[00:00:00] Dr. Sharp: Hey, y’all. This is Dr. Jeremy Sharp. Welcome to The Testing Psychologist podcast, episode number 26.
Hey, everybody, welcome back to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp, hope you’re all doing well this morning or this afternoon, whenever you might be listening.
Today’s episode is one that I’ve been looking forward to for a long time. As I mentioned in past episodes, I have been going back and forth with Dr. Karen Postal to schedule an interview with her. And today is that day. I am very excited to have her on the podcast. We’re going to talk about a lot of different things related primarily to feedback. Karen has written an amazing book called Feedback that Sticks. We’re going to talk about some of those pieces, as well as some other things that she’s got going on.
Karen, just briefly, welcome to the podcast.
Dr. Karen: I’m very happy to be here. Thanks.
Dr. Sharp: I’m very happy to have you. Let me do a more lengthy introduction and then we can jump into it.
Dr. Karen: Great.
Dr. Sharp: Dr. Karen Postal is board-certified in neuropsychology and pediatric neuropsychology. She’s a clinical instructor at Harvard Medical School where she teaches postdoctoral fellows in neuropsychology. She is the president of the American Academy of Clinical Neuropsychology.
Dr. Postal has a lifespan private practice dedicated to helping people think better in school, at work, and throughout later life. She frequently works with students from elementary school through college to overcome barriers to academic success. She also has expertise in working with traumatic brain injury.
Dr. Postal is the author of the Oxford University Press book Feedback that Sticks: The Art of Effectively Communicating Neuropsychological Assessment Results.
Karen, once again, welcome. I’m so glad to have you this morning.
Dr. Karen: Yes. I’m really excited to talk to you.
Dr. Sharp: Good. I know that we’ve had some rescheduling bumps over the past few weeks. That’s the thing that happens over the summer. So I’m really glad that we’re able to connect and have some time this morning to talk through your book and maybe some other things as well.
Dr. Karen: Sure.
Dr. Sharp: Maybe we could start off if you could talk just a little bit about what your practice looks like right now. I know you’re doing a little bit of research as well. Could you just give me an overview of what your professional life looks like these days?
Dr. Karen: Sure. Most of my time is spent in my private practice. I see kids starting at age 6 and I go all the way up to geriatric folks, 99, 100. It’s a really varied patient population, which I like a lot. And then I teach once a week.
The research that I’m involved in, most of it has to do with how we communicate better with our patients, with colleagues, and most recently, in the court system. I do qualitative research. The book that you mentioned, Feedback that Sticks was the result of a three-year qualitative research project. My co-investigator for that one was Kira Armstrong. And then more recently I’ve been involved in a qualitative research project looking at how we communicate better in the court system. How do we share our results with jurors, judges, and triers of fact?
I also do some research on report writing. We’re in revisions with a paper, a group of assets at Harvard Medical School. We call it The Stakeholder’s Project. We’re looking at what are stakeholders in the neuropsychology report writing process. Think of what we’re doing. So we asked neuropsychologists and we also asked our referral sources, physicians, and other referrals to comment on the reports and that’s been super interesting.
Dr. Sharp: Sure. Is that the thing that you are hoping to turn into another book or what are you looking at as far as […]?
Dr. Karen: The Stakeholder’s Project, we are in a revision process with the clinical neuropsychologist. So it’s a journal article at this point. Most likely we’ll go on to survey other stakeholders including patients, patients’ families, probably school districts as well, and the attorneys: what they need, what they think of what’s valuable to them in our reports.
Dr. Sharp: Well, I can just say that I think all of that information is so relevant and very practically applicable. As you’re describing that, I’m like, please, I needed that yesterday.
Dr. Karen: I always tell people that I feel very selfish in my research because as I’m talking with colleagues about best practices for communicating with patients and writing reports, I’m really busy integrating that stuff immediately into my practice. So it makes me a better practitioner.
Dr. Sharp: Sure. Well, I guess you can make the argument, that’s the best use of research. You can turn it around right away.
I know we have some other things to discuss, but I am curious how you run a research program primarily as a practitioner. I think a lot of folks may be interested in how that works.
Dr. Karen: The genius thing about having one’s own private practice is that you can make an executive decision that it’s worth your time to engage in research. For me, I follow my passion in terms of what I’m truly interested in. And so, for me, communication has been my main clinical and research interest. As a private practitioner, I can just say, you know what, I’m going to devote so many hours of my time and essentially pay myself for that time and then engage in the research. It’s not grant-funded, I suppose I could go out and look for grants, but essentially by the time I did that, the hours and hours and hours of grant writing, I could just do the research itself.
I fund my research with my income from my clinical practice and then in turn that research gives me a platform to talk about my work and leads to more referrals. In other words, it helps people know that I am a skilled clinician. I’m just realizing the phone is ringing in the background. I’ll turn that off.
Dr. Sharp: Sure.
Dr. Karen: Oh, sorry. The research and the writing that I do help people understand that I’m a skilled clinician and it leads to more referrals. Therefore, I think it’s a wise business practice. There’s a lot of psychologists who do that. Robert Heilbroner is a great example of a clinician who’s done a ton of really wonderful work. Manfred Greiffenstein who we just lost, was a wonderful clinician and researcher. Basically, he had the same model. They were people who did a lot of very helpful work but self-funded.
Dr. Sharp: Yeah, sure. I think about it from the business side. We talk about that a lot on the podcast. I would imagine that’s certainly not the only reason you wrote the book, but it certainly doesn’t hurt either. I would imagine people read the book and probably seek you out and that’s it.
Dr. Karen: Yeah. I think it’s a smart business decision, but in a way, I get to fund my research habit with my clinical practice.
Dr. Sharp: Yeah. Well, that’s great. I admire how you and others have integrated research into your practice. I think that’s something that can get lost pretty easily once we move into clinical work.
I am really curious, just to transition a little bit, how you came to the idea of writing a book about feedback specifically.
Dr. Karen: Well, I read a book called Made to Stick. I don’t know if you’ve come across this book. It was a best-seller in the business trade book market for two years in a row. It was wildly popular. It was written by Chip Heath and Dan Heath. One is a folklorist and one is a professor of organizational behavior at Stanford Business School. It was this genius book where they were looking at the question, how do we take boring information that is outside the framework of listeners’ understanding and make it compelling and interesting.
