Week 5 of the COVID-19 shutdown of spring 2020. I don’t know. I’ve honestly lost track at this point. I know that we have been home starting with what was supposed to be our kids’ spring break. Well, it was our kids’ spring break back in mid-March and we are just hanging out. I hope that y’all are taking care, adapting, and at this point, figuring out some means of assessment in your practices, whether it’s remote or if we’re getting back to in-person by the time this is published. We’ll see. But just a kind word to all of you out there who I know are struggling through this and trying to figure out how to make it work.[00:01:00] Today’s episode is again, a non-COVID episode. I have Dr. Alison Wilkinson-Smith with me. I have to give a shout-out to Dr. Stephanie Nelson who introduced the two of us. Alison and Stephanie are good friends. Stephanie is a celebrity podcast guest and member of The Testing Psychologist community. I’m thankful that she brought the two of us together here.
This is an amazing interview. I talked with Alison all about her expertise in therapeutic assessment, particularly with kids. She is a classically trained neuropsychologist but employs a therapeutic assessment model in her evaluations. And it was just fascinating to talk through.
So we talk about the research behind therapeutic assessment with kids, the structure of therapeutic [00:02:00] assessment with kids, typical measures she would use, and how to integrate this in a hospital setting. These are just a few of the topics that we cover.
A little bit about Alison. Alison is a pediatric neuropsychologist At Children’s Medical Center, Dallas, and an associate professor of psychiatry at UT Southwestern Medical Center. She’s board-certified in clinical neuropsychology with a subspecialty in pediatric neuropsychology. She’s also certified in the therapeutic assessment of children. She provides neuropsychological evaluations and therapeutic assessments to pediatric patients of all ages.
Her clinical and research interests include therapeutic and collaborative assessment techniques, functional neurological disorders, autoimmune encephalitis, and neuropsychological assessment in the context of complex psychosocial issues.
She got her Ph.D. in school psychology from the University of Texas at Austin and did her internship at [00:03:00] university of Oklahoma Health Consortium. And then her two-year postdoc in pediatric neuropsychology at the University of Minnesota Medical Center.
Alison and I cover a wide variety of topics, but we do focus on pediatric therapeutic assessment for the majority of the interview, which is one I think you will enjoy.
All right. I will not keep you in suspense any further. Here’s my conversation with Dr. Alison Wilkinson-Smith.
Hello, and welcome back to another episode of The Testing Psychologist podcast. It’s good to be back with you. Today, like I said, I have Alison Wilkinson-Smith on. Alison is going to talk all about therapeutic assessment with [00:04:00] kids, which is a topic that I’m really excited to talk about:
- Because we don’t hear about it a lot,
- Because I think a lot of us can get wrapped up in just doing assessment without necessarily incorporating these therapeutic elements and I think they’re very necessary and helpful.
Alison, welcome to the podcast.
Dr. Alison: Thank you. I’m very excited to be here.
Dr. Sharp: Thank you so much for being here. I was really excited to be able to lure you into doing an interview, I suppose. So I should say, always like to give a shout-out to the small world that we live in and the different folks that connect us. And in this case, it was Stephanie Nelson who was much beloved in the podcast world and in our Facebook group. So I’m just glad that y’all were friends and we’re able to make this happen. How do you…?
Dr. Alison: We were in postdoc [00:05:00] together.
Dr. Sharp: Oh, that’s right. That’s amazing. So, you have front-row seat to Stephanie’s awesomeness, I suppose.
Dr. Alison: Yes, I do. I’m very lucky to have that front-row seat.
Dr. Sharp: Nice. Well, I would just like to start as usual and just ask you why this niche in the assessment world is for you?
Dr. Alison: Well, therapeutic assessment is actually really how I learned to do assessment back in graduate school. I went to the University of Texas at Austin- the school psychology program.
While I was in graduate school, Dr. Stephen, who is the originator of TA Therapeutic Assessment, he and Deborah Tharinger who was one of the [00:06:00] professors in our program at the time were just starting a research project looking at therapeutic assessment in children. I joined that research project, and it was really just at the same time that I was taking Dr. Tharinger’s class to learn about emotional personality assessment. I had already started training in neuropsychological assessment. So I was already realizing that assessment was what I was interested in. And so from those very early days, I learned about the therapeutic assessment model, the techniques, and how to integrate them.
