that. In fact, there are some other facts and those facts would be A, B, and C that would suggest otherwise.

If I find myself disagreeing, I try to phrase that in words that if my mother read it and would understand it with her 6th grade education, she would not be mad at me for being nice. You can disagree with somebody, but try to address it in a professional way.

Dr. Sharp: Yeah. Can I put you on the spot a little bit [00:57:00] to ask for maybe another example of how you would do that? What the wording would sound like to politely disagree?

Dr. Donders: This patient had a prior psychological evaluation with Dr. Jones. Dr. Jones gave her a diagnosis of a major cognitive disorder due to traumatic brain injury. I find this somewhat puzzling because we’re talking about an individual who is now more than two years after an uncomplicated mild traumatic brain injury and the literature suggests that the vast majority of people typically recover with a matter of weeks to months. That’s not just my private opinion, but here are some different literature references.

I questioned the terminology do too, because there’s clear evidence in the school records that this child had special education services because of cognitive impairment well before is brightened. It is excellent to ever have. And that’s all I say.

[00:58:00] Dr. Sharp: Okay. I like it. That was a great on-the-spot performance. Thanks for entertaining that. Like I said, this has been incredibly valuable. I’ve been taking a lot of notes. I think that listeners are going to find this very informative. I really appreciate your time. We will have links in the show notes to your book and any other resources that I might be able to dig up to support anything that you’ve said.

So Jacobus Donders, I really appreciate it. Thank you so much for coming on The Testing Psychologist.

Dr. Donders: Oh, you’re welcome. It was fun.

Dr. Sharp: Good. Take care.

Dr. Donders: You too. Bye bye.

Dr. Sharp: Hey, y’all. Thanks again for listening to this interview with Jacobus Donders. Dr. Donders is obviously a very well-decorated member of our field and has done a ton over the years. I found this conversation valuable just to get some insight into [00:59:00] the elements of a report that are truly helpful and some ways to cut down our report writing time to deliver what is most important.

Like I mentioned during the podcast, we’ll have links to his book in the show notes. He has several articles published on a variety of topics that you can look up through Google Scholar or your university library.

A final shout-out to Practice Solutions. They’re a full-service billing agency just for mental health professionals. They do it all. They have greatly helped our practice. They will give you 20% off your first month if you follow up with them and mention The Testing Psychologist, or go to practicesol.com/jeremy.

So thank you as always for listening. This has been a big week. The size Facebook group has literally grown by about 20% maybe [01:00:00] 25% just this week. So something is happening. The word is getting out and people are jumping in, which is fantastic. If you are not a member of the Facebook group, come check us out. It’s The Testing Psychologist Community on Facebook.

If you’re enjoying the podcast, I would invite you to take 30 seconds and subscribe and rate, or even review the podcast. I’m very grateful for any of those thoughts that you are willing to share or the time you’re willing to take.

Of course, as always, if you are looking for consultation for your testing practice, feel free to give me a shout. That is what I do. That’s what I specialize in. I would love to talk with you about how to grow your testing practice or hone your testing services to make things more efficient and make sure that you’re making money like you should be. You can get that contact information at thetestingpsychologist.com. All right, y’all, take care. I will talk to you next time. [01:01:00] Bye bye.

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[00:00:00] Dr. Sharp: Hey everyone, welcome to The Testing Psychologist podcast episode 37. Hey everybody. Welcome to another episode of The Testing Psychologist podcast. I’m Jeremy Sharp. Today, I am talking with Dr. Molly McLaren.

Dr. Molly: Hello everyone. Happy to be here.

Dr. Sharp: I’m excited to have Molly for two reasons; one is that Molly is probably my most familiar guest because we have worked together for the past many years, five maybe six years.

Dr. Molly: Has it been that long?

Dr. Sharp: It’s been a long time.

Dr. Molly: Wow.

Dr. Sharp: Molly started working with me back when she was a graduate student, she was a psychometrician here in the practice and [00:01:00] then went on to do her postdoc here in our practice, and now she is a staff psychologist in our practice so we have a long relationship. Molly’s a pretty amazing person in lots of ways.

Let me introduce you real quick, Molly, and then we can jump right into it. We’re going to be talking all about evaluations for emotional support animals today. This is something that has popped up in the Facebook group quite a bit and maybe a lesser-known area of evaluation but one that we get a lot of requests for, and I know, a lot of listeners get a lot of requests for. We’re going to talk with Molly all about emotional support animal evaluations.

In the meantime, though, Molly is currently a licensed psychologist. She is practicing, like I said, here in Fort Collins, Colorado with us. She graduated and got her doctorate from Colorado State University. She has many years of clinical experience in university counseling centers, college career centers, and community [00:02:00] mental health settings.

She was also a psychometrician, not just for me, but for a clinical neuropsychologist in the community during graduate school as well. Molly has done all of her dissertation research on, how would you phrase it, career assessment, and vocational services.

Dr. Molly: I think that’s fair, about career matching based on fit and online assessment.

Dr. Sharp: Cool. Molly brings a wealth of experience to our practice and we’re super lucky to have her here.

One of the things that we’ve gotten into and started to dig into over the last several months is evaluations for emotional support animals. Do you remember what those initial referrals look like or where those came from? I’m trying to think.

Dr. Molly: I think the first ones I received were from therapy clients who were struggling and end up in a [00:03:00] situation where they’re hoping to get emotional support animal living with them in an apartment.

Occasionally, it was after other types of evaluations like ADHD. I had one after a PTSD evaluation and she came back and asked for an emotional support letter.

Dr. Sharp: Got you. Some of those flow from other evaluations or therapy clients. I know that we’ve gotten some calls from out in the community as well. I think for me, that was the impetus to start looking into this and figure out what’s the deal here.

We’ll talk about all sorts of things related to emotional support animal evaluations, but maybe we could just start with defining what an emotional support animal even is because I feel like I see emotional support animals everywhere, like those vests in airports or in schools or the grocery store. [00:04:00] What is an emotional support animal?

Dr. Molly: That’s the tricky thing because people can just buy a vest and designate their dog emotional support animal in some ways, walking around and pretending that that’s an official thing because people don’t know what the definition is or how it goes about getting official. And so I think you touch on a controversial aspect of emotional support animals.

Technically, how they are meant to be defined is an animal that provides emotional support to someone who has a mental health disability, meaning a diagnosis of some sort, like major depression, anxiety, some phobia issues, or things along that line. The thing about emotional support animals that’s often confused is that they’re different from service animals.

Dr. Sharp: Okay. I didn’t even know that.

Dr. Molly: In a lot of ways, [00:05:00] the best way to define them is what they’re not.

Dr. Sharp: Okay.

Dr. Molly: So a service animal specifically, is an animal that’s trained in several ways to help someone with a disability. That’s usually some sort of physical disability such as maybe blindness or some sort of mobility issue. A dog might be trained to be, can be a guide dog or fetch things, be able to get things for an owner who has mobility issues whereas an emotional support animal is not necessarily trained in any way whatsoever.

Dr. Sharp: Oh, okay.

Dr. Molly: It’s just a pet that a person with a mental health diagnosis has found to be supportive for them and helped them feel better, maybe eases their anxiety or brings joy in their life if they’re depressed, that sort of thing, or in the example of maybe flying on a plane, if you have a phobia of flying, having your animal with you maybe helps you stay calm. [00:06:00] But that animal to be designated an emotional support animal doesn’t necessarily have to have any kind of training whatsoever, which is tricky.

Dr. Sharp: Oh, got you. Yeah, I would imagine. I have a lot of questions with that; can service animals be considered emotional support animals?

Dr. Molly: That’s a good question. It’s like a hierarchy; a service animal could provide emotional support but in order to be defined as a service animal, it would have to be trained beyond what an emotional support animal is.

Dr. Sharp: Okay. Got you.

Dr. Molly: Does that make sense?

Dr. Sharp: Yeah, certainly. It sounds like service animals actually go through specific training. Now that I’m talking about, I feel like I’ve heard of them being specifically trained to provide support for a seizure or something like that. They’re pretty specialized in what they can do, but an emotional support animal could be any animal.

Dr. Molly: A lot less than that. Yeah, it could be any animal. I think a lot of people think of [00:07:00] dogs initially. Dogs are probably the most common, but it can be any animal. That’s not even defined.

Dr. Sharp: Oh, wow. I’m getting a little bit ludicrous, but you could have an emotional support fish or frog, okay

Dr. Molly: Yeah.

Dr. Sharp: Good to know

Dr. Molly: As far as I know, that’s my understanding.

Dr. Sharp: Okay. That sounds good. The majority though, I would imagine are dogs or cats maybe.

Dr. Molly: Mm-hmm.

Dr. Sharp: Okay. Anyway, that opens up a lot in terms of how we handle the evaluation, what we’re recommending but I wonder, just in general, before we dive too deep, when would someone perhaps seek an evaluation for an emotional support animal?

Dr. Molly: The main benefits or permissions you get with an animal that is designated emotional support [00:08:00] animal is that they can be allowed under the Fair Housing Act to live with you in a residence that does not typically allow pets, for instance, sometimes that’s apartment complexes.

Sometimes, they will waive the fee as well. So sometimes it’s an apartment that you can have an animal, but you have to pay a pet deposit, rent and you can get that waived if it’s an emotional support animal or if they’re not allowed, you can then have them.

College dormitories is becoming a more common thing that students are requesting to bring their pets with them to college dormitories and they’re having to figure out how to handle that. Additionally, I mentioned earlier, flying on a plane. Those are the only two places that emotional support animals are actually allowed.

There’s a big misconception that they, like you had said, are allowed grocery stores, out and about while you’re shopping. I think the public thinks that and a lot of people think that so people bring their animals and then [00:09:00] there’s no repercussions for that because people assume it’s allowed. They have the vest on. They don’t want to pry or ask and so people get away with having their animal in public places. Even if they were designated emotional support, they aren’t allowed.

Dr. Sharp: Oh, that’s interesting. So all those signs that you see are specifically only for service animals.

Dr. Molly: Just service animals, yes.

Dr. Sharp: Okay. That’s really important. I don’t know if there’s any way for you to know this, but do people try to bring their emotional support animals into those situations?

Dr. Molly: My understanding, I believe that does frequently happen.

Dr. Sharp: Yeah, I would imagine so.

Dr. Molly: It’s controversial for that reason.

Dr. Sharp: Yeah, sure. That word, controversy, has come up two times already, so I think it’s probably worth diving into that. A lot of the testing and assessment that we do is [00:10:00] presumably empirically supported and we’re making recommendations that we think are going to help with whatever the person’s concerned with or their problem might be or their diagnosis might be.

We’re pretty big on empirically supported interventions. How does an emotional support animal fit into that paradigm? Do we have research to say that an emotional support animal is an empirically supported treatment for anything?

Dr. Molly: I would say the short answer is probably no. There’s research that definitely suggests animals can provide a soothing impact for people. There’s research suggesting that petting a dog, for instance, lowers blood pressure or increases oxytocin, serotonin, other feel-good chemicals in the body. [00:11:00] There was a study about older adults in nursing homes that their depression and loneliness somewhat alleviated by having companion animal or even a plant to take care of.

There’s some research that it can be a positive thing, but surprisingly the research isn’t very convincing that they mitigate mental health disorders. There’ve been meta-analyses on the research that is out there and it’s borderline and more research is needed for sure to fully determine that.

Dr. Sharp: Certainly. It seems like one of those things that, on the surface, it would make intuitive sense that an animal would certainly help you feel better, certainly if you’re an animal person and you choose to be [00:12:00] around an animal, it would help you feel better. I wonder if it’s one of those areas where the research maybe hasn’t caught up or there’s not enough yet or something along those lines, I don’t know.

Dr. Molly: That’s certainly plausible. It’s also plausible that there’s a specific subset of people and disorders that might be benefited by emotional support animals. And then it’s possible that some could be harmed and we don’t know that.

Dr. Sharp: Sure.

Dr. Molly: So it’s definitely tricky.

Dr. Sharp: Do you have thoughts just off the cuff about when an emotional support animal would not be helpful or people who might not benefit from that?

Dr. Molly: I could conjecture.

Dr. Sharp: Sure.

Dr. Molly: I don’t have any evidence other than my own opinion based on working with clients but I could see potentially someone with maybe severe [00:13:00] social avoidant tendencies, social anxiety feeling better having an animal companion, but then maybe feeling less motivated to go out and make human friends because it’s easier to have a canine friend and as such, their life getting limited or potentially their mental illness getting worse because they can rely on that animal rather than getting out.

Dr. Sharp: Sure. That makes sense.

Dr. Molly: Not that I’ve necessarily seen that happen, but could see it being a possibility.

Dr. Sharp: That makes sense. I can absolutely see that. On the flip side, though, are there things that you have worked with or maybe common concerns that people come in with that you think an animal is more beneficial for has more propensity for helping?

Dr. Molly: I do think that animals make people feel better in their home if they’re [00:14:00] anxious or feeling low, or if they, again, the same example, the flip side of social anxiety, if you’re struggling to make human connection and you can make animal connection, that can probably make you feel better but you have to be able to balance it by continuing to work at what’s going on for you.

Same thing with depression, having an animal in your home could potentially boost your mood, make you feel a little happier as long as you’re continuing to combat the depression in other ways. People who are not in favor of emotional support animals argue that other strategies could do that, too and so do we really need to have emotional support animals?

Dr. Sharp: That’s always the question when we’re talking about treatment efficacy; is it better than whatever the standard is, CBT or medication, whatever [00:15:00] intervention might otherwise be used.

Dr. Molly: And in this case, that’s maybe even particularly important because we’re talking about giving special permission to people to have these animals in places that they wouldn’t ordinarily be because it needs to be far and away better than any other options they have to get that access.

Dr. Sharp: Yeah, that’s a good point. This came up in the Facebook group maybe, if anybody’s not a member of the Facebook group, it’s The Testing Psychologist Community on Facebook. We have a lot of cool discussions in there about testing-related stuff.

When we were talking about emotional support animal evaluations, someone brought up the point that there’s a certain amount of the population who is actually allergic to animals, and that’s something that we have to consider when we’re granting treatment, so to [00:16:00] speak, that happens in public that puts other people at risk

Dr. Molly: For sure, especially on an airplane.

Dr. Sharp: On an airplane, yeah, exactly. I wonder, this is totally spinning off, do they ask the other passengers if someone can bring in a service animal or emotional support animal? I’ve never been asked.

Dr. Molly: I don’t think so. You can bring your pet on a plane if you pay.

Dr. Sharp: That’s true.

Dr. Molly: In the cabin, if they’re small enough. This just waives the fee.

Dr. Sharp: Oh, got you.

Dr. Molly: And let them sit in your lap rather than under your seat.

Dr. Sharp: Yes, right. It seems fair to say the jury is maybe out on the efficacy of emotional support animals. Anecdotally, it seems to make sense. I’ve certainly heard stories of folks on the autism spectrum who have a good connection with animals and that can sometimes facilitate connecting with people as well.

You move in this direction of doing an evaluation [00:17:00] to see if this would be helpful. What does that process actually look like?

Dr. Molly: So again, that’s not very well delineated. To put it out there, my bias, initially going into this as we were talking, one of yeah, sure, of course, that’s helpful. I was all gung-ho about doing these ESA evaluations until I started looking into the research and I’m like, wow, this is a lot more complicated than I had realized.

So I had a protocol set up that would involve a clinical interview with the client, collateral interviews with people in their lives, whether other professionals that they’ve worked with around their mental health concerns or family, close friends, that sort of thing, who could corroborate their symptoms and concerns for a little bit of extra data there.

And then also personality assessment of some sort, so PAI, MMPI, MCMI, one of those [00:18:00] to get an assessment and some backup objective data of their symptoms to document that there’s truly a mental health concern present.

I think the biggest concern with the evaluation is making sure that people aren’t just trying to game the system in some way and save $1, not have an animal with them when they’re not supposed to, because they love their pet, which I sympathize with. I love my dog but there’s rules in existence for a reason with these institutions that aren’t allowing animals to make it important that we are being thorough in how we do this evaluation.

Dr. Sharp: Sure. But there’s no standard, you said, set forth by any agency or APA or anything like that. It’s not like we have standards of care for emotional support evaluations.

Dr. Molly: Unfortunately, no. It’s not empirically supported so there’s no [00:19:00] empirically validated way of measuring something that we don’t even know necessarily helps.

Dr. Sharp: Yeah, that’s true. Circular argument there.

Dr. Molly: You can certainly argue that there’s an empirically validated way of establishing diagnosis, that mental health disability exists. That’s about as far as the evaluation process goes. That they have social anxiety, that they have major depression but not to say necessarily, that the animal is going to lose help.

Dr. Sharp: Right. That makes sense. In that way, it’s similar to any number of other, I would say, personality evaluations for like egg donation or adoption or something; you’re just getting a good, and I don’t mean to minimize by any means those types of evaluations, but getting a good sense of someone’s personality, mood, [00:20:00] social-emotional functioning just to see what’s going on with them.

Dr. Molly: Yeah, definitely.

Dr. Sharp: Sure. I know that you have to document those results somehow, so what does the documentation look like? Do you write a report? Is it something different? What’s that look?

Dr. Molly: You certainly could write a report. I’m not big on report writing so my plan was to focus on the necessary documentation for their request. For instance, most of the time people are coming with something specific that they’re wanting.

They usually have some sort of form that they need filled out from their apartment complex or from their dormitory or you can write a very generic kind of letter acknowledging that you did the evaluation with them, that you’ve diagnosed them with a mental health disorder and you’re prescribing [00:21:00] an emotional support animal for that.

Dr. Sharp: Oh, that’s an interesting word, prescribing.

Dr. Molly: Yes, that’s the word they use.

Dr. Sharp: Huh?

Dr. Molly: It is interesting.

Dr. Sharp: Wow. That is interesting. That makes me think, can a physician write a letter for an emotional support animal?

Dr. Molly: I believe so, yes.

Dr. Sharp: Okay. That’s good to know. So the prescribing, so you are actually saying, yes, this animal …

Dr. Molly: Prescribing it for this issue.

Dr. Sharp: Absolutely.

Dr. Molly: And sometimes the forms also have some liability language as well, which is interesting.

Dr. Sharp: What do you mean?

Dr. Molly: That you would be willing to go to court if something were to come up and testify that everything was legit and that you do support this emotional support animal for this person.

Dr. Sharp: Got you. I think that’s maybe where we were getting stuck within the practice in whether we do these evaluations or not. I’ve talked before on the podcast about [00:22:00] scope of expertise and using that question, what if you had to defend this in court, would you feel comfortable?

And so when it comes down to it, when you’re actually signing a letter that says, I will testify that this person needs an emotional support animal, that’s hard when there’s not a ton of research to back it up, right?

Dr. Molly: Yeah, definitely. It definitely gave me pause and was part of why we were like huh, let’s think a little bit more about this and do some good research to make sure that it feels valid to prescribe an emotional support animal for someone.

Dr. Sharp: Absolutely. There are a lot of questions with these, in terms of moving forward with the process though, if it felt like that was reasonable, you can write that letter or sign that form. Before we started to pull back from these, did you ever have to tell someone that they did not [00:23:00] qualify for an emotional support animal or deliver that kind of feedback?

Dr. Molly: I did not. I think that brings up another interesting issue is that when we were planning to do this, it was something that we thought about ahead of time to make sure was in the disclosure that just because someone is coming in for an evaluation does not mean that they would necessarily get support. The people I did see for a support evaluation, I did end up supporting, I felt like it was valid.

Another piece of that that I was planning to do was to make it pretty comprehensive, thorough, that it would be a lot of work for someone to go through just to save a few bucks and that it costs money for them. So it’s not necessarily just about that, it’s about a need for them to try to weed out people that maybe are trying to gain the system, [00:24:00] so to speak.

At the outset, that would be a tricky conversation to have with someone. The good news would be that if they aren’t qualifying, it’s because you didn’t find them meeting criteria for a mental health disorder. And so I think one way to frame that would be like, hey, you’re actually functioning pretty well, I don’t think you meet criteria for a mental health disorder. In some ways, that’s very good news.

Dr. Sharp: Sure.

Dr. Molly: That could help soften the blow, but I do think it would be tricky, especially if you’re their therapist.

Dr. Sharp: Right. So then we get into that dual role issue. You said that you had some therapy clients that were requesting these letters, how did you handle that?

Dr. Molly: Fortunately, if memory serves, I’ve had two. I felt, at the time, comfortable recommending the emotional support animal for [00:25:00] them. I felt that it was valid and that they did have a documented mental health disorder that was mitigated at least in their eyes by their animal.

I think that it could really put a rift in rapport with a therapy client if that therapy client asked you and you said, no, I don’t think that is appropriate. If you say you’re not comfortable doing it, they probably roll with that, but it’s hard to know who then to refer them to.

Dr. Sharp: It’s a good point.

Dr. Molly: So that’s where we were thinking about coming in but it’s hard.

Dr. Sharp: It is hard. I think that’s the thing that’s come out of this conversation is that there’s still a lot of question marks with how to do an evaluation like this. We’re still waiting for the research to catch up and better guidelines for how to do it.

Dr. Molly: Yeah. [00:26:00] A lot of people are, and I think there’s frustration across the board for providers that don’t know how to handle it, don’t know what to do, don’t want to turn people away, especially with no good person to refer them to as an expert in this. So there’s a gap.

Dr. Sharp: Sure. That makes me think, I know that there are a lot of resources online to, if you google emotional support animal letter, there are all kinds of places that you can fill out an online survey. Maybe you meet with someone over Skype, I don’t know, but they’ll give you a letter just over the internet. Do you have thoughts on that process or the validity of that or what do you do with that? Because I would imagine clients would just walk away from the psychologists and go google it online.

Dr. Molly: Probably. In my opinion is [00:27:00] that it seems sketchy. It seems like a way to make money because they charge $150 or something for this letter, maybe. I don’t know, don’t quote me on that, but a little fee.

And then they say that it gets reviewed by a mental health professional and you just send in information saying, here’s what’s going on for me. They review your case, and maybe they look at some documentation. I don’t know how thorough, some may be more thorough than others but having not met the person and the fact that it’s just all over the internet seems a little sketchy.