They gave this great example, there’s a nonprofit organization called Center for Communicating Science to the Public. I have something like that. This nonprofit is a national organization that they’re tasked with explaining nutrition information and other health facts to the American public. The authors of this book said it’s just intrinsically boring information that most people ignore, right? I mean, we all know that we should be counting calories and looking at cholesterol, et cetera, but very few of us actually pay attention to that.
This group had this breakthrough where they were supposed to explain the amount of saturated fat in the movie theater popcorn to the American public. And instead of having a press conference with some charts and graphs, they did this amazing thing. They took this banquet table and they put an entire day’s worth of disgusting high-fat food; eggs, and bacon for breakfast, a big Mac and fries for lunch, a steak dinner with all the trimmings for dinner. They put that huge banquet out and then they also put a single small movie theater tub of popcorn and they had their press conference. And they said, you could eat all of this high-fat food, or you could have the same amount of fat in this small popcorn.
I don’t know if you remember this, but I remember this. It was all over the Today Show. It’s about 15 years ago. The Heaths point out that within two weeks, the Ever Single Major Movie Theater chain switched the oil that they use to pop their popcorn too low saturated fat. It was so wildly successful. What they point out in their book and their research is that we can take even intrinsically dry boring information and make it compelling and engaging if we work at it.
I read this book and I was like, oh my God, that’s exactly what we need to do in this field, right? Here we’re sitting in feedback talking to people about standard scores and statistics and T scores and Z scores. It’s not accessible. It’s boring. It doesn’t necessarily connect with people’s lives. And if we’re going to do all this work to do an assessment, we really need to figure out how to make this information accessible, understandable, and memorable for people. And so that was the aha for me, was reading that book.
Dr. Sharp: What a story. I like that last thing that you said about making it accessible and meaningful. It is easy I think to get bogged down in a lot of the dry information and to just know what’s important to different people.
Dr. Karen: I think so. Another point that the Heaths made, and I think it’s so critical is that, as professionals, it doesn’t matter what your profession is. You could be an accountant or an attorney or a physician or a psychologist, we’re so used to speaking in our jargon and thinking with our basic assumptions that we learned in psychology 101 all those years ago, that those assumptions and jargon, it become invisible to us.
So we literally can’t see that other people have never heard our jargon or they don’t know our basic assumptions. And so our message is inaccessible to them. It’s like, if you or I sat down with our tax attorney and they started talking about what they talk about, we can’t access it. It doesn’t make sense to us. We can’t remember it. Not because we’re not smart, we’re smart, but it’s just we haven’t heard those assumptions. We don’t know that jargon. And so part of what my research has been about is how do we consciously and intentionally create access? Be aware of what words really are jargon that people don’t really know about and be aware of our basic assumptions and needing to explain those in an engaging way.
Dr. Sharp: Sure. I think that makes a lot of sense. As we’re talking about it, it occurs to me it’s almost like we have this feedback session time to teach someone an entire or a family, an entirely new topic in an hour or an hour and a half, and somehow make it relevant to their lives, but we’re starting from zero and there’s a lot of information.
Dr. Karen: I truly believe that it’s the most difficult thing that we do as professionals, being able to take all of this rich data from the history, from the medical records, from our testing, our knowledge of statistics, developmental history, brain function, and communicate it in a way that’s accessible as you said, in an hour without losing people. It’s very difficult.
Dr. Sharp: Well, I think that’s a nice segue to talk through some of the things that you found that you ended up turning into this book. I just want to point out before we totally dive into it, that something you said earlier sticks which is that this is research-driven. You were pretty methodical in putting this information together, interviewing folks around the field, getting it on the ground perspective for what really works in feedback sessions. I think that’s really valuable. It’s not just theoretical.
Dr. Karen: Right. My goal and the goal of Kira Armstrong, who was a co-investigator, we really wanted to interview seasoned neuropsychologists who had methods that they felt were really effective in communicating specific issues. So we ended up interviewing 85 seasoned neuropsychologists from across the lifespan in different practice settings. And we said to them, look, all of us have had the experience of talking to patients and their families and you’re explaining stuff and you can see their eyes are gazing over, you’re losing them. And other times, you can really see by what you’re saying, that they’re nodding and they’re smiling and they’re with you and they’re engaged in a back and forth.
And most of us, when we hit upon a way of explaining something where we really see that our patients are understanding it, we’ll use it again. Those stories, those analogies, those concise explanations. Over time, we’ve hit upon those. And we use those pearls on a regular basis. Or maybe a supervisor or close colleagues shared those with us. And so we said to people, look, that’s what we want to hear about. Don’t tell us theoretically what you might say, but what do you actually say. We ended up collecting thousands of those pearls from our interviewees. And that’s what we put together in a book.
Dr. Sharp: I would love to hear some of that. I think there’s a lot that goes into a feedback session. So maybe from a big picture perspective, can you speak a little bit to what y’all found makes up, let’s just say, a generally positive or successful feedback session to create a good experience for the family?
Dr. Karen: Sure. The first thing that we found, and it was very clear to us early on in the research was that there’s no one single way to provide outstanding feedback. It really was multiple effective strategies that really depend on the practice setting, the disease entity, the culture, the language background, the family systems background, and then the test scores themselves. So, pretty early on in the research, we realized that what we were going to find was multiple effective pathways.
As we personally heard these pearls and methods, some of them would fit with our personality. And they were like, wow, I definitely can see myself using that. Others might’ve been a great thing to say or a great way to approach it, but may not have felt quite as comfortable.
So the research, and looking through the research, the book format was the way we decided to publish it because it was just so much. It couldn’t have possibly gone into a journal article. But as you access all of that rich data, what we found most people do is they’ll end up gravitating to certain pearls and methods and other methods they won’t gravitate to so much. So that was the first thing that we found.
Another thing we found is that even though there were multiple effective ways of approaching feedback, there were some common denominators. One of the things we heard very frequently from seasoned clinicians is that it is well worth our time to engage in feedback sessions. I say this because the process of doing a feedback session at all is really something that’s evolved in our field.
When we interviewed senior neuropsychologists, meaning, folks who were around from the beginnings of our field of neuropsychology, what they told us is that back in the day, they were discouraged from giving feedback sessions. Most people learned in their graduate and in post-doc experiences that what you did is you did the test and you wrote a report, you sent the report to the referral source, and that person gave the feedback.