So then when it was time to go off on internship [00:07:00] and then a postdoc, I eventually decided what I wanted to do in those final stages of my training is that I wanted to be able to do a comprehensive assessment of kids as I could. I wanted to put as many tools in my toolbox as I could. And so, that is why I went ahead and completed the two-year postdoc in pediatric neuropsychology because I wanted to have all those neuropsychology tools in my toolbox, and then I’ve always continued to use projective performance-based measures, as we call them.
So after [00:08:00] postdoc, my first job was at Children’s Medical Center in Dallas. That’s where I am now. So I’ve been here a long time. I won’t say exactly, hope that won’t give away my age there.
Dr. Sharp: Okay. I won’t press you.
Dr. Alison: So it was a standard hospital neuropsychology job. Initially, I was seeing patients who were referred from our general neuropsychology service; kids who have complex medical needs- something involving the central nervous system.
I was also seeing patients through our autism clinic. And in that clinic, I was mostly seeing school-aged kids. So kids who were like 6-18 [00:09:00] but mostly in that 6 to 14 range because we had a separate clinic for the little ones. And a lot of what I was seeing was kids who were referred because somebody thought they had autism spectrum disorder. And most of them, just for whatever reason how our clinic pulled referrals or who it attracted, those kids did not have autism.
And so a lot of what I did was tell parents that their kids did not have autism. I would have a lot of parents who would not take that very well, who would come in and say, but look, I printed out the criteria from the internet, here they are checking them off. And so, just trying to explain to parents that there are lots of reasons why kids could have social problems and sensory issues and things [00:10:00] like that.
And so I started encountering quite a bit of defensiveness. And I think anybody who’s been assessing children for any length of time has had the experience of a parent just rejecting what you say at the feedback saying Nope. That’s not right. I don’t think you understand. I don’t think you got it. And so, I realized, oh, I know how to deal with this. I have all this training and therapeutic assessment. So I gradually started pulling in more and more of the techniques. And then at some point, I just gave up and I said, I’m just going to do the full model because these families need it.
And then the autism clinic went through a transition and I wasn’t seeing exclusively those families anymore. But by then I had gotten a therapeutic assessment up to and running. I had convinced the powers that B at our hospital, that this was a good thing [00:11:00] to do. And so I just broadened it. And so now I see all kids; I still see some of those convincing people it’s not autism cases, but I also see all kinds of kids who really need this model.
Dr. Sharp: That was one reason that I really wanted to chat with you specifically because you really have that balance of the neuropsychology piece with the therapeutic assessment piece. And I think that we could dig into that a bit more, just how you merged those two and even how you convinced the powers of B that that was okay to do. I would imagine that maybe wasn’t easy in a traditional neuropsychological hospital setting.
Dr. Alison: I’m very fortunate. It was easier than I worried that it would be at first. Really the big challenge at first was just to make sure that we could bill for [00:12:00] it and get paid. I’m very fortunate that our department is really receptive to what clinicians want to do, and really listens to us in terms of like what we see as the needs of our patients, and our populations.
And so, throughout our department, we’ve developed a lot of great programs because of that. And really this is one of them. I started doing it, and we realized that this is what our families need. And we started just working with our admin people to make sure that the billing codes were getting paid for. And once we figured out that they were, we just started doing it more and more. And now, we’ve done training and this is now a [00:13:00] rotation in our outpatient fellowship program. So we’re actually training postdocs.
Dr. Sharp: That’s amazing. That’s so cool. Well, we have a lot to talk about here over the next several minutes. First, though, I have to get the most important question out of the way, which is when were you in Austin?
Dr. Alison: I did my undergraduate and graduate in Austin. So I was there from 1996 through 2005, almost 10 years.
Dr. Sharp: Wow.
Dr. Alison: I’m trying really hard not to give away my age and you’re just not making it possible.
Dr. Sharp: I’m sorry. That was not a thinly veiled attempt to get to it. People on the podcast, I’m sure, are tired of me talking about [00:14:00] Austin, but I’ve had a lot of guests who were in Austin and that’s where I did my doctoral internship, at the counseling center at UT Austin. So, I was there in 2007 and 2008, and I just liked to talk about that with people because it was a good time in my life. I enjoyed my time there.
Dr. Alison: Yeah, me too. One of the reasons why I applied for the job in Dallas initially was because I was trying to get back to Austin and I thought maybe this would be a stepping stone, but I’m still here.