Dr. Sharp: Sure. I’m with you on that. There’s a lot to sort through here. It’s an interesting situation in that there aren’t a whole lot of other evaluations that you can also just go to the internet [00:28:00] for, right?

Dr. Molly: Very true.

Dr. Sharp: It’s got me thinking about is this a service that psychologists need to think about providing or not.

Lots to think about.

Dr. Molly: Indeed.

Dr. Sharp: Like I said, we’ve talked about this topic a lot in the Facebook group and it’s popped up here and there, other places as well. It was when we started talking about doing the evaluations and then the podcast and digging into it, I was surprised that the research was not present. I just assumed that it was out there.

Dr. Molly: Me too and as a dog lover, there was something I was reading brought up the point that media tends to support emotional support animals. Everything that they put on media is yay, emotional support animals and so people assume that it’s well documented.

There’s [00:29:00] also an important downside. I want to just mention that a lot of people don’t think about as well is that, the fact that emotional support animals are not well trained and if people are taking them in public places, even though they’re not meant to, and their animals misbehave or goodness, bites somebody, think about how badly that reflects then upon service animals, because people don’t know the difference.

Dr. Sharp: Sure.

Dr. Molly: Service animals are not going to misbehave like that. They’re so well trained, but people who have are dependent upon their service animal have to have the animal out with them in public, but then gives that service a bad reputation because people are bringing their untrained animals out and about with them. That’s a big concern.

Dr. Sharp: Sure. I would maybe even take it a step further and then say that some of the empaths falls on us to take some [00:30:00] responsibility for that and really be mindful certainly of the person’s presentation and the evaluation results, but also of the research in general to say yeah, this has got to be an ironclad kind of thing to recommend that folks are allowed to take, you never know, I hate to assume worst case scenario, but untrained animals in public where they maybe shouldn’t be.

Dr. Molly: Yeah, for sure.

Dr. Sharp: And then does that reflect poorly on us as well?

Dr. Molly: And one thing we can do is recommend to the client that they get basic training for their animal. As long as it’s not a gerbil, I don’t know if they have, but assuming it’s a dog of some kind, but there’s no way of following through with that or enforcing that. There’s not a framework in place for that yet.

Dr. Sharp: Sure. This is interesting. I appreciate your time and willingness. I know that you’ve spent a lot of time digging into [00:31:00] this and we’ve talked about, is this a worthwhile service and if not, why not? And if so, why so. I know you’ve spent a lot of time with it and appreciate you being willing to come on and chat and talk about it. Hopefully, it’s been somewhat informative for other folks out there who are considering taking on these evaluations.

Dr. Molly: Yeah, absolutely. Thanks for having me.

Dr. Sharp: Of course. I should ask, putting you on the spot, but any resources or things to look at if someone is considering doing these evaluations, anything?

Dr. Molly: I don’t know the website; web address is offhand. When I was doing some hunting, I was able to find some pretty good resources. Psychology Today had some but just discussing the pros and cons and the complications of it. So keyword searching for ethics in emotional support [00:32:00] animal evaluations or empirical support and emotional support evaluations, you can find a lot of good websites discussing the issue and both sides of it.

Dr. Sharp: Okay. That sounds good. I’ll dig around and try to find some of those links to put in the show notes in case people are curious and want to look more into it.

Dr. Molly: Great.

Dr. Sharp: It sounds good. Dr. Molly McLaren, it’s great to have you on the podcast and provide another dimension to our working relationship. So thank you so much for coming on and sharing all of your knowledge.

Dr. Molly: Absolutely. Thanks for having me.

Dr. Sharp: All right. Hope you all enjoyed that interview with Dr. Molly McLaren talking about emotional support animal evaluations. That’s something that we get a lot of questions about. Hopefully, that shed some light on that whole process.

As always, I would love to hear from y’all about your own experience with emotional support animal evaluations, or particularly in this case, letting me know if there’s any [00:33:00] research out there that I might not be aware of that could support doing these evaluations and feel a little better about recommending emotional support animals.

Once again, I want to thank this month’s podcast sponsor, Practice Solutions. Practice Solutions is a full-service billing company that specializes in mental health practitioners and practices. They integrate right into TherapyNotes, which is their preferred EHR. So if you use TherapyNotes, they’ll be a great fit for you. If not, they’ll help you get up and running with TherapyNotes.

They do everything. They do benefits checks, claim submissions, follow-up billing, collecting payments, and anything you could ask for on the billing side. They’re very knowledgeable, like I said, about mental health. They have really helped our practice. So if you are interested in a billing service, give them a ring or a click rather, you can get 20% off your first month’s service at [00:34:00] practicesol.com/jeremy.

Thank you again for tuning in. Great to be back with you doing some interviews and gaining some knowledge from other folks. There are a lot of great folks out there and we have some cool interviews coming up. Hope to catch you next time and take care in the meantime. Bye bye.

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[00:00:00] Hey y’all, welcome to The Testing Psychologist podcast, episode 36. I’m Dr. Jeremy Sharp.

Hello everyone and welcome back to The Testing Psychologist podcast. Today is episode 3 in the 5 Quick Tips series. I hope you’ve enjoyed the previous two. If you haven’t listened to them, maybe go back and check those out. I did Five Quick Tips for Billing Testing Services and Five Quick Tips for Getting Reports Done Efficiently. Check those out. They’re definitely on the website, thetestingpsychologist.com.

Today, I’m talking all about Five Quick Tips for Marketing.

Before I jump into that, let me give a shout [00:01:00] out to Practice Solutions who is sponsoring the podcast this month. They help you to not waste your valuable time and energy focusing on an administrative task like billing. They save you time. They make sure your billing is done with integrity and transparency, and they are a fantastic choice. We have used them for the past few months. Even in what I would have considered a pretty efficient practice, they’ve increased our collections significantly. So I can vouch for their services. They’re kind. They’re always available. They’re around 24/7. They’re very transparent and very skilled.

Check out Practice Solutions. The website is www.practicesol.com/jeremy. If you sign up through that link, or even just tell them that you signed up or heard about them through The Testing Psychologist, you’ll [00:02:00] get a 20% discount on your first month. So check them out if you’re in the market for a billing service.

Today, we are talking about five quick tips for marketing your testing practice. These are things again, that I’ve found over the years that have certainly proven helpful and things that we do in our practice day in and day out.

Quick tip 1, very easy. Send thank you faxes. Every interview that I do, I always ask who referred to the client for testing and if I have permission to contact that person just to say thank you in an anonymous way. I rarely run into anyone who does not want me to do that or is not okay with that. So after the interview, I fill out an interview follow-up form, which we have developed here in the office, and one of those items on the [00:03:00] follow-up form is a checkbox where I can say send a thank you fax to the referral source and then I write in the referral source and our admin assistant faxes that over to the referral source.

Make sure that it’s on your letterhead. Make sure to craft a nice message that is personable but not so personal that you have to rewrite it every single time. I found that that helps to get our name out in front of other people’s faces and it was just kind to let them know that you appreciate their referral. So sending thank you faxes.

My second quick tip is go to the schools as often as possible if you are testing kids. I’ve talked before about school observations and how valuable those can be from a clinical perspective. I also think that they are incredibly valuable from a marketing perspective. Again, it gets you out in the community. [00:04:00] It lets you meet educators, administrators, teachers, and counselors at the schools, and it gives you a good sense of what different schools are like in your area.

So as much as possible, and as much as is clinically relevant, do school observations whenever you can. Get out there and make sure to meet people to always introduce yourselves to the teachers, to the counselors, even to the principal, if they’re around. Over time, you can develop nice relationships with schools. We’ve gotten many referrals from schools because of that.

Quick tip 3, always do collateral interviews with any other providers involved. This is maybe a no-brainer, but I have found that sometimes it can be hard to make the time- both making the time to schedule those collateral interviews and also coordinate schedules and actually finding the time [00:05:00] to talk with other providers because we’re all so busy.

This is another place where I would give a shout-out for having a virtual assistant or even an in-office assistant as someone to help you schedule those interviews. So you can add that to your list if you’re trying to decide if you need a VA or not as that person who could help schedule collateral interviews.

I always do collateral interviews with any other providers involved. Through that, I have talked to countless other therapists, psychiatrists, medical practitioners, massage therapists, acupuncture, like anyone that seems like they would have relevant info and would be a valuable person to chat with for your testing case. Go for it. Do those collateral interviews. It doesn’t have to be long. 10 or 15 minutes usually gets the job done. I’ve heard so many times those folks say, thank you for reaching out. [00:06:00] We don’t hear from evaluators very often. So, again, that’s a great way to network and build relationships in the community and subsequently get referrals.

Tip 4 is to ingratiate yourself and get to know the referral coordinators at various medical practices. So at least in our community, we have probably three, I’d say big medical practices that have multiple locations here in town and serve a lot of people.

In some cases, the referral coordinator is a person that oversees referrals for the entire office or medical practice in multiple locations. In some cases, each office location has its referral coordinator. So I would do some research again, a great task for a VA, and figure out who the referral coordinators are. It’s [00:07:00] easy to shoot them over some information, a quick one-page fax, or a little a one-page brochure flyer, and make sure that you know their names, you know where they work and they have your information.

Related to this, you can keep a spreadsheet or contact sheet with all these referral coordinators’ contact information, locations, and all of that so you’re not reinventing the wheel every time you want to send out an update for your practice or just get some information out there.

So get to know your referral coordinators. They are the ones who are talking with the physicians most frequently, networking with the patients, and sending those patients out when they need to get connected with services.

My last quick tip for marketing is to consider digital marketing as part of your practice profile. [00:08:00] A few episodes ago, I interviewed John Clarke from Unconditional Media. I will link to that again in the show notes here. 

There are a variety of ways to do digital marketing. I think it can be particularly helpful if you are adding clinicians and you need to get referrals quickly, or if you’ve moved to a new town and you need to get referrals quickly in a place where you maybe don’t know folks to do the networking.

There are many different forms of digital marketing. I would highly recommend not trying to do it yourself unless you want to spend the time and energy to figure out how to do it well. I’ve said since way back in the beginning when I started my practice and started to do these private practice talks that digital marketing, search engine optimization, AdWords, Facebook ads, all of that are science unto itself. I have personally lost a lot of [00:09:00] money trying to do it myself and not doing it well. So take it from me. If you consider digital marketing, talk to a professional, but it can be really helpful for your practice.

All right, folks, that concludes my last 5 Quick Tips episode. I hope you took a little something away from these tips for marketing your practice.

As we conclude this 5 Quick Tips little series, I’ll give you the info again, just for the website. If you want to find out more or check back on past episodes, you can go to thetestingpsychologist.com and check out all of the past podcast episodes. There’s also a link there to the Facebook community, which is fantastic. It just continues to grow. We have 300 people in there now at this point, probably more by the time you hear this episode. We’re talking the business of testing insurance, billing, different [00:10:00] measures, all kinds of good stuff. So you can find that Facebook community either by searching Facebook for The Testing Psychologist Community or by clicking through on the website.

If you’re interested at all in talking about consulting or collaborating on how to grow your testing services, you can find out more about that on the website as well. You can also give me complimentary anything, but I will give you a complimentary 20-minute phone call just to talk about whether consulting could be a good fit for you or anything else that would be helpful in moving forward with your practice. So if you are interested in that, feel free to shoot me an email, at jeremy@thetestingpsychologist.com. We can talk for a few minutes and figure out if consulting might be a good fit for you.

Finally, I will give one more shout-out to Practice Solutions. They’re a fantastic full-service billing [00:11:00] company. They do eligibility, benefits checks, statements, insurance verification, and collections. They do it all. They are kind. They know what they’re doing. They’re very responsive and they’ve increased our collections significantly just in the few months that we’ve been working with them. So I can highly recommend them from working with them in our practice.

If you do want to check them out, the link is www.practicesol.com/jeremy, and they will give you 20% off their first-month services if you mention The Testing Psychologist or go through that link. So check them out if you’re looking for a billing service.

So, like I said, we have some cool interviews coming up. I’m looking forward to getting back to the interviewing game and bringing some great content to you from some well-respected folks in the field. As always, if you have any ideas for podcast [00:12:00] episodes or anything you want to hear about, feel free to shoot me an email. Otherwise, I will talk with you next week. Thanks. Bye bye.

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[00:00:00] Hello everybody. This is Dr. Jeremy Sharp and this is The Testing Psychologist podcast episode #35.

Hey yáll, this is Jeremy. Welcome back to The Testing Psychologist podcast. I hope everybody is doing well. We are definitely full-on fall here in Colorado. I am looking out the window of my new office, which I love. It has an amazing mountain view off to the west, but in between my office and the mountains, there are a ton of trees with the leaves changing yellow. A lot of them have the leaves totally gone. We’re getting there. It snowed two weeks ago. That’s what it’s like to live in Colorado here. It’s a little crazy.

Hope y’all are doing well. Hope that you were enjoying the weather, whatever that looks like for you [00:01:00], and heading into the holiday season.

Today is the second episode in a series of 3 of 5 Quick Tips. Today, we are talking about Five Quick Tips for Billing.

It’s a nice segue, I think before I get into billing to give a shout-out to this month’s podcast sponsors, Practice Solutions. They are a full-service billing company.

Spending valuable time and energy focusing on an administrative task like billing can be the biggest limiting factor to your practice’s growth. I experienced this in our practice even. Between saving you time and making sure your billing is done with integrity and transparency, Practice Solutions is a great choice for that.

We’ve been working with them for a few months now, and they are doing a fantastic job. Our collections have gone up at least 20% month to month. They’re doing a great job [00:02:00] from eligibility and benefits checks to denial follow-up, they will get you paid as quickly and efficiently as possible. Their services are very transparent and easy to understand. You’ll know the status of your billing 24/7. They’re super nice and friendly. So that helps too. If you sign up through the podcast link in the show notes, they will give you 20% off your first month as well.

Talking about billing, we have several things to consider today. I have five quick tips for you with a little bit of a bonus tip as well.

If you are billing insurance, my first tip is to keep a pretty comprehensive spreadsheet for the information that each insurance company requires; whether they need a pre-auth for testing services, which codes they authorize- whether 96101 or 96118, and how many [00:03:00] hours they typically approve. Now, some of this information you can get from the insurance company’s website. Some of that information you learn over time. Another piece that you can include on that spreadsheet is whether they require preauth for specific diagnostic codes or not. I like to keep track again, like I said, of the CPT code, the diagnostic code, how many hours they typically approve, and whether they require a preauthorization.

That’s tip number one, keep a good spreadsheet based on your experience and based on your research on the internet and in your contracts with the insurance companies.

Relatedly, my second tip is to make a template for pre-auth forms. Most insurance companies do require pre-auth. They have a form that you have to fill out. I’ve created fillable PDF documents that [00:04:00] have the critical information already filled in. So depending on what diagnoses you typically test for, as I’ve said many times, I work with kids, so we have pre-auth forms that have the questions already filled in relevant to whether we’re testing for ADHD or autism or a mood disorder or some other differential diagnosis, brain injury, whatever it might be and we have a separate pre-auth form for each of those primary diagnoses so that once we go in to fill out on the pre-auth, all we have to do is fill in the client’s personal information; their insurance ID, their date of birth, address, that kind of thing. And then if there’s anything you have to tweak specific to that client.

I found that most insurance companies that require pre-auth want you to say [00:05:00] the same thing each time. They have the same questions that you want answered and goals of testing and things like that. So templates can help you there.

My third quick tip is to outsource your billing as much as possible. Unless you have someone in-house or you have a family member or something who is pretty skilled in mental health billing, I think it makes sense to consider outsourcing your coverage and benefits. I’ve talked before about the benefits of knowing coverage and benefits for clients. So when I say outsource your coverage and benefits, if you’re not ready to outsource your entire billing operation, which is fine, I would at least outsource the coverage part. Again, this is if you’re taking insurance. So when I say outsource your coverage and benefits, I [00:06:00] mean, contract with a company who can check benefits for the clients before they come in for testing. This will allow you to give people an estimate of their cost right up front. That way, there are no surprises. Now, if you’re not billing insurance, then that’s a moot point, I still think it’s helpful to talk with people upfront about the cost.

In fact, that is my fourth tip. So three and four, I separated, but they’re kind of like the same tip. Tip number three was to outsource your coverage and benefits if you’re taking insurance. Tip number four is more be sure to speak very clearly about the cost right up front. I think some of us can shy away from talking about money and you may have to do a little bit of work around that. I always say, just practice saying your fees over and over again in the shower, while you’re driving to your friends, to your partner, to [00:07:00] get used to it because testing is expensive and it can feel intimidating and a little shaky to put that out there with our clients right up front, but I think it’s really important for clients to know what they’re getting into.

So, speaking very clearly right up front on that initial phone call to help people know what it’s going to cost, I think is helpful. That way, they can plan and there are no surprises down the road.

My 5th quick tip is to seriously consider collecting a down payment or a deposit of some sort for your testing services. The way that we do this is we give people an estimate of the cost right up front when they are scheduling their appointment or when they come in for the first appointment and we collect half of the estimated total cost at the testing appointment. [00:08:00] In our practice, that means that’s the second appointment that families come in for.  And like I said, we collect half of the estimated cost. I found that it is extremely rare that we end up having to give refunds and it has drastically improved collections rather than collecting everything at the end.

I’ve heard of people collecting a deposit of a set amount, that might be $500, it might be $750, might be $1000 depending on what you charge for your evaluations, but I think it helps to greatly increase your collections and make sure that people are invested in the process.

Now, a related tip, I’m just throwing this in here as a bonus tip, but a related tip is to seriously consider taking a credit card on file as part of the intake process. I have found that very few people balk at [00:09:00] giving a credit card number and it again drastically increases your collections if you get to that point where you have to charge a card because someone didn’t pay. So consider taking a credit card as well.

My last tip, another little bonus tip is don’t sell yourself short. I’ve heard some discussion in the Facebook group, even recently around people making comments like I can’t possibly bill for all the time I spend writing reports. Well, I think you should bill for all the time that you spend writing reports because if you’re spending that much time writing reports, my hope is that it’s because you’re being thorough, and comprehensive, and you’re providing a really good testing service.

Now, you can check in with yourself if you are taking too much time for whatever reason; you’re overly meticulous [00:10:00] or unfamiliar with something, or you’re learning about a particular aspect of testing that you’re trying to integrate into the report. I think that’s a different story. But for people who are writing comprehensive reports, especially if you’re not billing insurance and you’re not limited by insurance company reimbursement for hours, certainly bill for the time that you spend writing your report. This is a very specialized service and people find it valuable and you have to spend the time that it takes to write a good report. So don’t sell yourself short. Bill for the time that you take.

Those are my 5+ plus quick tips for billing testing services, a few related to insurance and a few not related to insurance. I hope that is helpful for you as you consider tweaking your billing services a little bit.

Stay [00:11:00] tuned next time for our last five quick tips episode. That episode is going to be 5 Quick Tips for Marketing Your Testing Practice. In the meantime, if you are looking for a billing service, consider Practice Solutions. They’re great. Their website is www.practicesol.com/jeremy is the landing page here for The Testing Psychologist. If you sign up through that link or mention that you heard about them through The Testing Psychologist, they will give you a 20% discount on your first month’s services.

So hope y’all are doing well. Take care. Enjoy the holidays here as they come up and we’ll talk to you next time. Thanks. Bye [00:12:00] bye.

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[00:00:00] Hey everybody. This is The Testing Psychologist podcast episode 34.

Hello everyone, welcome back to The Testing Psychologist. This is Dr. Jeremy Sharp. Glad to be back talking with y’all. I took a two-week break from the podcast here for a big deal in our private practice.

We have spent the last probably 10 days moving offices. We have been working for several months now to find a space that would house all of our clinicians and give us a little bit more room to grow. Prior to this, we were in an office suite. We were spread across two different suites, so it felt disjointed and not good for our staff to be in separate places.

[00:01:00] I’ve been working over the last few months to find a space that would hold all of us, and we did. So we’ve been waiting on the construction to get finished and strategizing for how to move everything and try to be as efficient as possible. That has been happening over the last week or two. So we are here, we are seeing clients, and feels great to have everybody here in the same space and moving forward with a little bit of room to grow.

So thanks for bearing with me as I took two weeks off here with the podcast. I’m going to be back here, I think pretty regularly for the next several weeks. As I mentioned before, I have some cool interviews coming up with some reputable folks here in the field. Catherine Lord, if you’re familiar with ADOS, was an author of the ADOS; and Jacobus Donders who wrote a book all about feedback sessions. Those are [00:02:00] all coming up. I think we have some good interviews for you in the coming weeks.

In the meantime, I’m going to do a little podcast series here called Five Quick Tips. I think I’m going to do probably three of these. Today will be the first one. The idea is to hit you with five really simple, easy tweaks to address some different issues with testing.

Today’s episode is on writing reports efficiently and getting your reports done. We’ve had a lot of questions in the Facebook group about how to get reports done efficiently. So today I’ll be talking with you about Five Quick Tips for Getting Reports Done. And then we’ll move on from there. In the coming weeks, I’m going to talk about Five Quick Tips for Billing. I’m also going to talk about Five Quick Tips for Marketing your testing practice over the next couple of weeks.

Before I jump [00:03:00] into the Podcast today, I wanted to talk with you about Practice Solutions. They are responsible for bringing you the podcast today and for the entire month of October.

Spending valuable time and energy focusing on an administrative task like billing can be the biggest limiting factor to your practice’s growth. Between saving you time and making sure your billing is done with integrity and transparency, Practice Solutions is the best choice. We use them here in our practice and they have just been fantastic for us. From eligibility and benefits checks to denial follow-up, they’ll get you paid as quickly and efficiently as possible. Their services are transparent and unlike any in their field. You’ll know the status of your billing 24/7. They take great care of you.

So if you are looking for a billing service, I would certainly consider Practice Solutions. Like I said, they’ve done a great job for our practice. I can [00:04:00] highly recommend them. And you get 20% off your first month when you sign up from the podcast link, which will be in the show notes.