As we’ve gone through a process, I think where patients are much more empowered, they really want to know about their healthcare. They don’t want Marcus Welby to make decisions for them. They want to be equal participants in making decisions. The focus has shifted to direct feedback. In fact, in a research project where we asked referral sources about our stakeholder’s project and report writing, we asked referral sources, Hey, do you like to give feedback about the neuropsychology assessment or do you like the neuropsychologist to give the feedback? And overwhelming, referral sources said, oh no, we want you guys to get the feedback.
Dr. Sharp: Sure. That makes sense.
Dr. Karen: Yeah. We had interviewed Muriel Lezak about, well for the book, and she had said to us, she thinks it’s immoral to spend all this time with the patient doing testing and to give them either a super brief feedback session or no feedback session at all. She called it a hit-and-run assessment, which I thought was always. Mark Brisa, who’s a wonderful neuropsychologist in Texas, he calls it diagnose and adios. If you just say to a person, look, here’s the diagnosis and you spend 10 or 15 minutes with them, ask the existential question, was it worth all this time?
The other thing that we found which was a real common denominator is, people really believe in the process of feedback and think it’s a worthy thing to do. Most clinicians felt that there was something psychotherapeutic about feedback. In other words, that real seasoned clinicians saw feedback sessions as an opportunity to do their clinical work with folks. And that plays out in a lot of different ways.
Many clinicians told us that this might be the only stop along the way in medical care where after a traumatic brain injury or with a developmental disability or something like Alzheimer’s disease, that a clinician really gives a person and their family an opportunity to grieve. Many clinicians spontaneously brought that up with us. They said this is really a place where at some point we need to just stop talking.
Most had some language that they would use to invite families into that grieving process. Some it might’ve been as simple as, this is really hard, or this is really sad. Sometimes it was a little bit more specific. Mike Westerfield had said something that was so striking. He says to families when a child has had a traumatic brain injury, he will say, your child was injured but really you all were injured as well. It night might not be a physical injury but it’s been an emotional one.
And so many clinicians rely on their primary psychotherapy training to not only share information in the feedback session that really open up a space to process that information.
Dr. Sharp: I think that’s so important. I’m just thinking back to many feedback sessions of different types. You can see the tears welling up in a parent’s eyes, and like he said, just to stop and say, I know this is really hard to hear.
Dr. Karen: That is right. This is really tough to hear.
Another common denominator with feedback is that many clinicians felt like one of the goals is to help empower people. Mark said to us, and I think this really summed up what a lot of clinicians felt like that if you just gave the diagnosis information but didn’t help the patient or family understand how they might make changes in their life, then you really haven’t done your job.
So empowering could look like helping families understand how to navigate an IEP meeting or helping people connect with resources in their community or helping people understand how they might get accommodations at work. Sometimes the empowering us about how to help people reframe the use of compensatory strategies. For example, one of my favorite Pearls in this area is, I don’t know if you work with elderly folks or not but I see a lot of people where we’ve identified either an early Alzheimer’s disease or mild cognitive impairment where there are some memory issues and I’m introducing the concept of using some compensatory strategies.
I think it’s very similar to hearing aids. A lot of people know they need hearing aids, but they’re embarrassed to use them. And for a lot of folks in the 65 and over the crowd, they feel very embarrassed about using memory compensatory strategies. It will Telegraph to people that there’s something less than about them.
What I’ll say to people is like, Mr. Smith, what you need is a presidential assistant. You got president Obama or you had to suss out if they’re Republican or Democrat, you can fill in your president, President Obama when he goes to a major state dinner there are like 300 people in the room, he doesn’t remember the names of everybody. He probably doesn’t even remember that he’s met most of the people on the ground.
He has a presidential assistant that stands by his side and says, sir, this next person in line is the ambassador to France. You met him last year with his daughter who’s a soccer player. And then President Obama will say, oh, Mr. Ambassador it’s nice to see you, how’s your daughter doing with her soccer game? And the president will look like a hero and the ambassador will feel great.
Mr. Smith, that’s exactly what you need when you go to the Seniors Center. You need a presidential assistant to stand next to you and say, Hey, that’s the Jones’ and we just played bridge with them last week. They’re going to go to Hawaii on vacation. Why don’t you get your wife to act as your presidential assistant?
Dr. Sharp: I like that.
Dr. Karen: And so you’ve reframed that idea to a status symbol as opposed to a symbol of weakness. And that’s one method that you can use to empower people.
Dr. Sharp: Yeah. That’s great. There we are. There’s something right away to take away. Empowering folks. Making it a therapeutic process.
Dr. Karen: Yeah. The other thing that came out which really fascinates me, I always loved sociology when I was an undergraduate, but we heard a lot about the use of social pragmatics in a therapy session. One is the tone of voice, one is facial expressions, the extent to which you might share personal information, how rapidly you’re speaking, the use of jargon, body language, all of that. It’s the language behind the words. It’s not necessarily what you’re saying, but it’s how you’re saying it.
The classic example of that is the phrase, let’s go outside. If you’re sitting with someone in a bar and you say that to them, depending on your social pragmatics, you might mean, Hey, let’s go fight or, Hey, let’s go outside and smoke a cigarette or whatever together. So that social pragmatic, that language behind the words is really important in communication.
What seasoned folks were telling us is that they specifically manipulate those factors to reach clinical gangs. In our personal worlds, we all have one set of social pragmatics, and we might have different sets of social pragmatics that we use with different sets of people.
I recently interviewed Desiree Byrd who’s a wonderful neuropsychologist and researcher. She was telling me that there’s a sociological term called code-switching which many African-Americans will describe as a way of saying, we have one set of social pragmatics, tone of voice, even accent for one group of people that we specifically switch in different situations. So what we discovered in our research is that many clinicians in the feedback session will take what they would normally use in terms of tone of voice and body language and alter it for clinical aim.
I’ll give you a great example. Gordon Clooney had said to us that for most of his patients, he has really folksy social pragmatic. He’ll lean forward in his chair. He has a slow tone of voice. He doesn’t use any jargon. He’ll say stuff like, Hey, does that make sense to you? But he says, when he has a patient that’s super high status, like an attorney or a physician or a CEO that he’s tested, he will specifically change those social pragmatics. So he’ll lean back in his chair and he’ll purposely use jargon and he’ll speak more rapidly and he’ll make more direct eye contact because he wants to alter his authority level through those social pragmatics so that the person will listen, respect what he is saying. It’s really fascinating.