Dr. Sharp: But you got stuck there.
Dr. Alison: Yeah. Luckily it’s only three hours away so I can pop down there if I need to.
Dr. Sharp: Sure. Made that drive when I was there. Well, let’s talk about therapeutic assessment. So for those who may not have heard, I did a two-part podcast series on therapeutic assessment with adults with Dr. Raja David probably close to a year ago now. So definitely go check those out for a real deep dive into therapeutic assessment in general. But Alison, I wonder if you could just [00:15:00] do a little brief overview of therapeutic assessment, and then I want to talk about how it applies to kids specifically.
Dr. Alison: Sure. I definitely want to give a shout-out to Dr. David for that series that he did, especially that first podcast where he really talks about the spirit of therapeutic assessment, and some of the empirical support and just general background to the model is a great starting place.
But globally, therapeutic assessment is this specifically structured model of psychological assessment and it’s really an intervention. So you use psychological testing as an intervention to promote change. And so the more traditional way of thinking about psychological assessment is to [00:16:00] think of it for diagnosis, treatment planning, and looking at strengths and weaknesses, that sort of thing, but the focus is on promoting change. And when we’re working with kids, we’re actually looking at promoting change in the family system. So it’s really a family intervention.
Dr. Sharp: I like that. So that’s just the lens that you’re looking through and that even if you’re doing some of those similar measures or even the process maybe is similar, we’ll get into that, but it’s just the lens that you look through that this is an intervention that in and of itself?
Dr. Alison: Yeah. Therapeutic assessment TA has that specific structure. And like you said, a lot of the pieces to that structure are very similar to what anybody would do in an assessment with a kid. We’re administering tests, we’re interviewing parents [00:17:00] we’re talking to collateral sources like teachers or therapists or whoever, we’re finding ways to present findings.
So those are all things that everybody does, but there is a shift in that lens like you said, to thinking of it as an intervention. And then there is some extra piece that capitalizes on that ability to make this an intervention to extend it. And I can talk more about the actual structure or the flow of how it goes.
Dr. Sharp: Yeah. Let’s do that. I think that’s a nice transition. Can you dive into that?
Dr. Alison: Well, for me, a lot of it starts with an initial phone call, because I really want families to understand what they’re getting into. Now that I’ve been doing this for a while, I have [00:18:00] a lot of people who are referring to me specifically for this. So those families will come to me already knowing that they’re getting something that’s going to be may be different from what they’ve had before, or different from something that they might get elsewhere in the community.
But a lot of the families who come to me, they’ve just been referred for testing. And so I talk to them initially and I say, you’ve been referred for an assessment with me. I want to talk to you about what I think might be helpful and you tell me what you think about it. This is a blend of testing and treatment.
I’m going to help you and your family figure out a new understanding of what might be going on with your kid. And that new understanding might lead to some changes: maybe changes in [00:19:00] your family or how you parent; or changes in the way the kid thinks about themselves or changes in what services you’re getting.
So just really from the beginning, I try to frame it as both. And so I tell families to expect to meet with me about weekly for 2 to 3 months.
Dr. Sharp: Whoa. I don’t even know that I have a question, exactly. Well, the question is what are you doing over those weekly meetings for 2 to 3 months?
Dr. Alison: Right. So if you think of this as testing, that sounds really wrong. If you think of this as an intervention, it’s not, right?
Dr. Sharp: That’s true.
Dr. Alison: If you think of it as this is a short-term family intervention, thinking that you’re going to be able to create change in a family system, once a week over 2 to 3 months, that’s nothing, [00:20:00] Right?
Dr. Sharp: Sure.
Dr. Alison: So I start with an initial session. Well, let me back up a teeny bit to refresh because I think Dr. David mentioned, that there are different types of therapeutic assessment. There are individuals, adults, couples, children, and adolescents. And so I’ll talk mainly about the child model. The adolescent model is almost like a blend between the child model and the adult model which clearly makes sense, but there are some additional pieces that you add in there.
So the child model. We start out with an initial session with parents. And again, this is probably a way that most people start their assessments. You start by meeting with the parents. In this model, the child is not there which I know some people do some people don’t, but in this model, you do not have the child there.[00:21:00] What you’re doing in that initial session is in many ways like you would do with any assessment, you want to get a history, get a sense of what’s going on, get a sense of what they’ve done before, what’s worked, what hasn’t worked. But the main goal of that session is to help the parents develop a set of questions that you’re then going to answer throughout the assessment. And those questions are the anchor throughout what you hook your findings onto and how you generate that curiosity in the parents that’s going to help you work on making that shift in the system.