Moving forward with our Five Quick Tips for Getting Your Reports Done, these are just a few things that I found over time that have helped. I’m not going to go into a ton of detail, but I’ll give you a few things to write down and start to explore to try and make some of these little changes in your practice.

Tip 1. Think about getting a dual monitor set up for your computer. The reason I say this is because it can help with paperless files which cuts down on storage, but more specifically to reports, I find the dual monitor setup to be helpful because I can be writing the report on one monitor while I am looking at relevant documents on the [00:05:00] other monitor. So if you get monitors that are big enough, you can have easily two Word document-size windows open at the same time. So you could be looking at two sets of scores. You could be looking at your history and scores. You could be looking at the report you’re writing and any amount of data on the other monitor. This has helped me switch back and forth quickly and get that data into the report as quickly as possible.

Another thing that you might consider is to extend your intake sessions to include time to write your history. For example, you could extend your intake sessions by, let’s say, a half hour. So, you just know that after that intake session, you go right to the computer or to your dictation software, whatever you might be using to write your history, and you [00:06:00] sit down right there and bang out that history as fast as possible.

This has helped me because, rather than going to write the report, maybe a week or two after the testing has been done, I already have the history there. I don’t have to spend time putting that together. And it’s a lot fresher on my mind right after the intake. So my recommendation is to schedule it right into your EHR. If you’re not using an EHR, block it into your paper planner and include it as part of the interview time.

Tip 3, I would look into software like Text Expander or simply use the autocorrect feature on Word to streamline the report writing process and let you put in familiar repetitive chunks of the report as easily [00:07:00] as possible.

Text Expander is a piece of software that lets you use a shortcut to expand into a longer paragraph. For example, I have a paragraph that I include in my reports pretty often that is an explanation of ADHD; what it is, what it typically looks like, and things like that. I have a Text Expander snippet is what they’re called. The snippet is ADHD explanation. Every time I type ADHD explanation, it expands automatically into this longer paragraph that I have put into the program at an earlier time. So it cuts down, if you have paragraphs like that, that you write pretty often, it cuts down on the time to do that. So you’re not typing them over and over.

You can use TextExpander or Word’s auto-correct function. They serve the [00:08:00] same purpose. I think Text Expander is a lot more detailed, nuanced, and comprehensive, but either would work. I have a video on the website, or let’s see, I don’t know if I have it on the website. I think it is linked in the Facebook group, but I will put a link to the video in the show notes on how to use Word auto-correct to expand your text as well. So consider something like that.

Tip 4. Develop recommendation banks and use the text expansion feature or the insert file feature in Word to insert those recommendation banks. When I say recommendation banks, these are templates, I suppose where I’ll have a set of recommendations, say for ADHD for kids, and over time, I add to that [00:09:00] recommendation bank based on all the kids that I might diagnose with ADHD. I will add those recommendations to that particular recommendation file. And then for future kids who also get diagnosed with ADHD, I will insert those recommendations. For me, it’s a lot easier to go through and delete recommendations that don’t fit than to conjure up new recommendations and type them in. So that’s the approach that I take.

Now, again, you can pair this with a Text Expander or an autocorrect. For example, you might have a snippet called ADHD kid recommendations, and then it just expands into that full set. Alternatively, you can use the insert file feature in Word, which is what I do. You insert the file and then it puts the recommendations in automatically. So you don’t have to copy and paste, which can take up a [00:10:00] lot of time.

The last recommendation that I have for getting reports done is to chunk your time. I’ve talked about this in previous podcasts in terms of scheduling and managing your schedule for testing. But I’ll say it again, chunking your time can be a huge asset. When you chunk your time, you set aside huge blocks, I would say at least 3 to 4 hours to write reports. Unless you are a superhero who can write reports and do meaningful work in a half hour or an hour, which I cannot seem to do, chunking your time can be really helpful.

I would take however much time it takes you to write a report from start to finish and have that many chunks in your schedule. It doesn’t have to be every week, but fit them in a time period that makes sense for how fast you want to turn your reports around.

For [00:11:00] me, I know that I can get a report done from start to finish in about 2 hours if it’s fairly straightforward, maybe 3 to 4 hours if it’s extra complex or have to write a lot of new content. So every other week I block out at least two full weekdays to write reports. Those days I just come in, and I do not check email except at the beginning of the day, maybe once in the middle, and then maybe once at the end. All I do is write reports and it helps to get in the flow and get in the zone to get those reports done.

Those were my five quick tips for getting reports done. I hope that was helpful to you. Again, in the next couple of episodes, we’ll be talking about five quick tips for marketing and five quick tips for billing your testing services. So check those out over the next two weeks.

[00:12:00] In the meantime, if you are in the market for a billing service, like I said, Practice Solutions has been fantastic for our practice. They are sponsoring this month’s podcast episodes and they are giving anyone who signs up through the podcast or this link, a 20% discount on the first month’s services. Catherine and Jeremy are fantastic. They’re a husband-wife team. They are super responsive and super knowledgeable, and they will take really good care of you with everything billing-wise. So check them out if you’re thinking about a billing service and take care in the meantime. Thanks. Bye-bye.

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[00:00:00] Dr. Sharp: Hey y’all, this is Dr. Jeremy Sharp. Welcome to The Testing Psychologist podcast, episode 33.

Hey everyone. Welcome to another episode of The Testing Psychologist podcast. I am Dr. Jeremy Sharp. Today, I am here with Brad Pliner. Brad is the CEO and co-founder of TherapyNotes, which is one of the most popular mental health EHRs that are out there these days.

I’m super excited to have Brad here on the podcast because, one, I have been with TherapyNotes for years. It seems like forever ago. They were the only ones I signed up with. I was very deliberate about that because of my interest in testing and the fact that TherapyNotes was testing-friendly out of the [00:01:00] box. So this is exciting for me to be able to talk with Brad and have him talk with y’all about the whole process behind TherapyNotes and how it can be helpful, and specifically helpful for testing folks.

So Brad, welcome to the podcast.

Brad: Hi Jeremy, thanks a lot for having me.

Dr. Sharp: Of course. Thank you so much for taking the time to talk with us today. Like I said, we can dive right into it, you are a pretty important person in the mental health world these days given the popularity of TherapyNotes and the amount that I hear about it or questions I get about it. So I’m grateful for your time and excited to talk with you.

Brad: It’s been very exciting since we launched TherapyNotes. The feedback and the demand have been overwhelming. It’s been wonderful.

Dr. Sharp: That’s fantastic. This is totally out of sequence, but I got to ask, did you ever think that it was going to grow [00:02:00] as quickly as it did when you first started?

Brad: I don’t know. I didn’t know what I didn’t know what to expect. We knew we had a great product and a great idea. At the time, there was no competition, there was no good web-based solution for what we wanted to do.

I was pretty optimistic, which is why we put a lot behind it, but no, I can’t say that I was going to expect this level of success. We’re doing very well.

Dr. Sharp: That’s fantastic. First of all, congratulations on that. I know I’ve seen y’all’s posts on Facebook lately that you continue to grow. I know from a business perspective, that’s really exciting. So congratulations.

Brad: Thank you. We just moved into our new office building. We had run out of space and now we’re at about 50 employees. We’re looking to build the team up closer to 100 over the next year or so. As quickly as possible, we’re hiring people.

Dr. Sharp: Oh, that’s wonderful. [00:03:00] A nice side note too, gosh, if any of the testing folks out there who are listening have spouses or relatives who are in the coding, maybe I’ll hook y’all up.

Brad: Absolutely.

Dr. Sharp: Let’s get into it. I’m curious, I know maybe just a bit about your origin story, but could you talk about how you even came up with the idea for a mental health EHR?

Brad: Sure. My wife is a psychologist and in fact does testing and therapy. I helped her start her own practice and it was growing. She had, at the time, maybe about six clinicians working for her. She needed an EMR and there was nothing out there that met our needs.

We looked at it. We didn’t start this off saying, hey, I’ll build you something. It started with, we looked at everything out there and we couldn’t find anything we were happy with. Finally, because my background, I have a web development company as well, we said, let’s build you something.

She was using that for about two [00:04:00] years before we finally decided, you know what, it’s time, let’s make it a commercial product. It took another two years of development because we overhauled it because we needed to make it ready for the masses so that thousands of people could use it instead of six. And then we launched it and immediately had wonderful demand for it. It grew very quickly.

We also launched it with very minimal features. When we first launched, we didn’t have any billing features. We just wanted to get it out there with the scheduling, the notes, and a place to keep track of your appointments and so forth.

Once we launched, then we added billing, electronic claims, appointment reminders, and so forth. We’ve been doing that based on demand and feedback from our customers. So my wife started us off and then from there, the floodgates were open of what do thousands of other people think we should be doing? And that’s how we decide what to do next.

Dr. Sharp: I like that. It’s like [00:05:00] crowdsourcing your software development, I guess.

Brad: Absolutely.

Dr. Sharp: That’s good. Just hearing you say that, it sounds like your wife gets a lot of credit in this whole process because I feel like it was pretty user-friendly right out of the box.

Brad: My wife designed the note templates. I did a lot of interviewing with her to understand her workflow, which is why when you schedule an appointment and ask you what type of appointment it’s going to be, it will then tell you what kind of note should you do, when should you update treatment plans, when should you notify the PCP that a diagnosis changed, and so forth?

A lot of interaction between my wife and I, as well as other clinicians in her practice and anyone that we could get to answer some questions, but my wife was instrumental in building the note templates in particular.

Dr. Sharp: I hear that. It’s nice, I would imagine, to have someone that close to do your beta testing, right?

Brad: Absolutely. To this day, her practice uses a version of [00:06:00] TherapyNotes, one version newer than the rest of the world. They know how it’s working and then once we know it’s acceptable, then we move it to the next stage, which is then when you and the rest of our customers will get it.

Dr. Sharp: Got you. Oh, that’s pretty cool. That’s a nice synergy marriage-wise, at least in that regard, totally good. So that sounds good. I am curious, it sounds like she played a pretty big role in the process and others in her practice. Were there other ways that you developed TherapyNotes? Research or interviews with other practitioners or how’d you continue to grow it and refine it?

Brad: Absolutely. First off, like I said, once we launched it, we got a lot of customer feedback, but we never take what a customer says by that word alone, we will then research it. We’re going to go online. We’re going to go directly to the source, whether it’s a, let’s say, [00:07:00] Medicare regulation or HIPAA regulation, we’ll talk to our attorneys. We have billing consultants that we work with.

So we do a lot of research in that regard just to make sure we’re not taking a misstep. We always make sure that we’re doing the right thing. We also analyze all the feedback that comes in and say, okay, we’re getting a lot of overwhelming feedback that this might not be quite right. We’ll prioritize that as well. There’s a lot of moving parts to make sure that we’re getting everything right.

We don’t do anything quicker than we need to. In other words, we want to make sure we get it right. We’re not going to release a feature and then realize we went the wrong direction. This is terrible. We’re helping our customers be HIPAA compliant, be secure that they’re doing their notes in a way that if they were to get audited, that they’d be in good shape. So we are very careful about any changes that we make that could impact in particular, those [00:08:00] items.

Dr. Sharp: That’s good to hear. I get a lot of questions from folks around that in terms of transitioning to an EHR, is it secure? How do I know that it’s not going to get lost? What if I lose my computer? The questions just run the gamut.

Could you speak maybe even in very basic terms of maybe the advantages of an EHR over keeping paper notes? When you say secure, what does that mean? Where does it live and all of that kind of stuff?

Brad: Absolutely. First off, in terms of security, all of your records are stored on our servers and not on your computer. So if someone breaks in your office and steals your computer or manages to remotely hack your computer, your computer is not part of the equation. Your computer is the gateway or the means to connect to TherapyNotes.

So we’re securing all your data behind levels of [00:09:00] firewalls, redundancy, backups and so forth. We certainly never want your data to be lost or compromised or breached in any way. If they’re on your computer, there’s a better chance of those types of circumstances because you are now more responsible for the security, the backups and so forth.

You don’t have a full IT department. Most of our customers are very small organizations, usually 1 or 2 people, and they don’t have an IT department. We’re the IT resource for our customers.

Obviously, that’s just one reason to use an EHR. The others are electronic scheduling, electronic notes. We have a place where you can upload your reports. For example, as a testing psychologist, you can upload all of those finished reports or even scan in the data and upload that so that you don’t have stacks and stacks of papers in boxes or filing cabinets.

There’s a lot of reasons to have EHR. Oh, of course, [00:10:00] e-streamlined billing. One in particular, the appointment reminder feature, if you allocate three hours to do an evaluation for a patient, you want to make sure they show up. So the appointment reminders feature automatically sends them a text, an email, or a phone call, or more than one of those things.

Let’s say they get an email two days before and then a text the day before, and that’s one of our settings. That way, it’s more likely that they’re going to show up, which is obviously really important. So there’s a lot of reasons to use an EHR.

Dr. Sharp: I can personally speak for the appointment reminder feature. That’s been a game-changer for us. It’s been years now since we implemented it, but it still is awesome. We work with a lot of adolescent clients and it seems like they only text. And so to be able to have that available is great.

Brad: Terrific.

Dr. Sharp: Totally shows up. Let me ask one more question with that, [00:11:00] I think people have the suspicion of data in the cloud and not knowing where it is or how to get it, is there any way for that to disappear or get lost or otherwise be unaccessible, are there any?

Brad: Our copies of your data, basically, your data is saved on our servers in redundant places. So our servers themselves have redundant hard drives and so forth. It means that the hard drive fails, it doesn’t impact anything because there’s other hard drives already with copies of it.

Then we have backups in multiple locations so it actually goes to another physical location outside of that data center entirely. So if that data center, for example, was the blow-up, we have all the data elsewhere. We have levels of redundancy so that no lost data should ever be a factor.

Unlike if you have all your reports in your paper and so forth in your office, if you have a flood or a fire or [00:12:00] theft or so forth, you don’t have multiple copies of those printed pieces of paper. So being electronic is certainly good.

As far as it being in the cloud, the cloud is this nebulous term that means I don’t have to think about it. It’s out there in the ether. Physically, it’s on a computer somewhere. It’s not magic. There’s a server somewhere. In our case, we own the servers, our primary data center. We physically own the servers, and then we have servers in our other location that it’s streaming backups to. They’re physically on servers that we’re protecting, as opposed to servers that are in your office, that then you would instead need to maintain.

Dr. Sharp: I know a little bit about this kind of stuff, but I’m even struck by how you talk about the redundancy and the fact that it’s not just multiple servers in one location, there’re different physical locations that the likelihood of your two server buildings [00:13:00] blowing up at the same time is pretty unlikely so it should be safe.

I think that goes a long way to ease people’s nerves a little bit. There’s something about being able to handle something in paper and know that it’s “real” but when you put it that way, it does live on a computer and in fact, lives on multiple computers in different places. That’s a good thing.

I’m curious about the testing-specific aspects of TherapyNotes. It sounds like your wife does testing and that was maybe a driver in developing, but I’m curious, did y’all have that as a specific focus as you were developing TherapyNotes from the beginning?

Brad: Sure. Like I said, we built it for my wife before it was even a commercial product. My wife, especially more so back then did a lot of testing. In fact, I helped her type those and we didn’t have a scantron. I would be the person who would type ABCD [00:14:00] as we typed them all in, but she would read them off to me. That was my job many years ago. I haven’t done that in a while.

Anyway, we had a psychological evaluation note template from day one. That’s always been there. It is a great way to track all the time that you spent on all the different measures that were performed. What’s the total time which it calculates for you? You put the diagnosis code and the patient information. It’s streamlined and integrated.

And then parallel to that, you would upload the finished report. So if you use a third-party testing product and you have a PDF file, you can then upload that. So the note and the PDF are right there next to each other in your list of documents. And then you don’t have to have any paper records. You don’t have to have files on your computer. As soon as you do the test, you upload that, and then your personal computer is clear of any patient information. So yes, on day one, we had the note template.

[00:15:00] We may have talked about this already, when you create the appointment, you specify if it’s an evaluation so it knows you need to do that type of note. It’s all streamlined and integrated from your scheduling the appointment to your to-do list telling you you need to do that note to then actually doing the note, which automatically pulls forward patient information, their diagnosis if you’ve already seen them in the past, and so forth. It will remember some of the measures that you do so that they’re available in pull-downs and so forth.

Dr. Sharp: That’s a good thing to highlight just as a side note is that when you’re putting in the time for each test that you administer, there is a, well, I forget what you call that, but the memory where it recalls the tests you’ve done in the past and you can just select from a list so you don’t have to type it every single time for every note. Just one of those small things that makes a big difference.

Brad: We don’t ever want you to have to reenter information. [00:16:00] For example, it used to be, you would have one system for your medical records and another system for your billing. That’s very common. So you’re reentering all of that information, or if you go to the portal for your insurance company and you have to manually rekey, we never want you to do that TherapyNotes. So we’re always mindful of that.

These are good examples. When you’re on that note template, you can see from pulldowns, things that you’ve previously entered in those fields.

Dr. Sharp: Oh, super helpful. It sounds like your wife played a big role in designing this testing note template. Can you remember back then or if you’ve updated it, where else you looked for guidance, and in terms of what was required for a testing note, what important information might need to be on that?

Brad: You know what? I don’t know if our templates changed that much since my wife designed it. A good question. I can’t remember other than that field, what we just discussed, the memory feature where it [00:17:00] remembers how you filled out those fields in the past, that was not in the original version. I can’t remember anything else specific to that.

People have generally, right off the bat, have been very happy with that note template. I do though have a list of changes, I shouldn’t say changes but improvements that we will be adding hopefully this year for all the note templates, but there are some specifically for the psychological evaluation that makes it even easier.

For example, those pulldowns having even more suggestions right off the bat, because right now, the first time you use the evaluation note, it’s blank and then it learns from what you use, what measures have you done in the past? We want to start you off with some the more common ones.

Dr. Sharp: Oh, I see. Almost like a drop-down versus a self-populating or something.

Brad: Yeah, exactly. We want not only to [00:18:00] make it faster, but so that the first time you use it, it’s more intuitive of how to use these fields because it’s going to give you examples of what you might want to put in that field, even if you don’t use our options. And then once you do put in options, it will remember those moving forward.

Although, as you know, the note template is pretty intuitive off the bat. If you’re a psychologist that does testing, this note template will make a lot of sense to you.

Dr. Sharp: I always highlight that with people who I’m consulting with and they’re asking about an EHR that would be appropriate for testing. I mainly consult with people who are doing testing. That’s their main focus. And so I always talk about that, the fact that it hasn’t changed is really impressive because I feel like it was good to go, like I said, right out of the box.

It was almost uncanny, that’s why I asked that question is because it seems like it hits a lot of those important pieces that we’ll get audited for testing [00:19:00] appointments, like the time that you spend on each test and how much time has spent report writing.

There’s a box to justify why you’re doing testing or add additional comments about the measures that you’re using. There were little details where I thought they’ve really put some thought into this.

Brad: I’m going give a shout out to my wife because that’s all my wife. I’m all about the user interface. My wife designed that template. Like we’ve said, it hasn’t needed to change very much because it was spot on right from the beginning.

Dr. Sharp: Speaking of the user interface, I am curious about that. When I signed up, that was a big draw for me. I’d previously been using an EHR that was maybe functional but not pretty. I like things to be pretty. So the fact that it sounds like y’all put some energy into the UX or how it looks is super [00:20:00] important. Can you talk about that process and how you’ve figured out what it should look like?

Brad: Yeah, absolutely. My background is computer science. I got a master’s in computer science. I had a web development company right out of college. I was doing that for a long time before we built TherapyNotes so I have a lot of experience building user interfaces, and that’s just always been my passion.

I love a nice, clean, simple interface. I’m a big Apple guy. I like that mentality. You may notice from TherapyNotes, as user-friendly as it is and nice looking as it is, there’s minimal images, there’s minimal clutter. It’s all about what’s the actual information you need when you need it.

So we want a streamlined interface that’s not confusing. It’s intuitive. The first time you use it, it should be very simple. We’ve never printed a user manual. We do have a knowledge base now where people, if they need help, they can get more information. There’s no user [00:21:00] manual like it used to be back when you get a CD-ROM and install software.

When my wife was starting a practice and we needed that software, we looked at all those CD-ROMs and they came with manuals. That was the inspiration where we said, no, we need something that’s easy to use off the bat. In some ways, I like to compare it to Facebook. It’s easier to use in Facebook in a lot of ways. There’s different tabs with all the information you need right there.

The one area of the system that where we get the most support calls about are billing, but that’s nothing. I wish we could make billing easier. We’ve tried, we’ve made billing as easy as possible. One click and your claim is out.

Unfortunately, insurance billing is what it is. We’re doing everything we can to make it easy, but that’s where most of our support questions are going to come up. How do you do add-on codes and so forth where things get tricky?

TherapyNotes is a very capable system. What’s nice about it also is we limit showing you features that you don’t need. For example, if [00:22:00] you’re a single-user practice, if it sounds like a single clinician practice, you don’t need to see all the group features where you can assign patients to other clinicians and so forth, or the calendar, just shows you your calendar and not the whole practice’s calendar.

If you have billing access, then you see those features. If you don’t, then they’re not there. We want to streamline interface as much as possible. So it’s more about what you don’t see than what you do see. We want you to see as little as possible so that you can find what you’re looking for.

Dr. Sharp: I think that makes a lot of sense. And then the option to add all that extra information is there and pretty easily accessible as far as I’m concerned, but you don’t have to see it if you don’t want to.

Brad: A lot of emphasis went into understanding your needs as a psychologist, you have an appointment, how frequently? Is it a once-a-week appointment? I had to understand all of that so we could [00:23:00] design our to-do list feature and so forth.

The to-do list feature is great because you have a busy day of appointments if you have therapy clients and evaluations and so forth. At the end of the day, you need to know what notes didn’t I do. With TherapyNotes, you can’t forget to do a note because every appointment has a corresponding note and you work against that to-do list. So if you don’t have time to keep up with your notes throughout the day, it will be there for you.