Another thing about the authority that I think was really interesting, most of us if we have a psychotherapy background, we’re trained in one of the many schools of psychotherapy where we’re taught to either have an equal sense of authority, status level or one down, right? The classic style munching family therapy is that one down stance or super neutral, like, the Carl Rogers, super neutral or the Floridian, not even saying anything at all, right?
A feedback session we heard from many people is a really unique time for a psychologist or a neuropsychologist when sometimes we have to take a voice of authority. Aaron Nelson, he’s a wonderful neuropsychologist in the Boston area, he said, it’s your job sometimes to be the authority figure. And you’ve got to be willing to step up and be that for people.
Oftentimes, people need to have some direction that directly relates to safety issues like driving or medication management or whether it makes sense to go back to work a certain amount of time, whether it’s safe to do so and having a one-down position or neutral position really isn’t necessarily the clinically best thing to do.
Dr. Sharp: Yeah, I think that’s really important. I’d imagine some folks may be listening saying, well, I’m not sure how to do that or that’s hard for me.
Dr. Karen: I’ll tell you a funny story. I had given a talk about this research to a group of developmental pediatricians at Tufts Medical School. There were, I don’t know how many, there’s like 20 or 30 of them in a room. They’re all MDs and they’re listening to this. Part of my goal was to share this research with them and then get their feedback on how this might differ from the way that they engage in feedback with patients. When I came to this voice of authority portion of it, they all said, oh no, we have no problem with that.
As physicians are taught from day one, you got to take the authority. But just as you point out psychologists, we are just not used to doing this. I’ll give you a great example. If for those people who work with dementia, probably the number one difficult thing to do is to successfully have a conversation about driving.
If you have a geriatric practice, you will have experienced the following a lot. One common thing is you’ll say, well, how is mom driving? Or how is dad in the car? And the adult children will look at you and they’ll say, well, I don’t know. I won’t drive with them. Or you’ll say, well, this person is pretty severely demented and I’m concerned about their driving. They have maybe a mini-mental of 16, or they have a full-scale IQ now of 60, that they’ve failed all the attention tests. I’m really concerned. And you’ll get the adult children in the room saying something like, well, he only drives to the post office and back.
What’s really happening is, patients with dementia have true anosognosia. They have a true neurologically-based unawareness of their deficits, but the part of their brain that could tell them that they’re not safe to drive, that part doesn’t work anymore. So they can’t know, but family members often have a psychologically-based denial. They understand that driving in this country has a lot of very rich, deep, important meanings for adulthood, independence, agency, dignity, and taking away a driver’s license is taking away something much more from their parent, right? They know it’s going to hurt them. And in a way, it’s kind of the death now for that person still being their parent in the way that they relied on through their whole life.
When you have a parent who’s who has Alzheimer’s disease, you’re losing that parent. And when you come to the realization that you have to take their driver’s license away, there’s no denying that you’ve lost them. It’s a horrible moment for everybody. But if as a clinician, you can’t make it happen, then you think about, well, I’m going to drive with my children in the car tomorrow and that exact same person could kill all of us. There’s public safety and there’s a personal safety issue. That’s so compelling, but are literally fighting against the patients neurologically based unawareness and the family members’ really compelling psychological defenses. So how do you do that?
That was one of the main things that we asked people who were seasoned, and I’ve got to say, one of the absolute best methods. A few different folks told us about this. People tend to use this one. Originally, I think I first heard it from Mark Burris, again, but what you say to folks and again, you have the patient in the room, the adult children in the room, and you say to folks, no one ever reads the fine print of their auto insurance policy. But let me tell you something. Every auto insurance policy written in this country has this little paragraph that says that if you have a medical condition that makes it impossible for you to drive safely, they don’t have to cover you.
So if dad gets into an accident, and the insurance company gets a hold of his medical records, they don’t have to cover this accident. He could lose everything he’s ever worked for. Similarly, I usually use both. I say also, everybody sues everybody in this country. And [00:43:00] so if dad gets into an accident, even if it’s not his fault on the way to the post office, then the person at the scene might get the idea that he has a memory problem because he’s asking questions over and over again. That person could Sue him even if it was her fault. They would get his medical records showing that he has Alzheimer’s disease and never got a driving test to prove he safe. Your parents could lose everything they’ve ever worked for. I am telling you, the first question out of the adult children’s mouths after you give them that Pearl is, where do we get the driving test?
Dr. Sharp: I can see that.
Dr. Karen: Because now you’re looking at a financial issue. If they lose everything they’ve worked for, how are we going to support them? Or are we now going to lose our inheritance? It is dramatically effective. For the person who has early dementia or late-stage dementia, even if they’re anosognosic, even if they don’t truly believe that there’s a problem with their driving, then they’ll still agree because they understand if I have this medical condition and I haven’t taken a driving test to prove I’m okay, then I could lose everything I’ve ever worked for. So that’s a very effective strategy.
Dr. Sharp: Yeah, absolutely. So let me ask you since we’re on this topic, just giving difficult feedback in general, I do wonder, and I selfishly I’m asking for myself, I work with a lot of kids, and so I think about how do you talk with parents about an intellectual disability diagnosis or even autism spectrum. That can be pretty heavy. Do you have thoughts on that or things that you’ve learned from others?
Dr. Karen: Yeah, absolutely. It’s such a great question. Just to expand it a little bit, even news that we don’t necessarily consider bad news could be taken as bad news by folks. I’ll give you an example. I had a physician couple that came in to get their child tested. They had their child in a very academically advanced private school. She wasn’t doing very well and they thought she might have learning disabilities. It turns out she didn’t have learning disabilities. She had what I would consider a wonderful IQ. She had a high average IQ, I think let’s say like around 115 or so. The mother was crying in the office because of that 115 IQ and literally said to me, I can’t believe that this is her IQ level. I’m going to have to rethink her entire childhood now that I know this information. That IQ number was a narcissistic injury to this particular parent.
Here’s another example. The somaticizing patient where you’ve got great news; you don’t have early Alzheimer’s, or there is no lasting effect from that concussion, or your scores are absolutely normal. That news could be taken as proof that yet one more doctor doesn’t understand them. So there is enormous potential for whether it’s truly bad news or whether the person thinks that it’s bad news to have people injured or experience what you’re saying to them as extremely difficult to hear.