Some parents’ questions might be things like, why is my kid having so much trouble in school? What type of [00:22:00] therapy does my kid need? Does my kid need to be on medication? And that’s usually where parents start. You want to try to broaden them to start thinking systemically. So again, that family intervention is present from the very beginning.
I like to help parents see if I can get them to become curious about the family system’s role or the environment’s role or their role in what might be going on with the kid. So see if they have questions around: Are there things that we can do as parents to better support what’s going on? Do these behavior problems have anything to do with our divorce? So things like that.
Dr. Sharp: Can I ask two questions about that?
Dr. Alison: Sure.
Dr. Sharp: Well, the first question is just generally, [00:23:00] is that a deliberate intervention or shaping that you’re doing throughout that initial session?
Dr. Alison: Yes.
Dr. Sharp: Okay. So then I guess the question that follows is how do you do that? How do you steer them toward those more systemic questions?
Dr. Alison: Yeah, it’s a lot harder than it sounds.
Dr. Sharp: Well, it sounds hard.
Dr. Alison: Well, maybe it is. I prepare parents for this. So they know. That’s one of the things that we talk about at the outset that this is what we’re going to do when you come in the first time. Then after they come in and see me, once we go over consent, I say, what we’re going to talk about today is what you want to get out of this process. I want to know what questions you have that you’re hoping will be able to answer for you. So I frame it that way.
One of those first interventions is something that Dr. Finn talks [00:24:00] about as getting parents up on the observation deck, above their problems. Oftentimes, parents will just start out complaining like, oh my gosh, my kid has these meltdowns and we’re just at our wit’s end. He’s in trouble at school all the time because he is doing all of this stuff.
And so, then you want to shift them from that complaining frame of mind to a curiosity frame of mind and to really think. So might just listen empathically to the concerns that they have about their kid, and then when you get to a stopping place, you say, okay, what is it that you’re maybe hoping that the testing can tell you about that?
Sometimes you need to be a little bit more… Some parents will immediately go, oh, I want to know why is all this happening? Some parents need a little bit more help to make that shift. And then you just think about what are the things that help people [00:25:00] shift their frame of mind. So you provide them with empathy. You give them a holding environment. You want them to really feel like I heard you, I’m hearing how difficult this is for you. So let’s now work together to figure out what we can do about it. What can we learn about it?
But when I’m looking at actually the family systems piece, I am asking a lot of questions about that. So I’ll say, how do you usually respond when she does X, Y, Z? And one of the things that I pretty much require, and that this model really requires is that if it’s a two-parent household, both parents need to be there for this session.
And so I’ll say, okay, well, does she seem to do better for one parent than the other? And do you guys have any idea why that might [00:26:00] be? And so that’s a way to get those questions. So just asking about the environment and the family, and then seeing if you can generate some curiosity about that.
Dr. Sharp: Sure. Yeah, I’m recognizing that it can be woven throughout the interview a little bit better perhaps. And the way that I’ve done in the past is distilled it into one very pointed question where I’ll say, Hey, this might be hard to answer. I’m not blaming anyone or assigning any blame here, but if there was anything in the environment or even with you as parents that might be contributing to these difficulties, what do you think that might be? And then they’ll answer however they answer.
Dr. Alison: I think a lot of parents are often relieved to get that out on the table because a lot of times [00:27:00] that’s something that they secretly fear.
Dr. Sharp: Sure.
Dr. Alison: I’m triggering this or he’s just like his father or something like that. So that’s often one of those unspoken fears or something that they have a lot of shame about maybe, but just putting it openly out there on the table. Sometimes for me, that’s the point where a parent might tear up.
Dr. Sharp: Yeah. I’ve had that too. The vast majority of parents answer that very readily and they are pretty insightful, honestly.
Dr. Alison: And if I get pushback, I get pushback, and then that tells me something. So that says, there’s some defensiveness here. I bet there’s something meaningful. So let’s keep our eye on that as we go through the process and see how am I going to work with this defensiveness? How am I going to get these parents a little less defensive, and more willing to look at themselves[00:28:00] and that kind of thing?