Dr. Sharp: For folks like me where if it’s not right in front of my face, I’m going to forget about it, that’s pretty important. I’ve talked to a lot of folks too, who come from, let’s say, a community mental health agency or a college counseling center or even a hospital where they use more enterprise-grade EMRs and those have a reminder list and a to-do list. I was thrilled to find an EHR [00:24:00] that was like what I was used to in a college counseling center with that reminder list.

Brad: In fact, we’ve been working with a number of college counseling centers where university training clinics are using TherapyNotes in that environment so those students who are training to be psychologists, they can be using a real-world application so that when they start their practices, they’re ready to go.

And then they’re even using TherapyNotes in the classroom to teach how to do their notes, how to do a progress note or a psychological evaluation note, and so forth. They’re actually bringing TherapyNotes up on the screen.

I think one of the neatest things about all of this is realizing if you search in LinkedIn, how many people are putting TherapyNotes on their resume, to me, that floored me. That meant we made it.

Dr. Sharp: Oh, that’s wild. You mean as a skill set that they have?

Brad: Exactly, they’re putting TherapyNotes as a skill set on their resume because they did billing at a practice or because [00:25:00] in their university training clinic, they may have learned it, or they simply used it as a psychologist in one of their prior jobs. To me, that’s amazing to the point now where it would be on your resume as a skill.

Dr. Sharp: Sure. I bet that’s surreal to see your company as a skill. That’s great. I know that’s helpful. I’ve been hiring folks here over the past, probably five to six months, I don’t know if it’s a major thing, but it’s definitely a huge plus if somebody says, yeah, I’ve used TherapyNotes before.

Brad: Absolutely.

Dr. Sharp: Related to that, I’ve talked about billing, especially insurance billing, to find billers out there who are TherapyNotes savvy or who require that you use TherapyNotes as your system, that is pretty telling as well.

Brad: Absolutely. We have a few that we’re in regular communication with [00:26:00] where if you’re in behavioral health, they want you to be using TherapyNotes. We have one where, he actually pays for your TherapyNotes subscription to get you started as a promotion. We work very closely with a number of billing providers.

What’s nice about that relationship also is they give us feedback as they hit walls where, hey, we can’t handle the circumstance because of a limitation of TherapyNotes, we work with them to see how can we better accommodate them. So they’ve been very helpful as well.

Dr. Sharp: Yeah, that’s great. I recently switched billing services and that was one of the big factors. I found one that was well-versed in TherapyNotes versus another billing company; they said, well, we could build you the software, it would be able to talk to TherapyNotes, but it’s two systems and we’d have to integrate them. I was like, that sounds hard. Let’s use TherapyNotes.

Brad: Billing providers absolutely have their place, but there are a lot [00:27:00] of our customers who have stopped using billing providers because we’ve made it so easy. They didn’t see strong need. Most psychologists, people in behavioral health, their billing is pretty straightforward. They have a service code, a diagnosis code, and that’s it. It’s pretty straightforward.

I’m not going to say you shouldn’t have a billing provider because there are absolutely reasons to have billing providers in many cases, but just to speak to how easy it is to do your billing in TherapyNotes, once you’ve done your note, you’ve entered your code at that point, your service code you entered when you created the appointment, your diagnosis code you created when you do your note, both of which automatically copy forward from prior appointments and prior information about the patient. So once you’ve done your note, you’re ready to click the button to submit the claim and you’re done.

Posting the ERA, which is when you receive the payment, we have a screen that automatically does that for you. It shows you, here’s what we think you should do, and then you click a button if the software got it right or you tweak it if you need to. In most cases, you don’t need [00:28:00] to.

The billing providers, what you can do in their scenario, you can give a user ID and a password to your billing provider, give them billing access only, and then they can click those buttons for you and make sure everything works well. We don’t charge for user accounts that are administrative.

If you’re giving a user ID to a biller, you don’t have to pay for that. They can do everything they need to do. It’s nice, they can’t read your notes, for example. They can see the diagnosis code and the service code, which comes from your note, but they can’t open the note to read the content of that information. They can’t read the reports in your case. They can’t download those files because every time you upload a file, you specify is it clinical or administrative, they won’t be able to see anything that’s clinical.

Same thing if you have a scheduler working for your practice, you can have them only see what they need to do their job. It’s easy, you just say they’re a scheduler. You don’t have [00:29:00] to start figuring out, should they have access to this screen or that screen, which is what an enterprise EMR would do. In TherapyNotes, you just say they’re a scheduler and we’re going to automatically give them only the access they need to do their job.

Dr. Sharp: Gosh, I feel like you said a lot of really important stuff in that segment. To emphasize a lot of that, one, billing is really easy in TherapyNotes just out of the gate. Brad said this but I want to reiterate for anybody listening that it literally is once you’ve entered the client information and written your note and put in their insurance information, from that point, it is a one click to submit an insurance claim, and then one more click to post that payment when the insurance claim comes back as processed. It’s super easy.

I tell people that all the time when they’re like, you take insurance in your practice but isn’t that so hard? It takes so much time. How much time do you spend on billing every week? I [00:30:00] get to say, well, maybe 15 seconds. How long does it take to click 200 times?

Brad: If you wait until the end of the day, you can click it once and it’ll submit them all at the same time. You don’t have to do it after each test. It takes basically no time.

And just so everyone’s aware of, you can also print a CMS form if you want to. Hopefully, you do it. I prefer you do it electronically, but you can print super bills. You can print CMS forms. We do also accept credit cards, so it’s a full, everything you need to do billing but electronic billing.

Oh, and then another point, electronic billing, you don’t have to be in network with the insurance providers. You can be out of network and still submit claims on behalf of the patient. A lot of people say, I don’t want to deal with insurance companies, but if you do it this way, you, first of all, you get paid in full from the patient and then you click the button for them.

They don’t have the anxiety of having to fill out paperwork and hope to get paid from the insurance company. They’re going to get paid [00:31:00] faster and you’re just doing a nice service for them. It’s actually easier for you than printing anything out and handing paperwork to the patient. You just click the button and it’s done. So something to keep in mind.

Dr. Sharp: I’m glad you brought that up. My wife is also a therapist. She is a cash-pay practice. I’m very biased to provide that service of submitting out-of-network claims for folks just as one less hurdle for them to have to deal with.

If you can say like, you pay us but we’ll submit the claim and they’ll reimburse you according to your plan. That puts people’s minds at ease rather than the whole super bill process. It’s another step for them to have to take care of.

Maybe we could talk nuts and bolts a little bit. A lot of people sometimes say, oh, I can’t afford an EHR or it’s too hard to get started [00:32:00] or what if I’m migrating from another system? Can you talk about some of those basic details of TherapyNotes and how you might handle some of that?

Brad: Sure. First off, if you’re converting from another product, we do conversions for free. So if you get us a spreadsheet of all your patients and so forth, we can take care of that.

There’s also no setup fees with TherapyNotes. We always offer one free month. So you could convert to us for free, pay no setup fee, and have a free month. After that, it’s month to month. We don’t do annual contracts. We don’t want to make you use TherapyNotes, we want you to love TherapyNotes. We’re going to earn that trust every month. We want to keep you using TherapyNotes.

The pricing, and obviously this is a podcast, if you are listening to this podcast in the future, the pricing might change, but currently, it’s $59 a month for one clinician and $30 for each additional clinician per month.

If you have a small practice, one person with less [00:33:00] than 12 or so patients, call us, we will be advertising a different rate structure in the very near future. We’ve never raised prices and we will not be raising prices as far as what I’m saying to you today that we will be updating pricing. What we’re going to do is be a little more competitive with the smaller practices.

We also have other pricing models. If you’re a nonprofit, we have a discount. If you’re education, we have discount. I won’t get into too much detail with those. And then there’s claims pricing and appointment reminder pricing, both subject to change in the near future so I don’t want to get into too much detail, claims are $0.14 each, appointment reminders are going to change soon, so I’m not going to even have outdated information on your podcast.

Dr. Sharp: Okay. Fair enough. I can emphasize too that, people, if you hear that $59 a month and think, oh goodness, I don’t have that, I just started my practice. Even [00:34:00] with one appointment reminder that works and keeps someone to coming to their session, that’s less than probably half of what you recoup. So it totally pays for itself within one client.

I think it’s important to emphasize for people who are hesitant to spend money on an EHR. I don’t need that, or it’s not worth it. It’s totally worth it.

Brad: It’s funny how we get calls, we’re talking to lots and lots of people every day calling interested in TherapyNotes and we have people who say, how can I afford $59 a month? But then we also have people that say, I don’t understand what’s the catch, why is it so affordable?

And those people usually, they’ve been out in the field and they’ve worked with enterprise EMRs, they’ve worked with other products and they don’t understand how is it so inexpensive, because if you were to look at an enterprise EMR, hospitals spend hundreds of thousands of dollars for their EMRs, just for their setup. A one-time setup fee could be $100,000 to set up a hospital EMR.

[00:35:00] Also we are the monthly model, that includes the fact that we’re backing up and storing all of your data, all of that’s in there. We provide unlimited phone support. So if you call us a lot, we’re not making any money on you.

We are trying to be as competitive or as reasonable as possible with our pricing. It’s more about the fact that we have thousands and thousands of users, it adds up and we’re very happy with what we’re doing, but we always want to keep it affordable.

If you’re a nonprofit or if you’re a small practice that for whatever reason, $59 doesn’t work for you, call us and we’ll hopefully be able to work something out with you as well, especially nonprofits. We never would want a nonprofit to not use us because of a budget. We want to do what’s best for the community. We do all kinds of things for nonprofits.

Dr. Sharp: That’s great to hear. You’ve alluded [00:36:00] to many upcoming changes here in the next little while, so it might be a nice segue, where do you see TherapyNotes going in the future in terms of features? I’ll just leave it at that, features.

Brad: We just launched our document library which allows practices to have files available to all the people in their practice. For example, you may have a form that you frequently have your patients fill out or a homework that you give to them, you can put it in there and then anyone can download, print them and then hand them off to their patients.

That’s the first step towards a much larger project is we want you to be able to send those files to your patients through our patient portal and the patient portals be able to sign them or complete them. That is what we’re actively working on right now and making a lot of progress on. So the ability for basically in a nutshell, online paperwork, so patients can do intake paperwork [00:37:00] and so forth.

We’re always working on usability improvements, minor design improvements, and anything security-related. We’re right now overhauling how we reset passwords, for example, when someone loses their password and they call us. We’ve been spending weeks on this. You’d think it would be a simple project but because TherapyNotes is so important to keep things secure that it has to be right.

For the future, there are a few specifically for testing psychologists that I’m very excited about that are more in the research phase where we can facilitate that testing process and the report writing process. I’m very excited about those features and one of the reasons I was excited to be on your podcast.

I am very much hoping that when those features are ready, I’m going to come back on your podcast and we can talk about those some more. They’re [00:38:00] in the research stages. I can’t give too much more information than that, but I’m very excited about some of these future features.

In a nutshell, though, the biggest priority right now for us is our patient portal. It’s been lacking for a little while because we’ve been focusing a lot on billing-related features, which is the least glamorous part of therapy. I want to be helping patients and our clinicians.

I want where we can help the clinicians provide great service to their patients that help them improve and whatever there it is that they need to be helped with. Billing is the least glamorous side of that. I want to help them where we’re making difference with the patient. For example, appointment reminders, patients love that. That’s a direct feature where patients get that text message and they’re like, oh, great.

The appointment reminders, we had an issue once where they weren’t working. We know what that happens because the patients get very upset. We love having that direct [00:39:00] improvement on outcome for the patients as best we can.

We’re obviously not doing the therapy and we’re not doing the evaluations, but we want to help you do those things. So the patient portal is really important for us over the next several months. That’s where we’re going to be doing a lot of work.

Dr. Sharp: Got you. That’s good to hear. I think of all the things that people ask about or maybe raise as a hesitation with TherapyNotes, it’s patient portal, when can we send clients our forms? How can we make that happen?

Brad: We are close to a feature where you’ll be able to send forms to your patients. We’re going to have electronic signatures and then where they can do their intake paperwork and so forth. That is all in active development. I played with some of the features already. So that’s how far along it is.

Dr. Sharp: That’s good to hear. That’s fantastic.

Brad: When we were talking before the growth of the company, the reason we moved into our new space is we [00:40:00] were out of space in the old place. We need to hire more people. We’re now, like I said, 50 people, about 16 of which are developers. That’s the biggest development team we’ve ever had.

We’re looking to increase that. We have two active open recs for developers right now. That’s only the next step. We want to keep hiring. We have two separate teams now for developers and we’re going to be breaking that into a third team soon. So the speed at which we’re going to be adding new features will continue to accelerate.

Also, as we’re growing, we’re constantly having to handle the demand of the fact that there are thousands and thousands of people using our software. Obviously, we’re constantly working on architectural improvements as well.

Unfortunately, they’re not glamorous when we release the news, here’s the new version of TherapyNotes, it’s not the most glamorous that, hey, and now it’s going to be a little bit faster so that we can handle the fact that we’ve another thousand customers. That is something else we’re constantly working on so [00:41:00] that we can handle performance when you’re using TherapyNotes, when you click from page to page, you’re not sitting there with the wheel spinning. It’s always very fast.

We’re very mindful of that because that’s an important part of the usability of the software. We want to make sure you can access the site that is quick and it does what it’s supposed to do.

Dr. Sharp: I totally agree. It’s funny, I read those updates and it’s definitely not, like you said, glamorous by any means but behind the scenes.

Brad: We just released an update where there was almost nothing to say. Meanwhile, we have 16 developers working full-time for the four weeks that that release accounted for mostly because those are features for the future portal work that we’re doing that are completed but not released yet because it’s part of a bigger project. They can’t release any of it until it’s all done.

So if you see a small [00:42:00] what’s new in the news message, it’s because all of that effort went into features that haven’t been released yet and that there’s something big is coming.

Dr. Sharp: Got you. It’s a good reminder. I’ll go back to something you said a while back that I think it’s important to highlight that I can’t remember a time where y’all have rolled out a feature that didn’t work or was super buggy. I think that attention to like, hey, we’re spending more time on this to make sure that it’s right before we let it go to the public is pretty important.

Brad: We definitely prioritize that. In a nutshell, the development process, once a ticket is planned, just to get to that point is a bit of an ordeal, but let’s say you have a ticket ready for the developers to work on, it’s been identified as something that’s ready to go. The developer does it. A peer reviews it. Quality assurance person will test it. Lead Review will then look [00:43:00] at it again, which is a senior developer is going to make sure everything looks right. And then it goes through business review, which often is me.

So it goes through a lot of checks and balances. Then it goes live to my wife’s site, like I mentioned, she uses the version that no one else is using yet just to make sure it doesn’t have a problem. After the release, we account for the fact that for two days, we might get some bug reports. When there’s a release and we go two days and we don’t get any bug reports, we are very happy.

Usually, there’s one or two and they’re minor. You can’t submit a claim in this strange circumstance or something unusual happens. They’re very minor, they’re silently updated, we fix it immediately. We don’t wait four weeks for the next release to fix these minor things.

We tell you about the releases every four weeks, but there’s updates every so often if we see something that’s urgent that we want to update right away. Quality assurance is important here. In fact, [00:44:00] we just hired six people. They started about two weeks ago. Two of them are quality assurance, which means that we have now four people that are dedicated to quality assurance.

Dr. Sharp: That’s great. I think that’s super important. We’ve talked about a lot of different things. I appreciate the time, like I said. Let me put you on the spot a little bit before we totally take off and ask, is there anything else, for certainly mental health practitioners, but testing folks specifically that you think is important to know about an EHR as they consider that step?

Brad: I think we did a great job as far as covering a lot of important points. As far as a testing psychologist, I don’t know a specific testing psychologist, but I will say we were talking about security. Your computer, you want it to be secure, so that means your computer should have antivirus, it should be behind a firewall. We [00:45:00] strongly recommend you use a computer with encryption enabled.

If you have an iPad, and I think MacBooks they’re encrypted by default. PCs or Windows, I think Windows 10 might be, but you want to make sure that your computer is encrypted. Even though you’re not regularly putting data on your hard drive, if your laptop is stolen and you had a report you were working on, then that’s a problem. If your computer is encrypted, it’s not officially considered a breach. I would strongly recommend that.

My final note is that more of a warning for everyone, I’m trying to think of what else we could have covered. As far as TherapyNotes is concerned, like I said, it’s a free month. You try it out, there’s no contract, so you could use it for free and if you’re not happy, you can print those records and put them in your folders with the rest of your paper notes. Of course, like I said, unlimited free support. So if you have any questions at all, we can help you out.

Dr. Sharp: That’s great. Well, thanks [00:46:00] again, Brad. This is a really good conversation. It’s been an honor to talk with you after having TherapyNotes be such a big part of my practice for so many years. So thank you.

Brad: Well, thank you. I appreciate being on the podcast. In preparation for this, I was listening to some of your prior podcasts and I saw, oh, here’s one about EHRs. I started listening to it. I put it on speaker so my wife could hear because we were in bed reading and I’m like, oh, you have to listen to this. You were talking about TherapyNotes. So I was like, I guess we picked a good podcast to be on. So I really appreciate your support as well.

Dr. Sharp: Of course. I look forward to seeing what happens next with TherapyNotes. It sounds like y’all have some exciting things on the horizon. So thank you.

Brad: All right. Well, thank you very much.

Dr. Sharp: Take care. Bye bye. All right, y’all. I hope that you enjoyed that talk with Brad Pliner, CEO and co-founder of TherapyNotes. As you could tell through that interview, I [00:47:00] am a big fan of TherapyNotes. I’ve used it for a long time and it has never failed me to be the EHR that works really well for a testing practice.

As a gift to Testing Psychologist’s listeners, TherapyNotes has given us a promo code for an additional free month on top of the initial free month. You’ll get two free months of TherapyNotes with the promo code “test psych”. I’ll also have a link in the show notes to sign up directly with that promo code if you are a new user of TherapyNotes and want to try it out.

Again, like I said, this month’s podcasts are brought to you by Practice Solutions. Practice Solutions is a full-service billing company that specializes in claim submission, collecting payments, sending statements, and insurance verification for psychologists and mental health professionals. [00:48:00] I use them myself. They’ve been fantastic. Jeremy and Kathryn are a husband and wife team, and they just do a great job for us. They know the ins and outs of testing and can help you navigate the billing process if you are looking for some help with that.

As always, if you are enjoying these episodes, take 30 seconds, go to iTunes, subscribe, rate, review the podcast, help spread the word about testing resources, and get more people listening to the podcast. You can also join us on our Facebook group, The Testing Psychologist community where we’re having some great discussions about all things testing; business logistics, batteries, measures, and different things like that. We’d love to have you join us there.

If you have any interest in growing your testing practice or want to talk with somebody about how to navigate the testing business side and set up a testing practice or add services, you can give me a [00:49:00] call. We can talk for 20 or 30 minutes and chat about whether consulting would be helpful. If not, I can still point you in the right direction. So don’t hesitate to reach out. You can email me at jeremy@thetestingpsychologist.com if that sounds interesting to you.

Great to keep talking with y’all. I’ve enjoyed these past few podcasts and we have some great interviews coming up as well. In the meantime, take care, will talk to you soon. Bye bye.

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[00:00:00] Dr. Sharp: Hey y’all, this is Dr. Jeremy Sharp and you are listening to The Testing Psychologist podcast episode 32.

Hey everybody, welcome to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp and today I am talking with Mr. John Clarke. John is someone who I met personally about a month ago at Slow Down School. So we have a little bit of an interview series of Slow Down School acquaintances here. I interviewed Jaime Jay last week and this week is John Clarke.

I had a run into John before that online in two Facebook groups and we originally connected when we found out we both were going to Slow Down School. [00:01:00] I put out a request for anyone who’d be willing to do some trail runs with me and John jumped on that right away. So I was like, this guy’s probably going to be cool. And that turned out to be true.

John was my roommate at Slow Down School. I got to talk with him and get to know him and found that he’s an incredible professional and also a nice, genuine individual with a ton of knowledge.

Welcome to the podcast, John.

John: Thanks for having me. I’m excited to be here.

Dr. Sharp: Me too. We’re going to be talking all about digital marketing and talking about how digital marketing can be super helpful for mental health practitioners in general but especially testing folks. So I’m excited to dig into that.

Before I do that, let me read a little bio for you just to give you an idea of who John is. We’ll try to summarize everything you’re doing. You’re a busy guy these days, [00:02:00] but this will give everybody a little taste of what you’re up to.

John is a licensed psychotherapist and the founder of privatepracticeworkshop.com where he helps therapists build or grow a thriving private practice. He is the founder and Director of Charlotte Counseling and Wellness, a group psychotherapy practice that offers innovative evidence-based therapy and coaching in Charlotte, North Carolina primarily for busy, anxious professionals.

Most recently, and maybe most importantly for us, John launched Unconditional Media, which is a digital marketing team specifically for therapists. I am excited to be talking about that. Again, welcome to the podcast, John. Glad to have you.

John: Thanks. I’ve always been wanting to demystify marketing in general, but also digital marketing. I think there are a lot of [00:03:00] images or fears or questions that come up when we start talking about this stuff among therapists and psychologists, and it can be daunting. It can be overwhelming. There’s been plenty of times in my career and in my learning of this stuff where it’s been overwhelming and daunting.

Above all else, I’m always trying to demystify it. The people who work with me know that that’s my aim or the same thing with my podcast. That’s the aim of everything that I do.

Dr. Sharp: I think that’s important and that was something that I was struck by during a lot of our chats in the dorm room and around the dorm there at Slow Down School. You know a lot about this stuff but the way that you talk about it is also easy to understand and very insightful at the same time. So I like that balance and I hope that we can communicate some of those elements to our folks [00:04:00] here today.

John: Yeah, for sure.

Dr. Sharp: I think we can jump right into it. Let’s start and maybe talk about, when we say digital marketing, what does that even mean?