Dr. Sharp: That’s such a great point. It makes me think about the flip side too. I’ve had a lot of parents and families be relieved almost to have a diagnosis that others might think is not a good thing. It’s pretty devastating.
Dr. Karen: Yes, it’s all about the frame. One of the best ways to have a successful feedback session is to go into it knowing what those frames are. And that means that you actually start your feedback session during your initial clinical interview. Karen Willis, a wonderful pediatric clinician, had said to us, and it just really stuck with me, that if you do the initial interview correctly, you’re going to know the fears of the person or the family. You’re going to know the different perspectives of major players in the family.
Maybe grandma doesn’t believe in ADHD or maybe dad had it as a kid and the medicine, he felt like it made him a zombie. You’re going to know the theories that people have. Maybe mom feels like the child is really lazy or maybe mom feels like their nonverbal child really has amazing cognitive skills that are hidden. I mean, if you do that interview correctly, you will know where all the minefields are. And so that way you can tailor the feedback so that you’re going to go softly, or you’re going to Telegraph, or you’re going to inoculate against some of those problems in the feedback session.
I’m forgetting who it was, but one clinician actually included in her intake form for families, please tell me the estimated IQ of mom, dad, and of the patient. She said she did this because that would Telegraph to her if they already knew that there was a discrepancy.
Dr. Sharp: Yeah. Oh, that’s really interesting.
Dr. Karen: Just to have that information before you went in. I think Joe Morgan had said, early in his career, he had a patient who he didn’t know until the feedback session when she started crying hysterically, that her goal was to go to an Ivy […] College. In the feedback, he was giving her the great news about a high average IQ and he just threw out, maybe this isn’t a Harvard, but this is something, right? It was devastating to her. And he said, from then on, he really made sure in the initial interview that he was getting that information about people’s dreams. So that’s one piece of advice about giving tough news.
Another wonderful way to think about it, and this was something that Kira had brought to our research and I think it was her supervisor who originally told her that this idea of leaving the door of hope open. This is particularly relevant when you’re doing assessments early on with someone who has a severe developmental issue or early assessments with someone who’s had say a severe traumatic brain injury or a really catastrophic tumor and oncology at treatment.
It’s to say, look, I’m going to tell you the worst-case scenario and the best-case scenario. My job is to tell you both. And what I hope for you is that you’re going to come back here in a year or five years and say to me, you know what, you were wrong. The outcome was the best outcome and all of your dire predictions didn’t come true. I hope that that’s what you’re able to say to me, but what my job is to do is to give you the worst case and the best-case scenario.
Once you’ve said that, you’ve left that door of hope open and the person can listen less defensively to both sides. You’re giving them space where you can tell them what you think will probably happen but you also don’t give them that space where they have to be in a situation or just denying it. Like that’s not true.
Dr. Sharp: That’s great. I like that a lot. That’s another thing I could easily see using very quickly.
I think we’ve talked a lot about successful feedback and elements that can help it go well. I wonder if we might talk a little bit about things that people would say are mistakes in feedback session or things that I think when I was, either the book or maybe some material online about the book that you said it’s not about the data, it’s not about the scores, something like that. I wonder, are there any common mistakes or paths that people go down that may not be so helpful in feedback sessions?
Dr. Karen: Yeah. I think that two things that emerged. What clinicians told us, almost all of them said is that the rookie error people make when they’re just starting, is they’re so attached to the test scores. They feel like their job is to sit down with people and explain all the test scores. And if you’re on the other side of that, it’s number one, mind-numbingly boring. It doesn’t have any relevance to their lives. They don’t understand the basic assumptions of standard scores anyways, right? And it’s not because they’re dumb. It’s just because, it’s like us listening to an hour of tax laws. It’s just boring and inaccessible.
So most clinicians will say that sharing actual scores is way down on their list of goals for the assessment. A lot of them don’t share scores at all. They interpret the scores.
Dr. Sharp: I’ve hard that. Yeah.
Dr. Karen: Now, there are exceptions to rules like this. For me, there are times when I will start with a score. For example, if I’m assessing an adult for dyslexia and this person is coming in maybe in his 40s because he finally wants to find out, I know that there’s a huge likelihood that all of his life he’s thought he was dumb. And man, if I get an IQ of 100 or better, the very first thing I’m starting with is that IQ score. I’m starting with, I just have to tell you, we gave you an IQ test and you aced it. Lots of people who have reading problems conclude that that’s because they’re dumb, but I want to tell you first piece of knowledge I can give you is that you are not dumb. You are a smart person. So I’ll start with that if it’s clinically relevant, right?
Or someone who’s worried well, and they come in with a concern that they have Alzheimer’s disease and they got a really good score on a memory test, I’ll start with that. And I’ll say something to let you know, Mrs. Smith, I got to tell you, you aced that test. If I took 100 people and I put them in a room, you would do better than 89 of those 100 people on this test. You make it accessible. So there are times when a standout score is great, but most of the time scores are not going to help move the narrative along.
The other thing that is a rookie error that people tend to make is they bury the lead. For some crazy reason, we have this warmth in our field of saving our conclusions in our report to the very bitter end, right?
Dr. Sharp: Yeah. Right.
Dr. Karen: We start with all the minutiae of the history and then all the minutia of the test data. And it’s not until the very last page that you say what you thought, right?
Actually, we had a writing coach from NASA whose job was to help the scientists communicate better with each other; faster communication with each other. We got him to help us with the question of how do you write better reports on the Inter Organizational Practice web toolkit, its the IOPC toolkit. What he was telling us is what they did at NASA was they taught people to use an inverted pyramid method for their reports, where they would start with the bottom line and then they would go into details as you need it, just like a newspaper article is written.
The idea is that we can do that with our feedback sessions as well. Why bury the lead? Why use this strategy of first talking with people about how we got to our conclusions and then finally at the last minute sharing our conclusions? Why not instead start with the conclusion.
Now, this really depends on the clinical situation. So many clinicians will say that depending on the type of results they give, they might start with the conclusion or in a different situation, they may do it a different way, but here’s two examples of where you might want to start with the conclusion.