Dr. Sharp: Sure. My second question with all of that was, how does this work with more, I’m not sure what term you’d use, like biologically based concerns or brain-based or neuropsychology stuff where it is like a complex medical issue. I could see parents saying, well, this is just how she is. It’s not our fault. Do you see what I’m saying? Like the diagnoses that are biologically determined. How does that play in there?
Dr. Alison: Well, I guess the first thing I would say is I don’t use this for everybody. This is just a part of my practice. I also do neuropsychological assessments that are more traditional. I always use those core values of therapeutic assessment: collaboration, humility, respect, compassion, openness, and curiosity. I’m always [00:29:00] grounded in that, but for saying a presurgical epilepsy evaluation, or a kid who’s had a brain tumor and you just want to check and see if anything’s been affected, they may not need all of this.
But I have a lot of patients who have something either neurological or chronic medical, and it’s just a part of the puzzle. And another part of the puzzle is the way the family is responding to it, or it is the learning challenges that come along with it that are causing some difficulty. Those kids have those complexities too. I guess this is probably the easiest way to say it. And so those are the kids that fit best with this model.
Dr. Sharp: That makes sense. Could you say a little bit more? Just while we’re on this topic, [00:30:00] are there any diagnoses or presenting concerns or family dynamics that are better suited to this model or are rule-outs for this model or exclusionary criteria for this model, so to speak?
Dr. Alison: I don’t have any strict exclusionary criteria other than obviously the family has to be willing and able to do the whole process. We have something we who come from three hours away, obviously they’re not going to be able to do this. I’ve done this with kids who are developmentally delayed, with kids who are on the spectrum, with kids who have epilepsy.
I can’t think of a specific rule out. I personally prefer not to do this if people are actively in the process of divorce. I [00:31:00] would guess that there are probably some clinicians who don’t have that hesitation, but I personally prefer not to, or just people who are in the middle of some giant family trauma. I don’t want to do this right after someone has died, for example. I tend to not take people who are in some acute change or crisis.
Dr. Sharp: That makes sense.
Dr. Alison: But really, I can’t think of any other specific exclusion. I don’t really use this in kids who are younger than 5, but I have a colleague who has adapted it and uses many of these techniques for kids who are 5 and younger. So it’s pretty flexible, I think.
Dr. Sharp: Sure that sounds like it. So what happens then after this initial session?
Dr. Alison: Okay. So after the initial session, we move into the testing. In the child model, [00:32:00] parents observe the testing. I’ve lost a bunch of people right there, I bet.
Dr. Sharp: Right. How does that work?
Dr. Alison: I do some of these in two-person teams with my postdoctoral fellow as training. And so, when we do that, one of us is in the room working with the kid, and the other of us is sitting with the parents watching over a live video feed. So we’re watching it as it’s happening, not in the same room. And then when I do these by myself, I record all of my sessions with the kid, and then I have a separate session with parents where I show them portions of our testing and we talk about it.
Deborah Tharinger and some of her colleagues have an article. I think it came out in 2012 or something like that in the journal personality assessment. It specifically outlines [00:33:00] many of the techniques that you would use while watching the testing with parents. And so some of the things are things like psychoeducation. What is this test looking at? Why am I giving it?
Well, I’m giving this questionnaire because you asked about why your kid is so angry all the time, and one of the things that we know is that sometimes depression in kids presents as irritability. So you asked about anger, we’re going to look at depression. And so sometimes that’s just like, oh wow. Okay. Did you ever think that he might be depressed? Has that ever been on your radar? So then that’s an opportunity to… You’re both explaining why you have chosen the test you have chosen and you’re educating them on various things we know in psychology.
Dr. Sharp: Can I ask a really basic [00:34:00] question?
Dr. Alison: Sure.
Dr. Sharp: How does this impact test security? I feel like that’s a thing that we are worried about that.
Dr. Alison: Yeah, it is a thing that we’re worried about. The recordings that I make are only for me and the parents to watch. They stay with me as part of their file. People aren’t taking pictures or taking things home or anything like that. It all stays within.
Dr. Sharp: Yeah, it’s even okay, and this is naive on my part but is it okay for parents to see stimulus books and stimulus materials and things like that from the WISC or the D-KEFS or whatever it might be?
Dr. Alison: Yeah. If we think about it, if you have a little kid and you need the parent in [00:35:00] there because the kid doesn’t separate, that’s something that most of us do without even a thought. And this is something where there’s a reason for doing this. There’s a therapeutic reason for doing this. We’re not just, Hey, come and watch this so you can see the test. This is part of the intervention. So we have a clinical reason for doing this.