John: The typical marketing strategies of someone in private practice or in a testing practice are; we have in-person strategies where we are connecting with whether it’s other providers or ideally potential referral sources. I look at those as one branch of marketing and one branch of a well-rounded marketing plan.

There’s print marketing that you can do as well. So that’s your printed materials. Maybe you’re sending those out. Maybe you have a physical mail campaign that you do or even delivering those physical materials, that’s [00:05:00] the traditional, the old school way of getting the word out.

As the internet continues to evolve and become more integrated into our lives, it becomes that much more important to have an online presence. What I mean by that is:

1. You want to exist in as many places as possible on the internet.

2. If you’re going to exist there, you want to have a quality presence. You don’t want to just be on there recycling NPR articles about mental health that you happen to see and not contributing anything original or anything that advances your position as an expert.

I think therapists and psychologists can get spread thin trying to do, one, exist everywhere and not do any medium real justice, not do anything particularly well with their digital presence. [00:06:00] There’s a caveat to number one in that if you’re going to use these different mediums, whether it’s your website, Psychology Today, or social media, I want you to make sure that you’re doing it well and having even two mediums that are strong rather than being scattered over six mediums that you’re not keeping up with.

Because what does that convey? Let’s say you have your website, Psychology Today, you have Twitter, Facebook, Instagram, and Pinterest, and someone starts to look at all the stuff you’re doing online, or they’re looking at all the social media platforms for your practice, what kind of impression does it give off when they go and your Pinterest has one post, your Twitter has one post, your Instagram has two posts. You’re just there.

I think it’s better to commit to two platforms that you know, that you [00:07:00] can figure out, the learning curve is not too steep and you know you can commit to having a strong presence with two of those mediums.

Dr. Sharp: Got you. We talk about being a specialist in the clinical sense, but it sounds like you’re saying it makes sense from a digital marketing perspective to almost be like specialists or have a niche in a particular social media platform.

John: It does, especially if you’re not getting help with it. There are plenty of folks who get whether it’s a virtual assistant or someone to do this stuff for them, or they use social media scheduling software like MeetEdgar or Hootsuite or something like that. That can be a bit of a game changer but you still need to put out enough original content to fill up those channels.

I think we just get sidetracked easily and we get overwhelmed easily in running a practice of any kind, and it’s [00:08:00] important to boil it down and say, okay, what’s important and for my particular client, where do I need to exist? So that’s the other thing is going back to choosing the channels that you’re going to exist on is thinking about, there’s no hard science to this part of where do my future clients hang out on the internet? Where do they go to search for someone like me, whether you’re doing therapy or you’re doing all testing or neuropsychological testing or something like that? I think any good marketing plan starts by getting into the mind of your customer.

Dr. Sharp: Absolutely. Maybe we could dive into that. I like the idea of where my clients hang out on social media or on the internet. Thinking about testing folks, I would say, for me, I have been working with a lot of kids, [00:09:00] my target client, so to speak, is the parent, most likely. And then we have school counselors and physicians as well but if I’m talking about a client that I might try to attract on social media, that’s probably the parent.

Do you have any way to gauge, guess, or determine how to target that and where you might find those folks or learn where they hang out, so to speak?

John: I would start with using the information that you know, or thinking of a typical client of yours or typical family that comes to your testing practice. First of all, look at how your current clients are finding you. If you’re going to network with other therapists and psychologists, one of the best things you can do is make sure you’re asking that person, hey, how do clients find you? What are your [00:10:00] top referral sources?

Most of the time, therapists will tell you and that information is so critical, especially for your area, because I will tell you that different things work for different regions, different cities. Is it a small town? Are you in a college town? Are you in a major city?

When I’m designing a marketing plan for a clinician, it can look different depending on where they are and depending on what’s already worked. So if you’re not already doing this and I hope you are, make sure that you’re tracking your referral sources to begin with.

For my group practice, our assistant, whenever she answers the phone, it’s Charlotte Counseling and Wellness, thanks for calling. And then also, oh, how did you find out about us? And that goes into a spreadsheet.

So I know, right off the bat, how people are finding me and what’s working. When I know what’s working, I can double down on that approach. For some folks, it’s as simple as that. If you know it’s working, [00:11:00] double down on that approach.

Dr. Sharp: That’s great. It’s a little something that might get overlooked over time.

John: I think so. Sometimes it’s hard, especially with the online stuff, to figure out, you’ll ask a client or let’s say for your testing practice, you ask a client, oh, how’d you find out about me? Either they won’t remember, or they’ll say Google.

Google can mean a lot of different things. Google can mean I put in testing psychologist Chicago and then it took me to Psychology Today or something like that, or it took me to a doctor’s website that had a link to your website or whatever it is. Even with that, sometimes you have to try to get more specific.

Maybe if your website is ranking high on Google organically and through your efforts of search engine optimization, you might be getting traffic that way. If you’re running ads on Google or using [00:12:00] what’s called Google AdWords, you might be getting traffic that way and it can be hard to differentiate, but you at least want to try to narrow it down and get that information from your new clients.

Dr. Sharp: Do you have any recommendations about how to narrow that down? Do you just list out all of the options on your intake paperwork or ask them specifically? How would you go about that?

John: I ask them specifically and if they say Google, I ask them to clarify if they can. What I’ll tell, for most people listening, you can already narrow it down by asking yourself this question, am I ranking on page one or the first two pages of Google for my kind of practice? If you are, then it’s possible that people are finding you organically in that regard, but there’s a very large number of practitioners who are not ranking at all for Google because they haven’t focused on that search engine optimization.

[00:13:00] For some folks, or let’s say, if you’re starting a new practice and you built a website last week, clients are not going to be finding you organically. That’s not enough time to rank up in Google and be competitive on that first page. That’s one way to realize it.

Even googling yourself or googling neuropsychological testing Chicago or whatever it is, and seeing if you’re ranking up for terms like that. You should know right off the bat how competitive you are with that ranking system. If you’re on page seven, you can pretty much know that you’re not going to be found organically.

Same thing is, I’ll tell, even if you’re on page three, the odds of someone finding organically are very low. People rarely even go past the first page of Google, better yet, the bottom half of the first page of Google. It’s crazy.

There are [00:14:00] numbers that are out there on what that threshold looks like, but it starts to drop off after about the second half of the first page. So it makes it that much more important to make sure you’re ranking up there and ranking up for the right terms.

Dr. Sharp: Sure.

John: Have I overwhelmed anyone yet?

Dr. Sharp: Probably, I’m just going to …

John: Take a breath. Take a sip of your tea and we’re going to walk through this.

Dr. Sharp: I like that confidence. Let’s back up a little bit and walk through, I’m going to own to that I’ve done a fair amount of research into some of this so I know a lot of these terms that you’re using and maybe a little more comfortable than some of the listeners might be, I don’t know.

Maybe we could back up and think big picture; you talked about marketing [00:15:00] in general, you listed there’s in-person marketing, there’s print marketing, and then we dove into internet marketing. Can you outline internet marketing or digital marketing a little bit and talk about what are the main ways to do that that people might even consider?

John: Yeah, for sure. That’s great. The most valuable asset to a practice of any kind is your website. I’ll tell you that and in the work that we do, I work with a lot of therapists, both as a coach and then also with our digital marketing team. It’s not uncommon to have a therapist come to us and say, hey, I’ve got my website. Maybe I built it myself. It’s ready to go. I just need it ranking higher on Google, or I want to pay for Google AdWords to get my site recognized and clicked on.

So I’ll [00:16:00] say, okay, great. I’m so glad you’re interested in that. I’ll click on their website. If I get to their website and I see, okay, this is not putting your best foot forward. If it’s not a website that is beautiful, functional, and has clear calls to action, or a CTA, call to action is a button or a link or something obvious that says call, click to call or click to schedule your first appointment or more information here.

We can increase traffic to your website, but I’ll tell to start with the essentials, if you don’t have a solid website, then all the work that you do on top of that could potentially not pay off. You can have all the traffic in the world, but if no one knows how to find your phone number or how to schedule an intake on your website, then you might be getting this traffic but not converting those [00:17:00] leads; converting visitors into paying customers. I think I’ve really overwhelmed people.

Dr. Sharp: Hey, no, I think we’re good. I want to ask maybe your top three tips for making a website, you said beautiful, functional, and easy to navigate.

Before we totally dive into that, I want to mention though, that I was talking to Jaime Jay who I interviewed last time on the podcast about websites and he put it really well, I think you would agree with this, which is that when someone comes to our website, we have to assume that they have no idea where they should go on the website or how to find us or schedule services. We want our website to walk someone through the process of finding out about us, learning about our services, and then scheduling.

So you have to make that clear with [00:18:00] the flow, with the buttons, with the calls to action, with the click here to schedule, that kind of stuff, and make it really clear what kind of behavior you would like your potential client to engage in on your website. Does that make sense?

John: That’s it. Jaime’s amazing with this stuff. He has a wealth of knowledge about it. There are people who study what’s called UX or user behavior. A friend of mine has a master’s degree in user behavior. And so it’s really amazing, just like we study clinical psychology for a number of years, people study website behavior for a number of years and have advanced degrees in that.

First of all, why would we know about this stuff? We spend all of our years becoming clinicians so cut yourself some slack in that regard and figure out what your comfort is with any of this stuff. Am I comfortable learning it? Does it cause me a ton of [00:19:00] anxiety? Do I have a budget that could pay someone like Jaime to do this stuff for me?

Your website, beyond encouraging the right behavior, it also needs to have some compelling website copy. Copy is the words on your website that are used to keep people there, communicate what you do and then also to encourage action. If you want, I can talk about that briefly, the way that I approach it.

Dr. Sharp: Yeah. And maybe that wraps back into some of those tips for making your website functional and useful.

John: One quick way that I look at it and that friend of mine has taught me about user behaviors, if you think about F, the way that people scan a website, and stop me if Jaime Jay said this.

Dr. Sharp: No, not at all.

John: If you come to a webpage, people tend to scan in [00:20:00] form of F. So if you’re starting at the top left corner, that’s where usually a logo is or something like that and then they’re going to scan right all the way to the end. In the very top right, that’s where a clear call to action or a button or something should usually be, because that’s such a critical point where people’s eyes just naturally go.

Moving down from there, moving down the F, they’re going to come down about a quarter or halfway, and they’re going to see some text, and they’re going to read about half of it. That’s the bottom part of F. They’re going to read a bit of that, they’re either going to keep reading or they’re going to click out of your website.

So that section is so important. It’s either your mission statement or you’re starting to talk about the pain points of your client, whatever it is, and then they might scan down a little bit and skim-read more of your website.

One thing I see a lot is therapists who have an overwhelming amount of website copy or have listed all of their credentials and this [00:21:00] and that on the first page or this elaborate paragraph form of trying to describe their clients’ issues and you can lose people that way. I tend to err on the side of simplicity and minimalism when I’m writing website copy and coaching therapists on how to do this as well.

First of all, you need to have the right buttons in the right places and in multiple places on every page. And then you need to have a compelling copy that is succinct enough to be skimmed.

Dr. Sharp: Got you. In terms of writing copy, do you suggest that people do that themselves, or are there folks that can do that for you? How do you approach that?

John: There are a lot of folks who can do it for you. I think a lot of the practice coaches are getting into this now and seeing the value in it. What I’ll say is this, if you’re a strong writer and then the reality is a lot of us are, especially clinical psychologists, you all have had to [00:22:00] a lot of writing and you do technical writing or you do report writing so you’re a strong writer in the most obvious way.

We’ve learned to write APA style and you’ve learned to write these reports, et cetera but writing website copy is very different. We’ve got to extract clinical language from it and clinical jargon and psychobabble. I believe most people don’t want to read about your credentials, at least not on the homepage. What people are looking for on the homepage is, am I in the right place and do you get me?

The way that we capture that is when I’m walking through this with therapists or even working on my own practice website, speak directly to the pain of your clients. And so for testing, it might be, your child has been [00:23:00] struggling in school for months, the school counselors or the staff can’t figure out the right combination of services and as a parent, you’re worried, you’re concerned. You want to make sure that you get the right concept of your child or the right understanding of what your child is going through so they can get the help they need, something like that.

You want to do it better than that, but you want to capture the pain of your client. Then you want to walk through the next phase, how do you help them? So the process of what you offer and then focus on the outcome of your product.

Dr. Sharp: That’s interesting. I think we lose the outcomes sometimes. When I do website reviews for my own consulting clients, I see a lot of focus on the testing process and what’s included, the measures, the price, and all of that, which is good but then [00:24:00] I don’t see a whole lot about the outcome, what will you walk away with and how is this going to make a difference in your life?

John: I think if most of your website was predominantly inclined toward the outcome, it wouldn’t be a bad thing. And that even comes down to things like the website images that you use, do they convey a sense of resolution or of greater understanding or of moving forward with your life? Did they convey this, by selecting a commercial of the dude with his head and his hands, who’s never going to get better and everything is blue?

Dr. Sharp: That’s an interesting point. When I was putting together my own website, I thought about, do we show pictures that capture the client’s experience as they find you or do you try to incorporate pictures that show where you hope they will be after your services. Not like it’s a black and white thing by any means, like sad and happy, but that [00:25:00] general theme. It sounds like you’re saying go for the hopeful, optimistic pictures that show the outcome.

John: That’s what I push for because I think what you’re doing with a website is you’re already starting to create expectations within your clients and within the families you work with. So when they arrive, I don’t do testing but at least in terms of therapy, we know that a large part of the success of therapy has to do with client expectation.

I would imagine there are similar studies out there in the academic world for testing psychology if the family comes and they believe that you are the one to help them, you’re the right person and that I’m in the right place, and that this testing process is going to lead to something beneficial for my family, that’s all going to show up when you get them in the office, when you’re sitting down with them, when you’re running through the actual test, you’re going to use the pricing, all of that stuff. So I do think it is [00:26:00] about building expectation and in a way, building hope.

You’re doing that with testing as well. You’re building hope that we can get you some clarity on what you or your child is struggling with. When we get you that clarity, it’s going to unlock X, Y, and Z, or the result will be X, Y, and Z. I think there’s a lot that we can look at there.

Dr. Sharp: Got you. That’s great. We’ve talked a fair bit about the website which has been super helpful. Can you talk about other aspects or arms of digital marketing that you find valuable?

John: Sure. Let me talk about two problems that we run into with websites. There’s some different solutions for them, depending on which problem you’re facing.

One problem is that you have website traffic, meaning people are finding your website, but they’re not calling. So that’s an issue [00:27:00] of conversion. Meaning when these potential customers come to your website, they’re not picking up the phone. They don’t know where to click or what to do or how to get in touch. Well, that’s a problem.

Dr. Sharp: Can I jump in, John, real quick and ask you a question? Getting basic, how would we even know if someone was finding our website but not calling?

John: Awesome question. It depends on if you run your own website or have built it or have access to editing your website, everyone should have what’s called Google Analytics set up for your website. Google Analytics is the tool that you can use and install for your website to study the behavior of your visitors.

Even in the most basic form of how many people am I getting to my website? And then even, which pages of my website are most important? That information alone can tell you a ton, because you might have 15 pages on your site that no one is ever looking [00:28:00] at.

Typically, the most popular pages are your homepage, your about page, and then your services and fees. Who are you? What do you do? What can I get from this? How much does it cost? You want to think about that as well. You want to, at minimum, get that tool for yourself or work with your web developer, whoever it is to make sure you have that tool. That’s where you’re going to get these metrics.

I’ll tell you, with anything you do with your marketing, it’s good to know what those numbers are. You might install Google Analytics and you might even jot down those numbers or just look on the graphs that they provide and see, okay, so in September, my traffic was at 200 visitors per month and then you might work with someone to do marketing or hire someone or do your own SEO work or your own promotion in person.

And looking at those numbers is a great way to [00:29:00] gauge what you’re doing. Given that you all are testing psychologists and are inclined toward numbers, results, and metrics, you should be applying that same philosophy to your own website and to your own marketing endeavors.

Dr. Sharp: Sure. Okay. Let’s say we have a good handle on visitors to the website. I’ll put a link to Google Analytics in the show notes, of course. So let’s say we have that information and we have figured out that people are coming to the website but not calling, then what do we do?

John: So then you look into where are you losing people and what is the fallout. Or on a page, is it not clear where to go, where to click, and how to start the process of working together? You might take a stab at that yourself if you can add buttons to your website or change the format and stuff like that, or you might hire someone to do it [00:30:00] for you.

You make that decision and you say, is it a good use of my time to learn this? Do I enjoy learning this or does it suck the energy out of me and give me a great deal of anxiety?

Dr. Sharp: Absolutely.

John: You make that decision. I will tell you, if that is your problem and you’re already getting good traffic to your website, that’s probably the better problem to have, overall. That’s a quicker fix than getting to rank up high on Google in the first place. Either one needs to be addressed.

The other website problem is you’ve got a great website. It’s beautiful. It’s got amazing images, and amazing copy. It’s got clear calls to action, but no one’s finding it. This marketing asset is only as good as its discoverability. So that’s a problem of SEO or of search engine optimization and making sure that [00:31:00] your website is actually being found by the people who need to find it at the most basic level.

Dr. Sharp: Yes. Okay. Let’s take that then, so for the first problem, you said that’s a little bit of an easier fix. You can add buttons to make sure that people know how to call you or email you. You can change the layout of your website a little bit to guide their behavior and make it clear what they want or what they need to do.

For the second problem though, how do you improve search engine optimization or how do you help people find your website or find your practice? How would you do that?

John: Great question. Let me say a few things about SEO. There’s a lot out there even for therapists to learn about SEO. You can get deep with it real fast. It can get really overwhelming. [00:32:00] Let me say this, first of all, SEO is an ever-evolving beast.

A lot of therapists that I work with, I’ll get the sense of like, well, someone said or my web developer said, “I’ll do your SEO”. It’s not black and white. It’s not like you either did your SEO or you didn’t, it’s that there is a complex formula that only Google knows that has to do with who ranks up and who doesn’t.

We know a great deal about this formula, but it’s changing all the time. There are people who stay on top of this just like you stay on top of politics, or some people who get really deep into foreign affairs, and stuff like that.

You can study and you can read the news of SEO and still not know it all.

In general, you want to be doing things to tell Google that your website is important. So how do we do [00:33:00] that? One, you have the right keywords in the right places for SEO. I won’t go deep into the technical parts because I think it’s going to get people lost, but you want to figure out, what are people searching for in my particular area.

You want to use something called the Google Keyword Planner. If you want to do some of this work, your stuff, that’s another tool for you is Google Keyword Planner because you might say, okay, well, I do neuropsychological testing and so I want to rank up for that term, neuropsychological testing, Boulder, Colorado. We don’t know for sure that people are searching for that. Maybe they’re searching brain injury testing or TBI test or something like that, Boulder. We don’t know necessarily until we do that research as to what people are searching for.

Dr. Sharp: I want to stop and highlight that pretty heavily. [00:34:00] I think that’s super important that we, especially as testing folks, can get into the nuances of what we call our service. We say neuropsychological testing or assessment or evaluation, it’s important to know for listeners that that might not be at all what people are searching for.

So using the Google keyword planner, finding some way to figure out whether our potential clients are actually searching for those terms or not. And then use that to guide your website copy.

John: That’s it. We can’t assume, we have to make sure that we’re making these edits to our website based on some research, which I think a lot of testing psychologists will resonate with, using data to draw conclusions and make decisions.

So having the right keywords in the right places, which we could talk about for six [00:35:00] hours here, but in general, you want more people to find your website, you want them to spend more time on your website, and then you want them to click around a good bit as well.

How do you do that? One way that you do that, and I get a lot of questions about blogging, should I be blogging? Do I have to have a blog? Well, you need something, you need some form of content. I’m not going to tell you it has to be a blog, but I’m going to tell you it needs to be some form of content. I’m also going to tell you that you don’t necessarily have to be the one to actually write it.

The purpose of blogging, for instance, or the purpose of content is sending more people to your website, having them sit there, read an article, watch a video, listen to a podcast on your website, because all that time spent is money in the bank for your SEO. When people are doing that, people are coming to your website from different sources, they’re [00:36:00] sitting there and they’re engaging in something, that tells Google, hey, this website’s important, you should rank it up.

Dr. Sharp: Got you.

John: It’s about building that content but it’s also about keeping that content coming. It’s not enough to write two blog posts in December and not at all for the next six months or whatever it is. There’s a lot things you do to rank high and then there’s things you do to keep ranking high as well.

Dr. Sharp: Okay. That’s great. So you can put new content on your website via a blog, which others might be able to write for you. I think that’s a good tie-in with our virtual assistant conversation from last time with Jaime. That’s also a task that I have delegated to my administrative assistant. You can also find graduate students or even undergraduates who can write quality blog posts. Just to put that out there that you can definitely outsource that.

John: Absolutely.

Dr. Sharp: Cool. [00:37:00] Earlier in the podcast, you mentioned AdWords, we also talked a little bit about social media. Can you speak to what is AdWords for anybody who doesn’t know and how would you recommend using social media as part of your marketing strategy?

John: Sure. At Unconditional Media, our digital marketing team for therapists, our two most popular services are SEO and Google AdWords. For SEO, when you work with one of our specialists, they are going to take your website, they’re going to sit down with you and figure out what do you do? Who are you trying to attract? What kind of services do you offer?

They’re going to take that information and do all the keyword research for you. And then they’re going to go through your website page by page, paragraph by paragraph, and plug in the right keywords in the right places. There’s a lot of places that those keywords need to be and you have to have the region-specific [00:38:00] keywords.

And then they’re going to use Google Analytics and set up everything there so they can watch this stuff performing. The other important step that often gets missed when people try to do it themselves is telling Google to index the pages. They have bots that crawl your different pages.

This is where it gets technical and crazy. When you make these changes to your website, it’s like raising your hand and saying, hey Google, I made a change, come look at what I did.

So once we make all these changes, we go through page by page, tell Google to reindex these different pages with their big system and their big algorithms. There’s a lot of steps. When you try to do it yourself, you might do 5 out of 6 steps, but not that 6th step. Sometimes that is the difference between your SEO taking off and it stagnating.