Let’s say you’ve got a family that’s brought their kid and they think he might have ADD. The kid is not in the room. It’s just family feedback. And here you are as a clinician talking, talking, talking, talking with them about all of the different things that you measured. You’re building up to your big conclusion which is in the last 10 minutes of the feedback session. Most of the time in the thought bubbles of those parents, it’s just static and anxiety the entire time. Like, is Dr. Postal going to tell me, it’s ADD, maybe it’s not ADD. He watches videos. And he seems to be able to pay attention to that. Man, if it is ADD and we’ve got to medicate him, my mom’s going to blow it. She has to blah, blah, blah. Right? That’s what they’re thinking when you are coming to explain stuff to them. And so they’re not really accessing your message because there’s so nervous about it.
And so what you can do is that you can start with, you know what, I got to tell you straight upfront that you all brought John to me because you were concerned that he had attention deficit. And I’m going to tell you, my bottom line is I think your instincts were really right on. My conclusion is that he does have ADD. I want to spend the next hour really unpacking that. We’ll talk about how I came to those conclusions and then we’ll map out a roadmap for what we can do about it. But I just wanted to let you know right off the bat that’s what we have.
Same thing if you have a worried, well the person who thinks that they might have Alzheimer’s disease and your conclusion is they don’t, you better tell them right up front. Why make them sit on pins and needles for the entire session? So I think that’s another area that people don’t really acknowledge the degree to which their feedback is what’s behind curtain number one, and you don’t want to keep people on pins and needles the entire time.
Dr. Sharp: Yeah. That makes sense.
Dr. Karen: Another error that people make, and this is one that’s specific to folks who do pediatric work. We also asked people about how we give feedback to other professions. So there’s a chapter in the book about giving feedback to other professionals- how do we talk to the pediatrician on the phone or how do we talk to the IEP team? I don’t know as a pediatric person if you’ve ever gone to IEP team meetings.
Dr. Sharp: Oh, sure.
Dr. Karen: So most people have had this experience of like this dreaded war of standard scores. That they’ll say, so Dr. Postal, we notice that when you tested Sally, you got a processing speed score of 89, and yet, we got one of 91, and you are like, oh, it’s going to be a long meeting.
So when I go to IEP team meetings, I resist this whole idea that I should present my report. They’ll say to me, “All right, well, Dr. Postal, you’re up. Can you please present your report?” I don’t touch my report. I literally do not take my report out. Instead, I bring a three-dimensional plastic brain model in a little bag and I pull that out. And so I’m using a prop. I pull up my brain and I say, so this is the part of the brain here- I’ll point to the frontal area. This is the part of the brain that brings us all the things that we value in a successful student: focusing, organizing, planning, and memorizing information, and also this part of the brain also helps us respond well to stress and handle frustration.
Now when Sally had a severe traumatic brain injury two months ago, this was the part of the brain that was injured for her. And the team, you guys probably noticed that as much harder for her to focus, harder for her to concentrate, but I know you guys have noticed that it’s really hard for her to handle frustration, right? When she can’t do something she expects to be able to do, she just flies off the handle, right? And that’s this part of the brain. So let’s talk for a while about what strategies we can use to help her accommodate these changes. I haven’t talked about a single test score. Instead, what I’ve done is I’ve used a prop to drag the conversation away from standard scores to this child’s brain and what she needs at the moment to help her. That’s really effective.
Dr. Sharp: Sure. So you sidestep that whole conversation and maybe argument about what diagnosis or cutoffs or whatever, and just say, okay, we know that this is what’s going on, and here’s what can help.
Dr. Karen: Yeah. Let’s talk about the brain, not scores.
Dr. Sharp: Yeah. I like that. I would imagine too, especially in a school setting, that’s nice to have a visual prop instead of just the other focus.
Dr. Karen: Yes. We ask people about props and people use props and all sorts of great ways. Monica Rivera offers people camomile tea. It’s really interesting. What she told us is that in the Latino and Latino communities, camomile tea has healing properties, and by offering people tea, you’re doing two different things, you’re creating a really warm and relaxed environment. You’re telling them that you respect their cultural background and that this is going to be a place of healing. She does that very specifically. She’s offering something very specific.
Michael Santa Maria gave us this genius one. He has a prop, he hands out full-color copies of a newspaper article showing a grisly car crash that an elderly person got into -a really gristly photo. He just hands it out to every member of the family sitting in the room and then he brings up the conversation about driving.
Dr. Sharp: Oh, gosh. Okay. That’ll do it.
Dr. Karen: If you’re at a tertiary care medical center, you might have a dedicated monitor in your office for brain imaging, and that can be a wonderful prop. Some people have a bell curve that they’ll have on a board and they’ll use that as a prop, but props can be helpful.
Dr. Sharp: Yeah. Absolutely. I’ve seen a lot of folks who will have that second monitor or an iPad where they can walk through and do some visual prompts.
Dr. Karen: I’ve used an iPad. I don’t know if you’ve seen them in 3D brain atlases you can get on the iPads.
Dr. Sharp: Oh yeah, those are great.
Dr. Karen: Those are awesome. To me, with the adolescent and young adult crowd, it raises your stock, right? Instead of just showing a brain model, to be able to rotate the same on the iPad I think it’s really helpful. You get their attention.
Dr. Sharp: Absolutely. Oh, this was great. I’m just looking and an hour has gone by so quickly. We have talked about so much.
Dr. Karen: Oh boy, that is fast.
Dr. Sharp: I’m wondering Karen if I might just ask you a few nitty-gritty questions about how you do feedback, and then maybe we could transition to any other resources or things that might be helpful but I’m just curious in terms of how you set it up, like how long are your feedback sessions? Do you have the kid present if you’re doing pediatric and like a rough estimate of how you divide up the time between scores versus diagnosis versus recommendations? Any of that detailed info.
Dr. Karen: For me, I have an hour-long feedback session that I always give. From my perspective, the more the merrier. So the more people who are present in that [01:08:00] feedback session, I think the more likely that some good is going to come out of it.
For my adult and geriatric patients, I’m super happy if I have an entire extended family in the office. Brothers, sisters, adult children. I think it’s just really helpful.
For my pediatric patients, with teenagers, I tend to have them present during the feedback session unless it’s an issue where there’s a big fight with the score and a substantial amount of what we’re going to talk about is a pitched battle with the IEP team. In that situation, I don’t think it’s clinically helpful for a child to hear about adults fighting. So I’ll have a separate one.