Dr. Sharp: Okay. How, what does that testing look like? Like how many sessions of testing are you doing over that 2 to 3 months and how are they spread out?
Dr. Alison: For me, typically, I’m working with the kid over probably 2 to 3 visits, and so I’m choosing tests based on the questions. So based on what the parent has asked and what they want to know. Sometimes we need to test more [00:36:00] things than others, depending on what’s going on with the kid. So usually 2 to 3 sessions, and I would say they’re about 2 to 3 hours apiece.
Dr. Sharp: Okay. And can you comment on, is there a standard battery of sorts or tests that you’re always giving or is truly adapted to the questions? How does that work?
Dr. Alison: It’s truly adapted to the question. I personally, almost always give some IQ test. That’s probably the neuropsychologist in me that thinks of that as a grounding-type of thing. Depending on the age of the kid, I’m usually giving some self-reports. Performance-based measures of some kind, [00:37:00] really lend themselves very well to this process because they give you a lot of things to talk about, and you get a lot of richness. They’re a really good jumping-off point for, okay, the kid is telling us something about how they view the world. So mom and dad, what do you think about that?
Dr. Sharp: Which ones do you like?
Dr. Alison: I like drawings. Kinetic Family Drawing, in particular, tends to be really juicy for a lot of kids in this model. I use House-Tree-Person as well. I also use the Fantasy Animal technique, which is something that may be a lot of people don’t necessarily know about it. It was developed by Leonard Handler. And it’s a good way to look at kids’ defenses. So you ask the kid to draw some animal that no one’s ever seen before and [00:38:00] then you and the kid take turns telling a story about it. So it’s a drawing, but also a storytelling technique. I use Robertson TAT cards. I use the RPAs a fair amount.
I would say those are probably my go-to. Sometimes I use sentence completions and if I do sentence completion, I make a pull from some of those standardized ones that are out there, but I’m also going to use questions that come directly from the questions that the parents have and their concerns.
Dr. Sharp: I see.
Dr. Alison: And that’s probably a good time to mention that also I give the kid an opportunity to come up with a question.
Dr. Sharp: Okay. When do you do that in the process?
Dr. Alison: It varies on the kid. Sometimes I [00:39:00] want to just start out with that. So at the end of your session with the parents, you want to talk to them about how to introduce this process to their kid. So I say something like, does your kid know that you’re here today? Have you told them anything about this? Some say no, and some say yes.
And then I coach them to share one of their questions. Ideally, it’s one of those family systems types of questions with their kid. So tell your kid that they’re coming here because you want to learn what you can do as parents to help him grow. And then I give also things that probably a lot of people say, like tell them there are no needles and tell them we’re going to do some things that feel like school and some playing and some talking; a lot of those things.
So when I [00:40:00] first meet the kiddo, I start out by saying, do you know why you’re here today? And at that point, maybe I have the parent in the room or not depending on how we’re starting out, the age of the kid and the situation, and all that. And you’d be surprised that even when I coach parents and tell them we’re here for, parents basically, a lot of them will say, well, we’re here to find out why I’m so bad or are we here to find out about my anger.
So then I will either grab the parent and pull them into the room and say, was that what you said? And usually, the parent says, no, that’s not what we told them, but that’s the message that the kid is getting for one reason or another. But so for older kids and kids who are more psychologically sturdy, [00:41:00], I guess you could say, I will segue into that at the beginning there. So I’ll say, okay, so your parents want to learn this. Is there anything that you might want to know about yourself or about your family? And so then I might talk to them a little bit more about, well, okay. So it’s like a piece of my clinical interview with the kid.
And so then there are some kids who are younger or maybe a little bit more vulnerable where I want to do some things to build that rapport and get them comfortable with me before we actually start talking about stuff. And sometimes I revisit it multiple times. I would say most of the kids that I work with do not have a question but for the ones that do, that’s really important. And it usually becomes a pretty key piece of what we do.
Dr. Sharp: I could see them. If they don’t have a question, do you encourage [00:42:00] them or guide them to come up with one, or is it just like, okay, that’s fine.
Dr. Alison: Yeah, I definitely do. I try not to push. I don’t push too hard. With adolescents, they have to come up with a question or else we don’t go forward. But with kids, it depends on the kid. And so, like I said, I might revisit it.