In general, unless you’re pretty [00:39:00] savvy or you’ve done this in another job or another life, I recommend getting some help with it. The same goes for Google AdWords. I learned all of this the hard way for two years doing my own SEO and my own AdWords.

With SEO, you are ranking up naturally or organically for searches. You’re making changes to your website, to these keywords for your content to rank up naturally when people search for anxiety therapy in Charlotte. It takes some time. It takes anywhere between three and six months after you’ve done the SEO work for your website to rank up for the right terms.

You might be thinking; I need to rank up now. I need new clients right now. Or let’s say I just hired a new psychologist for my practice and I need to fill them up. If you call me and we talk about your different options, I’m probably going to steer you toward Google AdWords if your main goal is to [00:40:00] get people calling right away, calling this week or next week or whenever we launch these campaigns.

So for Google AdWords, it’s a pay-per-click platform where we create ads for you that are based on those same keywords that you need to be ranking up for with your SEO but we are plugging those into Google AdWords, creating ad sets for the different services you want to promote. And then we are paying Google per click to rank up for those terms at the very top in a section that is very subtly the ad section. It has a little yellow watermark that says, add on it and you can Google anything and you’ll see those.

That’s what Google AdWords is doing. You’re paying to show up at the very top and you only pay when someone clicks on your ad. That’s the great part about it as well, is you can set that budget. You can toggle that campaign on or off depending on the season that it is, or depending on where you’re at in your practice, maybe [00:41:00] you’re at a lull and you need to boost.

That’s one of the great things with AdWords is when you have two campaigns that are dialed in and dialed in professionally, it’s as simple as toggling them on or off when you want more clients. It’s a powerful platform. I love it.

Dr. Sharp: That’s great. I know that we are getting close time-wise. I want to be mindful of that. I wanted to ask maybe one last question that I think relates to what you were just saying. I get a lot of questions both about growing testing practices, which of course involves needing people to call soon. I’ve also gotten a lot of questions around how to start a practice in a place where you don’t know anyone.

Several of my consulting clients for whatever reason are setting up practices in communities where maybe they didn’t go to graduate school or they [00:42:00] moved there for their spouse’s job or something like that. Could we talk about that in a specific or focused way?

Let’s say someone has moved to a new city, let’s say it’s a medium to large size city. It’s not a rural area. They don’t have any contacts. What would you recommend from a digital perspective or marketing perspective to start to build a testing practice?

John: Right off the bat, I will say that for something like a testing practice in a new city, I do think it’s critical to connect with those referral sources because a lot of times when people are coming to you all, it’s through a referral or it’s through a doctor or school counselor, whomever who said, hey, you need testing or you need more than we can provide here or some names.

I do think you have to start there. I think for someone in that particular position, that’s the right [00:43:00] place to start while you’re also doing this digital stuff. I’ve started practices now in San Francisco and in Charlotte knowing absolutely no one. It’s a little different with therapy, but I do have a psychologist in my practice now doing testing so we have walked through this.

I would go back to doing some of that keyword research or hiring someone to do your SEO as you’re building a new site. That’s the optimal time to do the SEO work. If you’re already going to be building a new site, you should do that work in the beginning so that you’re building these pages and the page URLs and the page headings and all this good stuff to make sure that you’re optimized for all those correct keywords in the very beginning rather than having to come back and do it again.

If you need to build quickly, I would think about working with someone to create [00:44:00] Google AdWords campaigns for you based around those different terms. So if people are searching testing psychologists in Charlotte, I want to rank up for those basic terms. And that might be one way to start it.

Even if you do neuropsychological testing, maybe I also need to be ranking up for those basic terms like ADHD testing Charlotte or whatever it is. It’s going to pay off. You’re going to see a return on that investment and you could spend six months trying to learn it yourself or you could have someone like our team doing it in six hours and doing it way better than you’ll ever be able to do it because this is what they do all day.

I think making that investment early on is going to help. It also depends on how quickly you want to grow. Some psychologists might say, I need to get to X amount of clients in six months or this amount of revenue in six [00:45:00] months. I’ll say, okay, in that case, we need to structure your marketing plan accordingly.

If you’re growing slowly, you work at an agency full-time, or something like that, we’re going to take a different approach with your marketing. So it comes down to how much time do you have. How much money do you have to put into it? What is the other work that you’re doing? I want everyone to have a well-balanced and well-rounded marketing plan between doing some in-person stuff and also doing some digital stuff and making sure you’re giving some attention to both realms.

Dr. Sharp: That makes sense. We’ve talked a lot about the in-person marketing here for a testing practice so I totally agree with that. I like how you said, it’s this one-two punch of making sure that you have a great website if you’re starting a new practice because, you didn’t say this explicitly but I think through our conversation, I figured out that [00:46:00] you can run a great AdWords campaign and get people to click to your site but if you don’t have the content and the website layout to tell them exactly how to schedule with you and how to get them engaged, it’s going to work too well. So that one-two punches, that sounds really important.

John: Oh, it’s huge. The last thing I’ll say about social media, just because we don’t have time to get into it today, but I want to dispel some of this right now that I see going on. We feel all this pressure to be on social media and to exist everywhere. I think it’s good to exist on two platforms at some point, but I also want to tell you, especially if you’re just starting your practice, quit wasting your time on Facebook, quit wasting your time on Twitter because it’s simple, where do clients go to find their next therapist?

Do you open up Twitter and start looking for a neuropsychological testing? No, you don’t. Do you go to Facebook? No, you don’t. You go to Google or maybe [00:47:00] Psychology Today or something like that, but you have to think about where clients are.

And so social media is more useful for what we call brand recognition and this slower-burning solution to I need to keep getting my brand recognized. Especially if I’m growing a group practice, people need to know, hey, we’re open, we’re in business. We like to have our logo and our brand out there so it’s in the consciousness of people and in the consciousness of your community.

I want you to not feel pressured to be on social media and fall under this trap of, oh, I’ve got to be posting on Facebook or sharing articles. I see a lot of therapists wasting their time there right now. I want you to know there’s bigger fish to fry here.

Dr. Sharp: I think that’s so important. I’m glad that you said that because I think for a lot of us, Facebook feels like low-hanging fruit because we’re on there so much and we see so many ads and I know I’m certainly guilty of thinking, oh, this is so easy.

For a lot of businesses, [00:48:00] they’ll give you that little pop-up that says, boost this post or boost this ad. It seems so easy, but hearing you say that it’s not valuable and we should be focusing elsewhere is important.

John: Absolutely.

Dr. Sharp: Thank you for that and thanks for everything else. This has been a great conversation to lay the groundwork for what digital marketing is and how to spend our time. I could tell any number of stories of where I’ve tried to do it myself. I have that problem and have talked about that problem on this podcast as I have built my practice, but I have had many times where I have completely wasted money on Google AdWords because it seemed easy enough and I’m curious/dangerous enough to try to get into it myself.

I can’t emphasize enough that it is a [00:49:00] science unto itself and that there are people out there that know it way better than we do. It’s worth it. That’s one of those things that’s worth the investment if you’re trying to grow your practice.

John: Absolutely.

Dr. Sharp: Well, John, thank you so much. You clearly know so much about this stuff and I feel so privileged that I got to spend an entire week with you getting to be friends, building a relationship, and also sharing in all the knowledge that you have. Thanks for coming on the podcast. I think people will certainly find this helpful as they move forward in setting up some type of marketing plan for their practice.

John: Absolutely. It’s my pleasure. I love working with therapists and our whole team loves working with therapists. So if it’s something you want some help with or just want to pick my brain about, I offer free consultations with no expectations.

I want us to [00:50:00] all thrive. I want to see everyone advancing their practice and being better marketers or better business owners. And so that’s what I’m all about. Thanks for being here. Thanks for listening to what I had to say today.

Dr. Sharp: On that final note, what’s the best way to find you or get in touch with you if people do want to talk through some of this?

John: My two sites are privatepracticeworkshop.com for practice-building resources and courses and my podcast and stuff like that. And then the marketing team is at www.unconditional.media. From there, you can set up a free 15-minute consultation that will be scheduled on my calendar and we’ll sit down and talk about what you need and what’s going on and I’ll walk you through step by step what are your different options and here’s what I recommend right off the bat or I might recommend something entirely different.

I [00:51:00] don’t know, but I’m going to look at your practice very holistically and see what is it that you need right now that makes sense developmentally for your practice and where you’re at in conjunction with your goals. I’d love to talk to you.

For anyone who gets in touch with Unconditional Media and will reference this episode, I’ll offer $50 off an SEO package or an AdWords package when you reference this episode. So I’d love to hear from you.

Dr. Sharp: Oh, that sounds great. Thank you so much. I’ll have links to each of those in the show notes too, so people can make sure to find you easily.

John: Cool.

Dr. Sharp: Well, thanks, John. It was a pleasure as always talking to you. I look forward to talking to you again soon, I’m sure.

John: Sounds good. See you around.

Dr. Sharp: Take care, man. All right, y’all. I hope that you enjoyed that episode with John Clarke from Unconditional Media. John clearly has a lot of knowledge around this area and he has been on the [00:52:00] ground, so to speak. He’s a therapist by training. He started practices in two separate cities from the ground up and he’s done so very well. All of that knowledge goes into what he offers at Unconditional Media.

As you heard, John, was willing to offer a $50 discount for anybody who references The Testing Psychologist podcast episode if you give him a call. I know that he does complimentary consultations if you’re just interested in what digital marketing might look like for your practice right now. Links to that are in the show notes. You can get in touch with John that way.

Thanks again for listening. Been great to get back into the interview game and be talking with folks in the field about things that are important for us as testing psychologists. Next time, I will be talking with the President and CEO of TherapyNotes, which is an EHR that’s out there, and very friendly for testing folks. So hope [00:53:00] to look forward to that.

As always, if you are finding this podcast helpful please, go to iTunes or wherever you’re listening and subscribe, rate it, and review it if you have the time. I appreciate any of those actions are helpful in building the audience and helping others find out about TheTesting Psychologist and help us continue to spread valuable information.

If you are interested in talking about testing specific practice issues, I am happy to talk with you for 20 or 30 minutes totally complimentary. We can chat through where your practice is going and if consulting would be helpful in building your practice.

I hope everybody is taking care. Fall is definitely upon us here in Colorado. I think as I speak, it’s about 45 degrees, and looking out my window, the trees are changing and we are headed into [00:54:00] the fall season, which brings with it all sorts of nice things. So hope y’all are doing well, enjoying the fall. We’ll talk with you next time. Take care.

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[00:00:00] Dr. Sharp: Hey everybody, this is The Testing Psychologist podcast episode 31. I’m Dr. Jeremy Sharp.

Hey everybody, welcome to another episode of The Testing Psychologist podcast. Today, I am having my first guest in quite a while and it was well worth the wait, I think. I am talking with Jaime Jay from Slapshot Studio, bottleneck.online, and two other businesses that we will certainly touch on.

I met Jaime about a month ago in person. I had heard him on two podcasts prior to that. He’s been on Practice of the Practice twice. I was [00:01:00] fortunate enough to meet Jaime when I went to Slow Down School, which I’ve talked about here on the podcast a little bit.

He was one of the sponsors for the conference. It also turned out that he was my suitemate in our dorm-style dwellings. So Jaime and I got to know each other pretty quickly with some funny/awkward dorm moments. And then I got to hang out with him across the course of the week and learned so much from him and found out that he’s a pretty awesome person to boot. So super happy to have him on the podcast.

Jaime, welcome. How are you?

Jaime: Thank you so much for having me, Jeremy. I’m awesome and I’m super excited and pumped to chat with you and your listeners.

Dr. Sharp: Likewise. Thanks for coming on. Let me tell the audience a little bit more about you and then we will just jump into it.

Jaime is going to be talking with us today all about virtual assistants. He is an [00:02:00] expert in this area and one of his businesses focuses on virtual assistants. So we’re going to be talking all about that and how a virtual assistant can help your testing practice.

Before we get to that though, let me tell you a little bit about Jaime. Jaime started out in the U.S. Army. He was a former paratrooper. After he got out in 1994, he worked for a few corporations in corporate America over the next 12 years, learned a lot about business and working with others, but didn’t quite feel like he had found his calling.

In the summer of 2006, he co-founded a small real estate ad agency and fell in love, and found his entrepreneurial spirit. That word is always difficult, but he found that and got to go through the rollercoaster of the real estate boom in 2008 and the burst bubble that we all know [00:03:00] about.

After that though, he moved on to focus on digital advertising and websites and marketing and branding. Jaime founded Slapshot Studio LLC in 2013. It combines his passion for ice hockey with the ability to build websites and help others develop their branding.

So, Jaime, I feel so fortunate to have you here on the podcast. Again, welcome.

Jaime: Thank you so much. What a kind introduction. I appreciate that. It’s a lot of fun doing this, especially with Dr. Jeremy Sharp. This is amazing.

Dr. Sharp: Jaime, if you could see, I’m blushing right now, so thank you. You’re a kind person as well. I’m happy to have you mainly because, so a combination of factors; I’ve been asked many times about virtual [00:04:00] assistants. So just on that level, I’m happy to have you on here to be able to talk about them but also, there’s an added layer because you’ve been doing this for a long time. This is your business and you have a depth of knowledge with virtual assistants that will be helpful for all of our audience.

Forgive me, I’m going to ask some basic questions just lay some groundwork and then we can dive into it and get into some of the nuts and bolts of a virtual assistant and how they could be helpful in a psychology practice.

Jaime: Perfect.

Dr. Sharp: First of all, I’m curious, your bio told us a lot but can you say a little bit more about how you found yourself in the business of recruiting, vetting, and managing virtual assistants just as a business?

Jaime: Sure. That’s actually a great question. The genesis [00:05:00] of me being introduced to virtual assistants or as I refer to them as VAs was in 2006 when I helped co-found a small real estate ad agency in central California. The partner I partnered up with was from the Philippines and he was then living in California and together we came together. We both had a passion for real estate and we needed to bootstrap this product and service that we wanted to develop.

A more affordable way of doing this was he actually introduced me to my very first VA. We ended up growing to about 13 virtual assistants in 2007 from the Philippines. So we had our core staff at our local office there in central California of about six people, if memory serves me correctly, six or seven people and then we had 13 virtual assistants.

They did everything from production to website [00:06:00] development to marketing and all kinds of cool stuff. We even published a magazine that we had distributed 12,000 copies around and they did the layout. They did the designs, all that kind of cool stuff.

I thought that was really cool to be able to work with these people, even though they were in the Philippines, we were still able to communicate effectively, we were able to do amazing work, and get so much more done all the while bootstrapping this venture. We were attempting to grow and grow and ultimately, unfortunately, as of 2008, we all know what happened and you said that. We’ve lost 72 clients in the span of about three or four months. That was out of our control.

I don’t necessarily know if I want to say my passion or my love for my interaction with my VAs is what drove me, but I had a really good experience. I bonded with them. It was [00:07:00] an amazing opportunity.

I find that most of us that are starting up ventures, we obviously don’t have a lot of capital when we get started, or maybe we’re worried about, hey, if we hire people on, boy, that’s a big expense and you have this to worry about and that, all kinds of stuff, I can go on and on. We can probably dive into that but overall, that’s where my start was, and because of the relationships that I built early on, I just continued those.

So since about 2007, I’ve had the ability to source a virtual assistance for friends and people in my sphere of influence and about a year and a half, two years ago, I opened up my own company, bottleneck.online and we helped stop the bottleneck now with virtual assistance.

Dr. Sharp: Oh, I like that. I always thought that was a great name for a VA company. I can certainly identify with that bottleneck practice.

[00:08:00] One of the things that I thought about just as you were talking about that journey is the amount of trust that has to go into a relationship with a VA. I think we can talk about this as we go along, but I want to say that to bookmark it for myself that I imagine a lot of listeners are maybe saying like, well, how can I trust this person or how do I know they’re going to do a good job? And that sort of thing. Before we jump into all of that, I think it is worthwhile to maybe just define virtual assistant.

When I’ve mentioned it to other folks, I’ve gotten responses like, you mean a robot or a computer? What is a virtual assistant? Can you talk a little bit just about who and what is a virtual assistant? What they do.

Jaime: Sure. If you’re talking about a robot, that’s [00:09:00] an electronic virtual assistant, also known as a chatbot. If you’re talking about a virtual assistant without the electronics in front of it, that is a human being that is working remotely. It doesn’t have to be in the Philippines or it could be in India, it could be in the Ukraine, it could be right here in the United States, it could be in Canada, UK.

Virtual assistants are people that work remotely; meaning they can work in a coffee shop; they work in their house. They can even have one of those little co-working spaces that they go to. So that is basically what a virtual assistant is.

What a virtual assistant can do, well, there’s a plethora of different things and you can get into different specialties as well. So whether you need somebody to manage your bookkeeping, you want to have someone manage your website or build a website for you or be your webmaster for your business, or you need just a basic administrative assistant that’s going to go do research for you or answer emails or manage your calendar, book [00:10:00] your travel, there’s a wide range of different things that the VAs can do. Does that answer your question, about defining what a VA is?

Dr. Sharp: Yeah, it does. I think just that distinction and making sure people know that a virtual assistant is an actual person most of the time.

Jaime: Yes.

Dr. Sharp: Though, I would like to talk with you, I know that you have this chatbot project, maybe, is what you call it, going on. I got to hear a little bit about that at Slow Down School, and I think that’s super interesting. Maybe we can touch on that here in a little bit.

Jaime: Sure.

Dr. Sharp: But for right now, just important to say that a VA is an actual person, a human being that practitioners would interact with and almost like an employee of the company or more, would it be an independent contractor? That’s maybe an important question.

Jaime: Yeah because I wanted to make that distinction, [00:11:00] if they’re out of the country then, and of course, contact your accountant, your CPA, and find out what’s going to be best for you. The way that we work it here is they’re not even independent contractors so they are, in essence, a business expense because the money is going out of the country.

We can’t do a W-9 or a W-2 or anything like that. For the people that are in the states here, yes, of course, we can do that. I recommend you go explore the differences and the pros and cons of W-2 versus 1099. There’s benefits and cons to both of those.

I don’t call them employees. There are no “mandatory” meetings or anything like that they’re [00:12:00] there as support. So basically, it’s like they’re freelancers, so to speak. We’ve developed it in such a way to where we can say, hey, they’re 13 hours ahead of us, so there is some time that offsets the difference.

So we can just say, hey, can you get this done here? Can you do this? Hey, would you be available to meet with us at this time instead of, hey, mandatory meeting this day, this time, every single day?

Dr. Sharp: So that’s a way to get around the employee distinction or is that …?

Jaime: Yes, basically getting around that. Plus, you want to be mindful and respect that there is a time difference, but they have three different shifts there. They have first, second, and third shifts in the Philippines. So a lot of people in the Philippines are used to working our daytime hours anyway.

I think Manila is the number one [00:13:00] call center place in the entire world. So there’s more call center, they call them BPOs, more call center agents than anywhere. And so they work, obviously, during U.S. times there. So they have the first, second, third shift, but it’s a neat way to leverage your time, get a lot of stuff done.

Most of my VAs, I have 13 of them here that work with us and they work their hours. What’s nice is we will get all of our projects and everything set for the day, when we wake up tomorrow morning, all the projects are done. So it’s really neat.

Dr. Sharp: Oh, that is interesting. I like that. You’re not fretting over all these items, you’re sleeping and it’s happening while you sleep. There’s a certain magic to that.

Jaime: Exactly.

Dr. Sharp: So just a nitpicky question, I suppose, but one that popped into my mind, [00:14:00] how do you handle the payment then for an international VA? How do you actually pay them?

Jaime: Sure. We pay our VAs by monthly, there’s two pay periods, 1st and the 15th through the 16th through the end of the month. And so what we do is we have some time tracking software that we use, it’s called HiveDesk. Basically, what that does is it tracks their time and it also snaps shots of their screen while they’re working so you can make sure that they are really working.

We never had to use that yet, very fortunate. It’s really easy, it automatically calculates their time with the rate that they earn and we know exactly how much to pay them at the end of both these pay periods. And then what we do is either something like Xoom or PayPal.

The majority of our setup is set up through PayPal which is nice too because the clients that we have for bottleneck, we would invoice them, [00:15:00] they pay via PayPal, and then we turn right around out of that same PayPal account and pay our VAs.

Dr. Sharp: Oh, I see. I’m setting this up and spelling it out for anybody who might be listening. So if they were to work with bottleneck, for example, they would pay you for the service of having a VA, but you actually take care of paying the VA. Is that right?

Jaime: That’s right.

Dr. Sharp: So practitioners, like psychologists or therapists, it’s not like we would have to deal with sending money overseas to a VA or anything like that.

Jaime: Exactly. There’s two things that come up right here. I’m glad you brought this up because this is that area that a lot of people are uncomfortable with in dealing with VAs. There is a plethora of companies out there, our options are wide open and many of those companies are phenomenal. They’re fantastic.

There’s also companies out there [00:16:00] that you don’t know just like with any other business. One of the biggest challenges that I’ve experienced, I started in 2006 with this so I’ve had a little bit of a track record here, but one of the biggest challenges I found was maybe I sent some money off to somebody and then they didn’t do anything.

Maybe I sent them a computer because I wanted to make sure that they had the right equipment because I really liked them. They were working for me for a good while and sent them and then all of a sudden they’re gone. They vanished. And now you’re out that computer, you’re out that money. That’s a big concern to me. I’ve also heard that from many of our clients and people that we’ve talked to.

So what we do as an outsourcing agency, is we actually vet these VAs. They do a DiSC profile, we get their resume, they go through and usually one or two [00:17:00] vetting interview process type style thing. And then basically what happens is as soon as that’s done, before we even introduce them to the client, we pretty much vetted them out.

They are human beings, we can never know what they’re going to do, but I have to say we have a pretty doggone good track record and we have a really good way of figuring out what makes them tick and whether or not they are going to be a good person, good fit. There’s two flags that go up through our questioning and our vetting process that we’re able to cut down on that aspect. So this is a big reason why people look to agencies to help them out with this.