For younger adolescents and kids, I’ve gotten to the point where I always have two feedback sessions. I have a feedback session for just adults where we can speak entirely, frankly. And then I have a second shorter feedback session where I have the parents and the child in the same room together and I give a very positive kid-friendly version of the feedback. I do it that way because I think that almost all kids who are in your office for testing suspect that they’re dumb. And whatever it is, that’s the problem. They think it’s because they’re not a smart person. And I think it’s so critically important from an emotional perspective for them to hear straight from my mouth what their strengths are.
Dr. Sharp: I’m with you.
Dr. Karen: And then the other thing is that almost always, I find in pediatric practice, no matter what the diagnosis is, there are effective strategies that I want this kid to engage in and their parents to help them engage in; whether it’s more effective study strategies or 40 minutes of aerobic exercise every day or changing their sleep patterns. This, I think, requires direct buy-in from the kid. From a family systems perspective, I think that them hearing the information in the presence of their parents, not just them and me, but them hearing it then being asked to buy in in the presence of the family system is a more effective way of coming and getting a good outcome.
So, that’s typically how I do it. Usually, it’s an hour for the adult feedback and a half an hour for the kid feedback. Any time that there is a psychotherapist in the picture, I love to invite them. I think if I can get members of the IEP team on either in-person or on speakerphone, that’s also oftentimes really helpful. So again, not just the family members but important stakeholders are present. For adult populations, it’s oftentimes, like a worker’s comp case manager, it could be like a disability specialist. Those are important people to have for the feedback.
Sometimes, I will do some extra work after a feedback session which to me feels like an extended feedback session as opposed to psychotherapy. So if someone isn’t using their C-PAP machine which is one of the most common ways that you get to thank you have early Alzheimer’s disease when you don’t, tons of people hate C-PAP because they’re anxious about using them, I might have them bring in their C-PAP machine and we do a little bit of work to make friends with it, right?
If it’s an adolescent who’s going to bed at 3:00 in the morning and gets up at 7:00 am for the school bus, I might do a couple of extended feedback sessions about sleep hygiene, just low-hanging fruit. And if they still need some CPT after that, I’ll refer them.
So to me, I might do a couple of feedbacks initially about some study strategies. I do this, particularly with college kids. I’ll say, look, what I want you to do is come back and see me in three months after you’ve started the fall semester, and let’s do a course correction. We’ve mapped out a game plan, and let’s figure out what works and what doesn’t work and make sure that we get you totally on course so that you’re successful next semester. So, sometimes the feedback sessions might be in the distant future but I consider all the feedback sessions.
Dr. Sharp: Okay. I like that framework. It often feels like, admittedly I don’t do that very much, and so I like that extended feedback framework. So it’s not like you just deliver all this important information and then send folks on their way.
Dr. Karen: Yeah. From a business of psychology or neuropsychology perspective, I think we shortchange ourselves in terms of our clinical skills. A lot of us say, well, we’re either assessors or therapists and we don’t realize that there’s a fairly large gray area. If you think about the model of an ear nose and throat doctor or cardiologist, when the family physician refers to the ear nose and throat doctor because of a sore throat or because of adenoids, the ENT doesn’t say, oh, I’m here for the diagnosis and spit them back to the family practice doctor. They say, here’s the diagnosis. We’re going to do a little work to fix it, then we’ll send it back.
Dr. Sharp: It’s a great point.
Dr. Karen: So in terms of the business of neuropsychology, there’s no reason in the world that we can’t say, look, we’re going to do this consultation for your school district or pediatrician, whoever, we’re going to do a little bit of work, get the person back on track and then we’ll send them back.
Dr. Sharp: That makes sense. I like how you frame it that way. When you illuminate it, it makes sense and just a different way of thinking.
As you talk or as we’ve been talking, one of the themes that has jumped out at me is the overlay of therapy and assessment, but also maybe the need for flexibility. I think we get locked into data and the science of testing and that’s what draws a lot of us to do an assessment but then there is so much art and flexibility to it and reading people and knowing the family system and knowing people’s expectations, like all of that is just so important.
Dr. Karen: I think you are right on. I mean, a feedback session is just one of the most complicated things we do. We’re bringing psychotherapy skills, family systems skills, social power, developmental theory, brain theory, and standardized testing there. It’s all there all at once.
Going back to errors we might make when you’re just starting in practice, you might try to map out what you’re going to say during the whole feedback session. In reality, it’s like a battle. You can create these detailed battle plans all you want but as soon as the first shot is fired, it’s all chaos. You’ve got to be ready to be very nimble and attentive to what’s going on in the moment in the room.
There’s something that the US military uses. This was from the Heaths’ Made to Stick book that I love; it’s called Commander’s Intent, which is, that military leaders understand that detailed battle plans never work because everything is just very chaotic. And so instead of a detailed battle plan, what they’ll do is they’ll give their subordinates something called commander’s intent. By the end of the day, I want you to take that hill, how do you do it, who knows? But that’s the intent. And so you can go into a feedback session saying, all right, here’s the commander’s intent. By the time I leave here, this is what I help my students with. By the time you leave, you want to get A, B, and C on the table. That’s the goal. How you do it, you’ve got to be nimble in the process.
Dr. Sharp: That makes a lot of sense, know your path and know your outcome but be willing to adjust to get there. Well, this has been an incredible conversation, Karen. I really appreciate it. So just in terms of resources, I know we’ve barely scratched the surface of what’s in your book. So have to put in another plug for that. I think everybody should read it. It has so much good information. I’ll have that in our show notes, of course. But are there any other resources that you know of that might help folks learn more about feedback sessions?
Dr. Karen: Yes. And this is going to sound really crazy but my number one recommendation recently to people is to take improv classes, you get what I mean? Alan Alda for years had this PBS program, it’s like Nova, and he interviewed scientists. I don’t know if you’ve ever seen it. He was so struck by the fact that some scientists were great at explaining their science, but most of them were really bad.
He felt like if we don’t train scientists to communicate better with the public, science funding will dry up, right? And so he created this center at Stony Brook University and it’s all about training scientists to communicate better. It’s just a genius idea. They give these workshops all around the country. So you can take a one-day or two-day workshop. They come to major cities, a lot of universities. But once a year, they do a Bootcamp that’s for one week and they have scientists from all over the country come to this Bootcamp.