The other thing is we never, and it’s in the agreements both on the side of our clients and on the side of our VAs, that they’re not to discuss financial matters. They’re not to discuss getting new technology, meaning they can’t ask for a computer. They can’t ask for a raise. They can’t do anything directly to the client. They [00:18:00] have to go through us.

That’s fine, if they want to ask for a computer, totally fine. That is fine. I’ve had many of my clients buy computers or give them gifts, certificates, or whatever, because they want to reward them for doing such a great job. That’s totally fine, but it has to go through us.

And the reason why, is because we want to make sure they don’t take advantage of our clients. We want to make sure that our clients feel comfortable that when they engage with these VAs, that they’re engaging with them directly, obviously they’re going to build a personal relationship over time. It’s just human nature but we want to take the element of the financial matter out of it.

So any financial matters whatsoever, whether it’s a raise or maybe they need to discipline them for something, maybe they missed a deadline or maybe they missed a project or something like that, the client will contact us, we’ll contact the VA, and get that problem sorted and rectified. If they want to dismiss the VA, they contact us, we dismiss it. [00:19:00] That’s the reason you have the agency there. You have the extras like, okay, we’re here for you. We got your back.

And then the other thing is, what happens if someone just goes AWOL, what happens if they leave? Well, they’re in the Philippines, we’re not going to fly over to the Philippines to go find them or what happened. Maybe we’re worried, maybe they got into a car accident or maybe it’s something more than what we think.

So we have a network of agents over in the Philippines to where we can literally go knock on the door. If we can find them, we figure out what’s happening. So that’s a big plus. Luckily, I’ve never had to do that but if we did, we can.

Dr. Sharp: Oh, that’s pretty incredible. I would not have even thought about that. I know it sounds like in many ways, y’all’s agency or company serves as a virtual HR of sorts.

Jaime: That’s a great way of describing it.

[00:20:00] Dr. Sharp: Okay. Oh, that’s fantastic. I like that idea that you even have contacts in the Philippines to check on the VAs if something goes wrong or that you’re worried about them. That’s nice.

Jaime: And we have a good reputation over there. I’m not saying all of these and I would never mention names, but some of the companies over there, they work their VAs hard. They know they can get them for a lower rate. It’s not a good company working environment, in my opinion, that’s just me.

They are human beings; these are real people. They work, they have families, they have sons and daughters and husbands and moms, and so we embrace a very strong culture much in the same way that we do with our other companies, and we just want to make sure that they’re getting everything that they can.

So we have a really good reputation over there of [00:21:00] caring. We never miss payments. We’re always on top of it. It’s just a different kind of way that we look at doing things. We’re an advocate not only for our clients to the VA, but also from the VA to the clients.

Dr. Sharp: I like that. I can tell that just in the way that you talk about it, that there is a mutual respect there that I would imagine helps everyone.

Jaime: Oh my gosh, yeah.

Dr. Sharp: Let’s talk a little bit about specifics with VAs. How have you seen other, certainly businesses, but if you can think about mental health practices or psychologists, how do they specifically use a VA day to day?

Jaime: Sure. There’s several different things that they can do. We’re launching a little program here with a mutual friend of yours and mine, Jen, because she was looking for someone to answer phones. So that is a little bit of a different thing than we’re used to because typically, [00:22:00] the stuff that we do is administrative; computer-based or web-based, I should say, building websites or managing websites or booking travel, anything to do online.

We did not have the element where we can, someone, especially in the therapy world, can have someone answer phones for them and know what to say because you want to find somebody that’s going to embrace your existing culture in your practice and knows that, hey, when they answer a call, hey, is so and so available, I need a session or can we schedule, oh, he’s not available, no.

We know that they shouldn’t just say no, it’s, I’m sorry he’s not available at this time, but when’s it another time that maybe he can get back to you, that’s convenient for you? So there’s a way that we can train and work with them in such a way that lives up to the therapist’s culture, the practice, whatever [00:23:00] it is they want to be able to convey through the VA.

So that is one thing that we’re working on but for the most part, it’s going to be something like administrative assistant doing stuff like that. Oh my gosh, bookkeeping is a big thing.

One of the things that we have to be careful of is the HIPAA compliancy, there are going to be some things that we need to look into. Perhaps it’s the first time that we look into patient records and the whole confidentiality thing. So there are some things that are a little bit more difficult than having someone on staff in person that are there, but for the most part, there’s usually a way that we can find that we can help somebody out.

Dr. Sharp: Great. You mentioned earlier, you listed off several things that I didn’t even think of. The bookkeeping thing is pretty big. So when you say bookkeeping, do you mean like balancing the QuickBooks account?

Jaime: Yes. Exactly.

[00:24:00] Dr. Sharp: Okay.

Jaime: So here’s the cool thing, every single one of our VAs are college graduates. So if, say, if you wanted to get a bookkeeper, I would go out and find somebody that graduated with an accounting degree. Here’s the other thing, one of the biggest questions we get is, well, they’re in the Philippines, do they speak English? Will I be able to understand them?

The answer to that is they start speaking English. It’s their second language in about the 3rd grade and their entire college is taught in English. That’s why we focus on people with college degrees. While some of the programmers or the people that are a little bit more into the more specific programming, coding, development, that kind of thing, they might not have as good English as styles pronunciation, but they’re not going to be client facing.

But more and more, [00:25:00] you would never even realize, I’ll give you an example, if you go and check out any of my blogs, that’s written by Karen who lives in the Philippines and she actually taught English in the Philippines and she’s fantastic. If you talk to her, you would never know she was from the Philippines. So there’s that that we can look at as well.

Dr. Sharp: Oh, that’s great. So even there, writing blogs, that’s a legitimate task for a VA.

Jaime: Yes. Thank the Lord, we have Karen. Social media is a good thing too. If you think about it, would you say you’re pretty busy?

Dr. Sharp: I would say that. Yes.

Jaime: It’s that a lot of therapists, more I’ve learned about therapists and their practices, Lord almighty, they’re trying to do so many things. And then social media comes up or you’re blogging like, hey, you should write a blog. It’s a really good way to get [00:26:00] your word out there and share what it is that you’re doing because that’s SEO, and SEO is another thing that VAs can do for you.

All that is time consuming and the social media, oh my gosh, you need to post on Facebook and oh, Instagram, oh my gosh, Twitter and oh, this, this is crazy. I don’t have time to do this. I want to focus on either growing my practice or talking to my patients. So that’s what a VA can do for you.

I don’t even do any of my own social media posting hardly anymore. It’s all done by a VA. So the VA does all of our posts across all four different businesses that we have on, geez, that’s probably 24 different platforms.

My show notes for the podcast are written by Karen. All the social media is done by Christine and it’s just wow. It gets a lot done. I basically get to oversee it a little bit and make sure the brand is [00:27:00] represented well and stuff like that. But other than that, they are just killing it. They are awesome. They are my rocks.

Dr. Sharp: I’ve heard from other folks too, that to level up your practice or even just give you a certain amount of free time and just let you relax a little bit as a practice owner, it helps to outsource as much as you can. It sounds like the VA’s are a great way to do that if you can find the right fit.

Jaime: Yeah. And you know what too, Jeremy, is really cool and this will be helpful for the therapists that are listening, my good friend Scott told me this, he said, do something as if it was the last time you were ever going to do it. No matter if you’re going to hire a VA or not, but if you can add workflows and processes to everything you do, eventually you’ll be able to find out what you can outsource. In essence, in doing so, create [00:28:00] a job description so that when you are ready to do something like this, you’ve already got everything done.

What I mean by saying, do something as if it’s the last time you’re going to do it, the next time you go to post something on social media, write the steps down exactly the way that you do it. And the reason why I say to do that is because if you go, say you log into Facebook and then you go to click post and then you go here and then you got to go to a file that you set up or a folder, something like that, whatever your steps are, write that out and sure it’s going to take longer that one time, but here’s the deal.

If you ever do go decide to hire somebody, guess what? They’re going to do something and they’re going to learn about it the same way you do. No one’s ever going to be better than you at what you do because it’s your business. It’s your baby. It’s what you’ve built. So why not give it the next best thing. [00:29:00] And when you bring someone on, have a system to train them in a very similar way that you’ve done it.

Obviously, I like to be open minded and if they have a better way of doing it, cool, let me know. That’s awesome, but at least, this is foundational. It’s appealing and it’s very easy and it saves a lot of time during that onboarding process.

Dr. Sharp: As you’re talking, I’m thinking about, okay, how can we apply this specifically to folks who do a lot of testing? That’s my audience for this podcast. Two things that jump out right away are assuming the HIPAA compliance is in place, is there a way to you train a VA to take let’s say clinical intake notes and write up a thorough clinical history based on your notes and maybe a template that you provide, something like that?

Sort of like an alternative to dictation, maybe.

Jaime: 100%. There’s a form that’s [00:30:00] called Delegation Tool. If you go to bottleneck.online, click on the Delegation Tool. What’s cool about that is that it lists out all the tasks that you do in a given day. You list 1-3, what gives you energy to what doesn’t. All the 3s come down at the bottom of the form. And those 3s are the tasks that you can delegate.

And then from the tasks that you want to delegate, you can create a workflow for your VA. And we’ll find a VA that can do that, whether it’s transcription, dictation, whatever it is.

Dr. Sharp: Okay. You mentioned the Delegation Tool back at Slow Down School and I looked at it and it certainly is super helpful. So if there are folks out there who are listening, some of you psychologists or mental health practitioners, and you’re saying, I don’t even know what I would do with a VA, this Delegation Tool is a great way to help figure that out. It can help you identify the [00:31:00] things that you can outsource and start to think about letting someone else do.

Jaime: Yeah. It is totally free by the way. So if you go there, download that Delegation Tool. I don’t ask for an email, nothing like that. This is simply a really cool tool for you to use. And then it’ll open up into Google docs. What I recommend you do is you just go up to the file. There’s a file up in the upper left hand corner, click file, make copy, and then you can copy it right to your own Google drive and name it whatever you want to. And that way it’s native right on your Google drive.

Dr. Sharp: Oh, that’s fantastic. I want to take that and in just a minute, ask that question, okay, so I have filled out the Delegation Tool, now what happens? Before I get to that, just to touch on other things that I could foresee a VA being helpful with from a testing standpoint, I could see a VA perhaps doing some of the things that we traditionally assigned to a psychometrician who’s like [00:32:00] an assistant in testing especially logging onto online scoring systems and transferring those scores into the typed report that we turn out. I can see that.

I could see inventory and ordering testing materials could be a task for a VA where I think speaking to the psychologist now, we’ve all been on the Pearson website and know what a pain it is to go through and actually order new materials. So to be able to outsource that and just tell a VA how much of what particular measures you need, that could be an easy task for a VA.

My brain is turning with things that even I could outsource here in my practice and I think others could probably do the same. That’s great.

Jaime: That part, obviously, I have no doctor in front of my name, so I definitely don’t know [00:33:00] that much about the intricacies of it. However, the cool thing is in sourcing for a VA, if you say, this is what I’m looking for. We have a detailed questionnaire that you would complete before we start the sourcing process. If you list out what you want, we’ll go and find somebody who may not have that specific experience, but are affiliated with that industry.

There’s a lot of medical psychology. There’s a lot of that in the Philippines. I think it’s like the third or fourth largest number of graduates are in the medical field.

Dr. Sharp: Okay. That’s good to know. So that really gets back to the selection process is maybe how I would think of it. Say, someone goes out, they fill out the delegation tool. They’re like Jaime, I want you to find me a VA, what happens after that?

Jaime: The next best thing would [00:34:00] be to go and fill out a questionnaire right on the

bottleneck.online. That questionnaire comes into our system and we take a look at it. What we’ll most likely do is reach out and schedule a consultation to get an overview and a feel to see if this might be a good fit for them. That way, they can answer their questions and things like that.

If we decide that they’re already a good fit, maybe we’ve talked to them before, we can see from the questionnaire that this is something we can definitely do, we’ll send them out a questionnaire. And then they’ll complete the questionnaire.

Once they complete the questionnaire, we’d definitely follow up with them at this point to give them an idea of what’s happening. And then we ask them at that point to fill out the Delegation Tool but chances are they’ve already filled it out, they’re way ahead of the game.

It takes about 7 to 10 days for us to source a VA. The reason why is because we have to go through the vetting process if we don’t have anybody identified to fill all the needs for that specific [00:35:00] client, based on their questionnaire. So usually we just say 7 to 10 days.

During that time, if they’ve already filled out the delegation tool, great, if they haven’t, we ask them to, and we also ask them to fill out a job description. We also have a job description form that we send them via email during this process so that this is 7 to 10 days for them to get ready, know exactly what they’re looking for, fill out their job descriptions. They have a good idea of what they’re going to be doing when they get an interview.

So what happens is once we identify the candidates and we’ve vetted them and we’re ready to go, they will be contacted by our HR person moderator from the Philippines to arrange for an interview. We’ll identify three candidates. They’ll go through the interview process and it’s 10-minute interviews for each of the candidates.

It may seem like a long time, but it’s plenty. It’s usually done in the morning or afternoon because [00:36:00] as they’re not hired yet, they are 13 hours ahead of us. They’ll go through these three interviews, 10 minutes, all the while being moderated with Irene.

What she’ll do after that is she’ll have a short little meeting with the client to see which one they like best. At that time, they’ll say, well, I like this person the best. They’ll set up what they call as a confirmation interview. During that confirmation interview, it’s just the client and the VA, nobody else.

You can do a 10-minute call or you can do an hour long call. It’s totally up to you, but this gives you an opportunity to really dive deep, see if the belief system is shared, see if that you really believe and you fill in your heart of hearts that this might be a good fit for you.

If you decide to move forward, then we go ahead and make the arrangements to get them onboarded. If you would like to say, you know what, I didn’t connect with anybody and I don’t think anybody works for us, we’re happy to go out and source another three candidates for you and have you do the process again.

Usually, if you haven’t picked a [00:37:00] VA by this time, it’s probably not a good match for you. I don’t think we’ve ever even made it past the second total interview if someone had to redo it. So we’re pretty good at identifying good matches.

So then you would choose to work with them. And then what happens is our Irene will call you after the first day and make sure everything went good. She’ll call you at the end of that first week, make sure everything went good. She’ll also call you at the end of the second week and make sure that that went good.

And right before you hire them, we send out an agreement, let you know everything, the payment processes and when and all that. We do the same thing on the VA side. And then as soon as you go through that, we recommend you meet with the VA once a day for the first two weeks for training, a minimum of an hour.

And then after that, we think it’s really good to meet with the VA a minimum of once a week just to have like [00:38:00] a company meeting or whatever just to make sure that things are getting done and you plan for the next week, things like that. I meet with my VAs once a week as well. I really like that.

And then we do a 90-day probationary period where we usually reduce their rate for the first 90 days. After that, when you say, yeah, I really like them, I want to keep them, then we go back and they usually get a raise at that time and the relationship continues. We will also do an evaluation at the end of the 90 days, and then we do it every three months. We’ll send you out an evaluation once in three months.

At any time, people need help or they have questions, hey, I’m not sure what else to do. My VA is awesome, but I don’t know if I can delegate this or how do I delegate this or this is so sensitive, do I give them my passwords? So there’s a lot of things that we can help out with that.

There’s a really good piece of software called lastpass.com and that’s [00:39:00] what I use for access for all of my stuff for my VAs. I’ll tell you, at this point, I build up such good trust with my VAs. They have access to my credit cards to help me book travel. We’ve bonded, we’re big family.

So it just depends on what your level of feel is with them and how long you’ve been with them and how the relationship has been but just know that they are human. I cannot ever 100% promise that they’re not going to do something to upset somebody or not show up, but at the same time, I feel pretty good that they’re going to be good people.

Dr. Sharp: That sounds like it. The vetting process sounds pretty thorough, to be honest, and y’all been doing this for a long time and I guess some of it too is just trusting your agency or whomever to get the VA. Trust that [00:40:00] process.

Two questions from that, we should probably talk about how much a VA costs. I’m sure people are asking that question. So can you speak to that?

Jaime: Sure. That’s the beauty of this, is it depends on what level of expertise you’re looking for. It can range anywhere from $6, $7 an hour, all the way up to $15 to even $20 an hour. It depends on what you’re looking for and the higher end are more specialized. That’s programming, web development, design, something more specific, more focused. When more data entry, administrative assistance, those are a little bit more affordable.

Many times I come out and say this a lot, I volunteer it now because I’ve been asked so much, but they say, oh my gosh, that you’re paying them so low, how can they live? Well, just know that the average rent out there in the [00:41:00] Philippines is about $300 a month. It’s completely different than it is here in the United States.

To give you a great example, I had a client that was searching for a social media manager in the U.S., the lowest they got here after their interview process was $44,000 a year for social media manager. That was expensive. We found somebody that was more qualified, had a degree for $12 an hour. That was pretty amazing and had more experience than the person that was wanting $44,000. With $12 over there, $12 an hour, that’s a huge income.

Dr. Sharp: I think that’s something to wrap your mind around. Even being a little bit familiar with this setup, it’s so hard to think, is [00:42:00] that really okay to pay that little but I think that’s important to think about that. And for anybody considering it, to do your due diligence and whatever feels good to you, internally with hiring internationally or not, to know that you’re doing the right thing, but again, the trust comes into play. I know you’ve been doing this for a long time. You said you have very positive relationships over there.

Jaime: We are launching our United States virtual assistants as well. We are getting into that. Just know that you’re probably going to look about three times as much for the same types of services in the U.S. than you would in the Philippines. The other thing is, too, is they have a thing called the 13-month bonus. Have you ever heard of that?

Dr. Sharp: No, I sure haven’t.

Jaime: The 13-month bonus, it’s a bonus in the Philippines. It’s pretty standard over there. For all of [00:43:00] my clients, I leave this 100% optional. You do not have to do it. I do it. Basically what it is, is you take what they’ve made for 12 months, divided by 12, and that’s their bonus.

In my case, I give it to them on December 15th. As long as they’ve been out of probation and they are working with us on the time that the 13-month bonus is delivered, but it’s a neat way, you’re paying them at a lower rate than you would pay somebody normally here in the U.S. Still fair though. Let me reiterate, still fair.

I think it’s a good move on anybody’s part because it’s good for the holidays for them. It keeps them around; it keeps them motivated. They’re very happy. They feel rewarded because they worked hard for you all year long. It’s just not that much more to be able to do something for them like that.

[00:44:00] Dr. Sharp: Oh yeah, that’s fantastic. I like that idea, just in general but especially in this context. That sounds important. Let me ask you, I’m conscious of time, but you did mention a little bit or briefly folks that may not be a good fit for a VA service. Could you speak to that a little bit, like from the practitioner side, who probably would not benefit from a VA or not be able to use a VA the right way?

Jaime: Sure. Are you familiar with DiSC profiles?

Dr. Sharp: No, I’m not.

Jaime: On the DiSC profile, the high D’s the demanding people; it’s this way or the highway. Many times, people that have that personality may not realize they do but what I’ve found is when you have someone that’s [00:45:00] very dictatorish, it’s going to be a bit of a challenge. Normally through the interview process that when I get to talk to them, I will probably be able to discern whether or not this might be a good fit for them.

Here’s the number one reason why VAs don’t work out is because they weren’t properly trained. And that’s why we recommend, we don’t make this mandatory, but we recommend to the clients, hey, take an hour each day for two weeks and get into this, because if they don’t learn or they have someone that’s like, how do you not know this? I know this stuff. Well, they don’t know it because they’re not in that industry or maybe they don’t have the experience they do. Everybody’s different.

So if you’re that dictator; do this or, you’re probably not going to be very successful. If you don’t take the time to share your knowledge and share what you’re doing, then you’re probably not going to be successful in maintaining a relationship with the VA. And to that effect, if you don’t have the patience to [00:46:00] train and you just think they should know it already, you’re probably not going to have a good relationship.

So some things that I’m asked sometimes that throw up a red flag are; do I really have to train them? I don’t have time to train them. Don’t they just know? You know what, I can’t train them, I’ll give them all this stuff and I’ll see how they work out. I will probably say, you know what, I’m so sorry but it’s probably not going to work for you. They need one-on-one time. It’s really important.

Dr. Sharp: That definitely makes sense. I think that’s important to say that because even I, to be honest, when you said an hour a day for the first two weeks, I was like, whoa, that’s a lot of time. I don’t know if I could do that, but to be prepared and just know that that’s what it will take for an enduring fulfilling relationship with a VA, I [00:47:00] imagine that it’s worth it.

Jaime: You can think about it this way too, it is a lot of time, but one of my friends who helped me create our workflow process, Scott, for a five-minute task, he’ll train for about 30 minutes. For most people, that sounds completely ridiculous. He spends five minutes on this task every single day, but he’s going to take 30 minutes to train somebody on a 5-minute task to make sure it’s done right, well, what is five minutes times 52 work weeks?

Because he spent 30 minutes with them and trained them correctly, he makes up all that time on the back end. This is your business, if you’re going to take two weeks, that’s 14 hours out of two weeks, that’s a lot of time but that’s not a lot of time. If you can take 14 hours out of two weeks to make sure that somebody is trained effectively for your business [00:48:00] and you want to make sure that they’re going to be administering your business effectively, then it’s definitely worth that.

And what’s cool that I found that most of the time before somebody hires a VA, that’s what they’re worried about. Oh, I don’t know if I can afford it. Oh, I don’t know if I’m going to have the time. I’m so busy. Post hiring, oh my gosh, how did I live without a VA?

Dr. Sharp: I can’t believe it. I’ve had that experience even with folks here in the office so I’m sure that happens with a VA as well. One thing that occurred to me as we were talking, just jumping back to the pricing issue, I should point out too, and correct me if I’m wrong, Jaime, but the beautiful thing about a VA too, is that you are not necessarily paying these individuals full time. They are getting paid for the time that they actually work on your business, however that long that takes. Is that right?

[00:49:00] Jaime: For some companies, yes. You could go to a place like Upwork or something like that and they will do hourly. For bottleneck, we pay hourly but we base it on a minimum of 20 hours per week. We have a little bit different model than other companies, and the reason why is because if you were to call another company and they do hourly-based projects or project-based work, you may not get the same person every time because they have hundreds of VAs that are covering.

Don’t get me wrong, they do good jobs but if you’re looking to build a relationship with your VA and handle stuff, if I were to do less than 20 hours a week, they would go out because they ultimately want a full-time job. So they would go out and get all these different projects, and then this is what happens, your stuff may start falling through the cracks, or it may not be as much of a priority as this other client, because they’re making more hours, so they’re making more money.

I just alleviate all that. I say, okay, if you go part-time, they can take other [00:50:00] projects on, but I will not allow them to take another job on being long term because if there’s ever instance or an opportunity for them to go full time with this person, I want them to be able to say, okay, no more projects, I’m going to go full time.

It’s much easier to say, I’m not going to take on any more projects than it is to say, hey, I’m not going to be working for this company anymore, I’m going to go work over here.

Dr. Sharp: Okay. That’s good to know. I appreciate that explanation and that makes sense. That totally makes sense.

Let me ask you before I let you go; this has been a ton of good information. I should say too, before I forget that all of these things that you have mentioned, the delegation tool, certainly your website, and anything else that’s popped up over the course of our talk here will be in the show notes. So folks can access all of that there.

I wanted to ask you, this is just [00:51:00] personal curiosity, because I heard a little bit about your chatbots at Slow Down School, and I am curious, could you say a little bit about what these chatbots are and where y’all are at with this in the context of mental health?

Jaime: Sure. A chatbot is an electronic virtual assistant. You can go on Facebook messenger and you can see they they’ve opened up their API for chatbots, meaning that you can actually do chatbots on Facebook now where you can be talking to an actual bot.

We are taking it to the next level. We call it relationship experience technology where we’re actually animating the bots now. So the bots will actually talk with you. Their mouth will move. They’ll move. They’re fully animated and it’s an incredible experience.

Anywhere from typical lead generation, customer service, consumption bots meaning [00:52:00] that you if you have your phone, you can use the native scan code right on your iPhone or your Android device and scan a little messenger code, and up will pop the bot.

We’re seeing people using these everywhere from, oh my gosh, when you come to the site, if you need help with something, their customer service bots, or if you have an instruction booklet, say you have a sauna or a hot tub delivered to your house, and you want to learn how to put it together, instead of reading an instruction booklet, why not scan the code and have a bot walk you through it and talk you through it and show you how to do it.

We’re excited about this and it goes right in line with our brand mantra and our vision and culture because we’re marketers so what do marketers do when they get a hold of stuff, well, they ruin it. We want to be [00:53:00] careful with how we do this, that’s why we’re developing the CUI standards, the conversational user interface standards.

We’re working hard to help people build relationships 24/7 in whatever capacity they can via robot. So it’s not a human, it’s not a robot. It’s something in between. It’s that third way of looking at something that will help to improve the interpersonal communications between humans and chatbots.

Dr. Sharp: Wow. I love that kind of stuff, technology and artificial intelligence and all of that. So this is just fascinating to me. Could you see something like that being deployed, say, on a practitioner’s website for scheduling an appointment or maybe, like for us, getting information about the evaluation process or something like that?

Jaime: 150%. Yes. It’s wide open right now. It’s so new. We’re [00:54:00] working with the University of South Florida in developing a new bot project with them to where we are going to be a category killer meaning that there are certain software out there that will no longer be needed due to the fact that people can get this at a much more cost-effective way and accomplish much more at much higher conversion rates.

Dr. Sharp: It sounds exciting. I love technology. I love to see how we might […]

Jaime: We’re not quite there with AI yet. That’s still a little bit off, but I think it’s the end of email. I know people are going to say, what? No way but hey, fax machines are no longer relevant. Email replaced fax machines. So we’ll see.

Dr. Sharp: I’ll say, you heard it here first, everybody. Jaime Jay says that email is going to go away soon. I’m sure there are some people out there that are [00:55:00] rejoicing that.

Well, Jaime, I know you’ve taken a ton of time. I appreciate everything that you’ve shared with VAs and how to walk through that process and hopefully, practitioners are coming away with some idea of how a VA could be helpful in their businesses.

If anybody has any questions or wants to reach out, what’s the best way to get in touch with you or even pursue a VA service?

Jaime: Sure. Thank you so much, Jeremy. It’s been a privilege and an honor not only getting to meet you in person but continuing the relationship. You are amazing. And so thank you so much for having me as a guest. It’s been a lot of fun.

The best way is probably to go to bottleneck.online. You pretty much can get all the information you need there. [00:56:00] I believe there’s a download, seven things you need to know before hiring a VA and it’s totally free. So two things there to help people out.

Dr. Sharp: That’s great. All that will be in the show notes. I know we didn’t even mention Jaime or touch on some of your other companies, one of them, Slapshot Studio. You do website and branding and those services are pretty incredible as well. There are links to that on my website under the resources section.

Jaime Jay, thank you so much. You have a wealth of knowledge that I got to experience firsthand and I’m very happy to be able to share that with our podcast audience as well. So thank you very much.

Jaime: Oh, you’re so welcome. Thank you, Jeremy.

Dr. Sharp: All right, take care, Jaime. Bye bye. All right, thank you for listening to that interview with Jaime Jay. Like I said, Jaime is an incredible person. [00:57:00] Not only has he started what seems like a thousand different businesses, he is one of the most genuinely kind and compassionate individuals that I’ve met and just pure optimism, pure joy. I hope some of that came through here during the podcast.

Also obviously, very knowledgeable. So if you have any interest in a VA or like I mentioned at the end, web design or branding services, Jaime is definitely your guy. So hopefully you took away some helpful tips from this podcast and are thinking about different ways to outsource and level up your practice.

If you are interested in connecting with other psychologists and folks doing testing, feel free to come on over to the Facebook community, which is The Testing Psychologist community. You can search for that in Facebook and we’ll be happy to add you to the group. We have a lot of [00:58:00] cool discussions there about different aspects of testing from case consultation to batteries to business stuff. So we would welcome you if you’d like to join us there.

And of course, if you want to talk about how to level up your practice and add or grow your testing services, I am happy to talk with you about that. We can do a 20-minute complimentary consultation just to see where your practice is at. I will give you any ideas that I can think of. If it feels like consulting is a good way to go for you, I am happy to do that with you as well.

I’m also excited to say that I’ve been hard at work booking some interviews for the next several weeks. At this point, I’ll be talking with the CEO of TherapyNotes about an EHR and how an EHR can help you in private practice with testing specifically. I’ll be talking with Dr. Jacobus [00:59:00] Donders who wrote a great book on feedback. I will be talking with Dr. Cathy Lord, co-author of the ADOS. So we have a lot of cool interviews coming up and in the meantime enjoy your testing, grow your practices, and take care. Bye bye.

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[00:00:00] Hey everybody. This is Dr. Jeremy Sharp. Welcome to The Testing Psychologist Podcast, episode 30.

Hello, everyone. Welcome to another episode of The Testing Psychologist Podcast. Great to be back with you again this week. Loving this groove of podcasting, and getting back to weekly episodes after taking a break. I hope everybody’s summer is going well.

I guess at this point we are into September or we will be when this is released. For me, that’s super exciting because that means college football. I’ve talked about growing up in South Carolina. I went to the University of South Carolina for undergrad and that is a huge [00:01:00] football school. It’s in what a lot of people would call the biggest football conference, the SEC.

This is a super exciting time of year for me. There’s just something about that combination of sensory input; the weather changing, the leaves changing, being outside, and football that brings back so many memories. So, super exciting. I hope y’all are starting to get into some fall traditions as well. We’re heading toward fall. I know a lot of people love fall and there’s some nice rituals that happen around that time. So hope you are all doing well.

Today, I am talking all about furniture and office arrangements for testing practices.

When I was thinking about doing this episode, I thought to myself, is this even relevant, is this [00:02:00] boring, or do people need this? I eventually, obviously settled on, yes, this is relevant. I looked back in the Facebook group and there’ve been a lot of questions about how to set up an office, how to store testing materials, what furniture is appropriate, and what kind of office setup and layout makes sense. So I thought let’s just go for it. We’ll see how this turns out. Hopefully, you can take away some important info. I’m going to speak primarily to how I’ve done it which has, honestly been pulled from what I’ve seen from other practices over the years. So, here we go.

I think one of the main things, we can start big picture and what you might think about, I’m going to approach it from two different ways. One is if you are in the [00:03:00] situation where you might be moving offices or you have the choice to get a new office or find a new office, I’m going to talk about it that way where you can plan from the beginning, and then we’ll tackle it from what do you do if you are in your existing space, plan to be there, and need to change or tweak some things.

If you are in the market looking for an office and you know you’re going to be doing testing, I think that affords you a lot of… Well, that’s a luxury where you can do some planning. I would say, the essential features of a testing office are:

1. Having a separate waiting area of some sort. Whatever you have to do to make that happen, especially if you’re testing kids, it is so nice to have a little space where parents can hang out. We offer [00:04:00] free wifi. We set up a separate wifi network for parents or for clients to use here that’s separate from our internal network. So that’s pretty easy. You can attach a separate router and configure it to provide a different network from your main router. So we offer separate wifi for clients but we have a little sitting space. We have a bistro table where people can sit and spread out their work materials or whatever it might be so that parents who are hanging out for a while can do that and get some work done. So I think it’s pretty crucial to have a waiting area of some sort that’s separate from the testing space.

There was some discussion the other day on the Facebook group about how one particular person has an office where the main door walks right into [00:05:00] the testing office and that is posing all sorts of challenges. And so, if you can avoid that, I think that’s super important. So that’s step one.

Step two is finding some amount of storage space. I think this depends. We are fortunate enough right now. We have an office with a small storage closet. That goes a long way, obviously for storing testing materials. But if you are looking for a new office, I think there are two ways to approach that. You can look at a space that has a very small storage closet or you can just look for an exceptionally large office that will allow you to put furniture in there to store the testing materials. So that can vary. It does not have to be a huge [00:06:00] or anything like that.

At this point, let’s see, I’m thinking about between all of our protocols, test booklets, response booklets, behavioral questionnaires, checklists, that sort of thing, it occupies, and this is not actual testing administration manuals or test materials, this is just the booklets; so the paper stuff that, for us, occupies at this point, three entire file drawers in a regular-sized filing cabinet. Well, in one of our offices, we have a nice lateral file cabinet. So the drawers go horizontally and that’s pretty helpful. You can get a lot of testing materials in there and that’s just something to keep in [00:07:00] mind if you’re planning for the furniture that you’re going to use. So, three file drawers are at least what you’d need for the booklets.

In terms of the actual testing materials, then we’re talking about, what we do is put each one in a separate container. I just bought small, let’s say, 10 by 12 portable file boxes from Target and I have 8 or 10 of those where we have test kits stored in those file boxes. Now, we exchange testing materials between several different clinicians. So that helps where we keep it all stored in the central, that closet, and people can take the materials that they need and grab the test kit in the boxes and take them to the office.

I’ve seen different [00:08:00] variations on this. Some practices will have storage containers like those rolling Tupperware containers with rolling drawers. They put a test kit in each little drawer, and then the person comes in, grabs the materials, and takes the drawer to the office that they’re going to work in. That’s more of a function for multi-clinician practices where you’re going to be trading test materials back and forth. But I think ease of access is pretty important.

Now, I should say too, I mean all of this is largely rendered a moot point if you are using Q-interactive where a lot of the testing materials are contained in the iPad. You’ll still have the Wexler blocks and a few different manipulatives, but those are pretty easily transported.

[00:09:00] Anyway, getting back to storage furniture, if you don’t have a small storage closet, you are looking for an office that’s big enough where you will have room to store all of that testing stuff. So like I said, you can get a regular file cabinet. You can disguise that by one, either buying a horizontal filing cabinet that looks like a chest of drawers, but a little shorter. You can certainly decorate your filing cabinet. I’m sure on Pinterest or Facebook or something, there are all sorts of ideas to do that that will go way beyond anything I could think of.

So you can disguise or hide the filing cabinet or you could just buy a nice-looking vertical file cabinet if you would like. But like I said, about three drawers for that, and then for all the test administration kits, that would require at least another two drawers, depending on [00:10:00] how many kids you’re working with. Sometimes you get into awkward test materials like with the D-KEFs tower or little things like that, that just have awkward shapes. So keep that in mind.

Now, one thing that I think is important is if you’re doing an autism spectrum assessment and you have that ADOS kit, I, to be honest, have not found a great way to store all of those toys. I just keep it in that original Tupperware that it came in, which is huge and awkward. If you have a big enough office, you can store it in there. I would put a tablecloth or a drape or something like that over it to disguise it. And you can use it as a small table during the times when you’re not administering.

At times, I have even used the ADOS Tupperware as the table during the ADOS administration. [00:11:00] You shut it, you disguise it, and you can manipulate toys and things on top of that as the table. So that’s another, at least for me, a big selling point for having an actual storage closet. It doesn’t have to be big, but just room to put that ADOS Tupperware.

In terms of places to get cheap furniture, this question comes up a lot, I’m going to assume that everybody knows about Goodwill, secondhand stores, and things like that. So that’s definitely out there.

I’ll often get the question how much does it cost to furnish an office or a testing office? I found that generally speaking, and this is buying all new stuff that I think is decent quality, it’s not amazing, but it’s lasted so far for years, I can get away with $800 to $1000 to [00:12:00] furnish an office pretty nicely. That’s pretty much everything in the office aside from personal decorations. So little knickknacks and chalk keys and things like that and pictures and whatnot.

Places that I tend to go to look for furniture are Amazon, Wayfair- I get a lot of stuff from Wayfair and they have sister sites, AllModern, I’ll look on sometimes. I get a fair number of things from Target. There are these particular lamps that I really liked that we got from Target. So those are my primary sources for office furniture. I like Wayfair because they do have a business account and you can get business pricing from them at times on certain items, and they’re on the internet. It’s easy to access. They have a ton of [00:13:00] reviews. Most of the time those are pretty accurate and you can really tell what people are liking.

The other option, of course, is Ikea. We have an Ikea nearby. I’m sure people have any number of feelings about Ikea. Mine are generally negative, but the furniture though has been good. It’s been good. And they have a lot of options for hacking their furniture, so to speak. There are two websites out there that I will list in the show notes that talk about Ikea hacks. What that means is, you can buy separate pieces of Ikea furniture and hack them together or attach them or modify them somehow, usually pretty easily to create furniture that works.

What I’ve seen a lot of people do with with Ikea furniture is they [00:14:00] have two versions of a folding table, hinged maybe is the right word where the table is attached to the wall and it’s on a hinge so it can drop down and lay flat if you want it to, vertically against the wall, or you can prop it up and make a table out of it. And that’s super helpful, obviously for doing testing.

So Ikea is out there. Like I said, I’ll put a link in the show notes to to the Ikea hacks website, but I’ve seen people build testing tables out of that. They also have a nice cube system. I have three of their cube shelves. I think the ones that I have are the Klax or Kallax. Those are great for storing testing materials as well. If you happen to have just a single clinician practice or you have a testing office where everyone rotates through, I think [00:15:00] those are great to use to store the testing kits. And you could probably even figure out a way to store the booklets in there as well in a cube system. So that can be super helpful.

Now, one thing that people consider a lot is, how do I set up a testing space and a “therapy space” in the office? I’ve done this pretty easily, I think in even relatively small spaces. For me, the central piece here is an L desk. My taste and those of my clinicians lean toward a little bit more modern. So, we have an L desk. It is not huge. It doesn’t have a big hutch or anything like that on it. I will provide a link in the show notes to the one that we typically use, but I [00:16:00] got it from Amazon. It has a nice wood veneer top. And then the base is metal.

I’ve bought a few of these for the different offices where we do testing. I like it because it comes in black, but you can easily spray paint the bottom to match whatever the office decor might be. We spray-painted one white, we’ve kept one black, but you can match it to whatever color you’d like. It serves really well. The long side is great to have a computer, some files, a good workspace, and then the L side- the shorter side is perfect for administering tests. There’s plenty of room for the testing materials and seems to work quite well. Again, it doesn’t take up much space, but it definitely gets the job done. So we have [00:17:00] several of those in the offices that we have.

And then beyond that, it really depends. A lot of the time when you’re doing testing, you can assume that you will have at least two people in the room aside from yourself for an interview or a feedback session. Families typically are involved in testing whatever the circumstance might be.  Now, sometimes there are no families involved, and in that case, you’re fine. You have a chair for the testee and that’s about it.

I’m a big fan of Loveseats. This is a necessary evil, I guess that if people are present, they have to squeeze on the Loveseat. That’s just how it goes. And then I have a chair for myself and then we’ll typically put in [00:18:00] another chair as well, just in case. That’s my formula, I suppose, for testing offices, two small but reasonable and comfortable chairs and then a medium-sized loveseat. That has done very well for us over the years. There’ve been very rare cases when I’ve had to pull in an extra chair, like a rolling chair or something from another office, but you can get away pretty easily. A lot of loveseats, I think you can find on someplace like Wayfair, you can find between $300 and $400, chairs typically run between $100 and $200, and that gives you a pretty nice setup for a testing space when you couple that with your L-desk.

I have, I think, jumped around a little bit here. I started off talking [00:19:00] about how to plan your actual space if you are searching for an office. Just to touch base on that again, if you can have a separate waiting area, that’s fantastic. If you can, set up separate wifi. I think that helps to let people stick around and be comfortable if they’re waiting for their family member to get tested. A small storage closet is ideal. If not, a larger office is something that would be helpful as well. That larger office affords you room for storage. It also affords you room to put in plenty of furniture that can facilitate the testing and the feedback sessions.

Revisiting that, I definitely get chairs that are easily moved; ones that I can drag pretty easily and there are a ton of choices out there. So if you have to move the chairs around or make room for the testing like the [00:20:00] L-desk to make room for a chair for the client to sit in, that’s totally reasonable.

Aside from that, I think it is important to consider a couple of other things. One of those is what you might do in the event that you have an office that you’re not going to be moving from. It’s not ideal. What can you do to tweak that office to make sure that it is testing-friendly?

One major solution that I had to figure out very early on, just as a side story, I started out in a very small office. It was not set up for testing at all. The only pieces of furniture in this office were my chair, which is a rolling chair, a large couch, and a very small side table where I put my computer [00:21:00] and a cup of water or whatever.

Now, I was lucky in that the office had at least a tiny closet. It’s one of those closets, it’s like a foot deep. It just had two shelves in it. So closet is maybe even a glorified term, but I was lucky that had a little bit of storage where I could put some of the testing materials, but furniture-wise, I didn’t have much to work with. So I was doing a lot of report writing on my lap. What I ended up doing is very bare bones, but it got the job done. Nobody ever complained about the setup, but I went to Walmart, I bought a very inexpensive folding table that’s probably about 2ft by 3ft and I could store it behind the couch. It was that thin when it folded up and I used my [00:22:00] rolling chair for my chair and I used a folding metal chair for the client chair. So not great, but it was doable. So, at the very least, you can get a small folding table that would get the job done for you.

People also often ask about rolling briefcases. This is something that I used way back in the early days, certainly. You can get a good rolling briefcase for under $100 on Amazon. A rolling briefcase, if you pack it correctly, you can fit many test kits in there. I mean, at least 3 or 4 test kits, the Wechsler scales, WIAT, there’s even room for D-KEFs tower or Grooved Pegboard, something like that. So, if you’re a pretty good spatial organizer, you can [00:23:00] pack one of those rolling briefcases pretty full and get the materials back and forth pretty easily.

Something like that certainly could store in a corner of your office. It could store in your car. It could store in a closet. So, a good rolling briefcase is potentially helpful for you if you’re running super low on space to store testing materials. It’s not going to be the neatest, but it certainly gets the job done. In fact, when I worked for a Neuropsychologist in grad school, that was all that we used. We traded that rolling briefcase back and forth between 3 or 4 grad students every week. So that thing was pretty beat up after two years, but it got the job done. It held an entire battery for a legitimate clinical neuropsychologist. So certainly doable. 

So those are some thoughts just about [00:24:00] furniture, what to do if you are planning your office or moving to a new office. Basic info, but hopefully helpful and important. Also what to do if you are trying to start up some testing and don’t have the space to do it right now. So do not overlook the importance or the function of a simple folding table can go a long way and that’s all that you need.

Now, we can get on to all sorts of other office layout questions. If you have kiddo clients or people are going to be waiting, then I think it’s a great idea to have a kid’s corner with toys and games and coloring books and crayons and markers and all that kind of stuff where kids can hang out or siblings can hang out and spend some time if they’re waiting on someone to be tested. I think that’s a great idea.

We have a spare iPad in the office that kiddos can play games on or [00:25:00] adults for that matter. We have a water cooler, we have a coffee machine, there’s all that kind of stuff to consider. I feel like that’s more just general office layout kind of stuff. But for testing specifically, we do have some nuances that we have to consider. I’ll just say again, the L desk is going to be your best friend, and finding great places for quality, but fairly inexpensive furniture, I think are important as well. I’ll have all of those links in the show notes, like I mentioned.

I would love to have more discussion around this. There was a great thread in the Facebook group about office layout and folks were posting pictures of their offices and how they set everything up. So if you have a cool layout to your office or other ideas about how to lay out a testing space [00:26:00] efficiently and helpfully, then feel free to send it in. The Facebook group is called The Testing Psychologist Community on Facebook. And my email address is jeremy@thetestingpsychologist.com if you want to send that to me.

Hope you are doing well in your practices. I know that there are a lot of you out there in various stages of development with your testing practices. If you are running into any roadblocks or need support in any way, I’m happy to talk with you. You can schedule a complimentary 20-minute pre-consultation call on the website, which is thetestingpsychologist.com and you will see it’s pretty easy to set up a consultation call. We can talk for a few minutes about where you’re at and where you might need support and try to figure out if consulting would be helpful for you. And if it is, I would love to work with you. [00:27:00] And if not, I will point you in the direction of things that would be helpful.

Take care. I will be back next week and we’ll keep talking testing.

All right. Thanks y’all. Bye bye.

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