I signed up and I was accepted to the Bootcamp last winter. Half of the day, they spend teaching you about communication styles, but the other half of the day it’s improv training. And the reason for that is that they pointed out on anybody who’s been through graduate school knows this, like the process of scientific graduate school, getting your Ph.D. or PsyD, it literally beats the good communication out of you. We become terrified of making mistakes. We are over-rehearsing language and using jargon to the point where it makes sense to get up in front of a convention and literally read a scientific paper to the audience. We’re so jargon-laden, and we’re so afraid of actually using our bodies and moving them, or express an emotion to go with what we’re saying, or using analogies and stories. You can take a person who had perfectly good communication skills and then put them through a Ph.D. program and just beat it all out of them. So that you’ve got these scientists who just don’t remember how to communicate.
What improv training does is it really rapidly forces us back into good communication strategies. So with the improv training, what they would do is they would have these exercises where they would force us to make mistakes. So they would give us these like motions we had to do with a partner and they made us go so quickly. You literally, couldn’t make a mistake. And then when we made the mistake, we were instead of shriveling up a little ball of humiliation, we were to throw our hands up in the air and shout tada.
Dr. Sharp: I love it.
Dr. Karen: So here we were like 50 physicists from MIT and all sorts of fancy people all of us making the day mistakes and shouting tada. Other exercises force you to be in the moment, like really truly focusing on what’s happening in the room. The common denominator of so many of the exercises is this concept of yes and right. So you’re not allowed to say no in improv. You have to say yes. So someone hands you something, a patient says to you, is it this? And our typical way and feedback is to say, NO, it’s this, but you don’t know I know, but with the improv, teacher’s shooter is to take what they’re giving you and say, ah, yes, and right. You take their metaphor, their analogy, their story, and you extend it.
As you go through these improv techniques, what happens is you start to focus on what are the needs of your listener? What did they need at the moment from you to get access to what’s in your head? And it’s not about what am I saying, or what am I thinking about, and do I sound right? It’s about what they need and literally, the anxiety disappears.
So for trainees, I think improv training is just a genius way of getting people to the point where they can be nimble and in the moment and attentive to their patients and their patients’ worried families in the moment, not just trainees, I’m actually recommending that mid-career folk consider this as well because I have to say from my experience after a week of improv, it really was mind-blowing in terms of the difference in my not just feedback, but also public speaking skills.
Dr. Sharp: I got you. I think that’s such a good point. It’s interesting. That’s the second time in a week that I’ve heard improv classes mentioned as a, let’s say valuable addition to someone in life.
Dr. Karen: Really? That’s awesome. That’s so great.
Dr. Sharp: Yeah, who was the other, I think it was James Altucher’s show, which is a podcast about business and peak performance and things like that. He was interviewing a guy who was speaking about the book Play. I don’t know if you’ve heard of that. They were talking about the value of improv as a means of opening yourself up and saying yes, like that whole concept of just saying yes to things versus shutting down and it was effective.
Dr. Karen: If people want, I’m aware that Alan Alda Science or Center for Communicating Science. They have a schedule of where they’re giving the shorter workshops all year long, and then anybody can apply to do this week-long boot camp. And man, it is really worth the time. People want to invest in that.
Dr. Sharp: Oh, that’s fantastic.
Dr. Karen: The other resource that I would say it’s just a lovely resource the book, Therapeutic Assessment.
Dr. Sharp: Oh, sure.
Dr. Karen: It’s different but the Therapeutic Assessment Movement is really talking about actually conducting an assessment in a different way. The research we did was more traditional assessments. How do you explain the results. But I think many of the concepts from this therapeutic assessment model are so lovely and helpful in this framework.
Dr. Sharp: Yeah, that’s great. It’s nice to reinforce that. I did a podcast, I think episode 10 with Megan Warner, who’s actually in the Northeast as well. She talked all about therapeutic assessment, the value of that approach. So I’ll put that link in the show notes. I think a lot of people appreciate that approach.
Well, Karen, this has been fantastic. I really appreciate your time. I feel like there are just so many… It’s really important. You’re really doing what you are passionate about and what you love. It’s great to talk with folks who are doing that. I know that we did not talk about your new book, but I’m just going to take that as a motivation, I suppose to maybe have you on again, when everything it’s gets finalized with that.
Dr. Karen: That sounds great. Okay.
Dr. Sharp: That’s great. Well, thank you, Karen. Take care.
Dr. Karen: You too.
Dr. Sharp: All right y’all, thanks for listening in this time. I hope you enjoyed that interview with Dr. Karen Postal. I have to say that as you could tell while we were doing the interview, there were many times when I was picking out nuggets and valuable information that she was sharing. Even as somebody who’s read the book and looked at many parts of the book several different times, I was still picking up things, just hearing it directly from Karen. And I hope that y’all took away some nice gems from that as well that you can start to integrate into your feedback sessions.
Like I said, if you have not read her book yet, it’s definitely worth checking out. I’ll have the link to that in the show notes along with many other things that she mentioned during our interview.
Hope y’all are doing well. Summertime continues to roll along. I am really excited about an upcoming trip of mine here in two weeks. I’ve mentioned, I think in the past podcast episodes that I did some consulting with Joe Sanok at the Practice of the Practice about a year ago, and I am really excited to be going to his summer conference called Slowdown School. We’re going to take two days to totally unplug then really hit the ground running with some pretty intense business coaching and thinking through how to take practices to the next level and take our businesses to the next level. So if there’s anybody out there who is interested in doing something like that, you might check out to see if there are any tickets left, but that’s where I’m going to be headed in two weeks. I’m really excited to connect with folks up there.
In the meantime, I’m continuing to be so impressed with our Facebook group. We added about 40 members within the last 2 or 3 weeks, which for our little group, is quite impressive. It’s really cool to see that group continue to grow. If you’re interested in joining that group, it’s The Testing Psychologist Community on Facebook. We have some great discussions there about different measures, business practices for testing, insurance billing, things like that. So, I would love to have you join that discussion if that’s interesting to you.
As always, if you’re thinking about growing or starting testing services in your practice, that is what I am here for. So if you have questions, if you are thinking about consulting, if you may be just want to brainstorm a little bit, feel free to give me a call, shoot me an email; it’s jeremy@thetestingpsychologist.com, and we can just have a little conversation about whether consulting might be appropriate for you. If not, I will point you in the right direction and just help you get moving however that might look for you. So take care and I look forward to talking with you next week. Bye. Bye.
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