Sometimes, for example, if you do something with a kid that’s really hard for them, then you might stop after and say, wow, that was really frustrating for you. Tell me about that. And then you might say, oh, okay. That’s what school is like for you. Wow. I can see why. Is that something that you might want to know about? Is there maybe a question that the testing can answer for you about that? So sometimes that’s a way to get at those questions.
Dr. Sharp: Nice. So before we totally wrap up the battery, with a lot of [00:43:00] these evaluations, are you also doing executive functioning memory in more of a traditional neuropsychology kind of battery?
Dr. Alison: Yes. A lot of times the families have questions about memory. Or they have questions that relate really well to executive functioning. The kid is disorganized, they’re a mess, they’re impulsive, and they can’t regulate. So if it’s relevant to the questions and the concerns, I absolutely am pulling any of those things.
Dr. Sharp: All right. And these testing sessions, are those happening right after the first parent interview? Like, will you do the next 2 to 3 sessions just testing and then transition to whatever the next phase is or are they spread out?
Dr. Alison: Yeah. So week by week.
Dr. Sharp: Okay. So they’re about once a week. So this first phase, I guess, the testing phase is maybe a month?
Dr. Alison: Yeah.[00:44:00] Usually. I didn’t mention this, but I am usually at that first session going to give parents those questionnaires rating scales. Again, that’s something that probably most people do and often send forms for the teachers to fill out as well, things like that.
Dr. Sharp: Are there any questionnaires that you found that maybe fall outside the norm that has been helpful in this model? So things other than BASC, BRIEF, SRS?
Dr. Alison: I don’t think so. Although, if the parents have questions about themselves, what can we as parents do? Is there something that I as a mom doing to trigger things like that? Then, we will test parents as well with the MMPI, usually. And [00:45:00] so, I’ll say to parents, you have this question about yourselves. It might be helpful for me to learn a little bit more about you in order to best answer this question. Would you be willing to fill out some questionnaires about yourself?
Dr. Sharp: That’s fascinating. I’ve said so many times I wish we could test parents as part of kid evaluations. Just a very logistical question. Do you have any idea how the billing works for that? Is the parent a separate patient in the system, and then you bill them?
Dr. Alison: No. I don’t bill for that piece of it.
Dr. Sharp: Okay. I’m just curious. The private practice part of me is like, how do we make this work?
Dr. Alison: Right. But it’s usually just one thing. So Just an MMPI. I guess I’m technically billing for the interpretation of it when I’m interpreting everything else because it’s all part of the package, but I don’t.[00:46:00] Dr. Sharp: That’s a good point. So that could wrap into the interpretation perhaps. Okay. So then where do we go from there? After the testing is done, then what happens?
Dr. Alison: So after the testing is done and the parents have watched it either live as you go along or in a separate session where you specifically do that, then you have… Dr. David talked about the assessment intervention session. So in therapeutic assessment with children, it’s a family intervention session. And in many ways, it’s a family therapy session, just plunk down in the middle of your assessment process.
But just like in assessment intervention sessions for individuals, what you’re trying to do there is take some really important findings from the assessment and bring them into the room [00:47:00] for the family to trip over. It is much more meaningful for them to experience something for themselves than it is for you to tell them.
Dr. Sharp: Right. Do you have examples of that?
Dr. Alison: Yeah, I would say that honestly the majority of my families we are doing in that session some version of me teaching them techniques of listening. And so some examples of techniques that you might use in a family intervention session, this is often one of the hardest things for my fellows to learn to do is to plan this session because you really have to be creative. But I often do consensus, Roberts, or TAT cards.
So hand the family a card and give them the standard, make a story with the beginning, middle and end, but you guys need to agree about [00:48:00] the story. You come up with the story together. And then you’re going to look at family communication patterns around negative emotions specifically. So, for example, you might see…
It’s pretty common actually that I will see a child respond to something negative in the card. So somebody is dead or somebody is hurt or there’s a failure, and mom or dad or both will say, oh, no, she’s not dead. She’s just sleeping. Or, oh, no, I don’t think that that’s blood. I think that that’s just… Or I don’t think that’s a gun. I think that’s car keys, right. That TAT card right there.
So a lot of times what we do is if you get a series of those, stories where the parents have tried to minimize whatever negativity the kid brought into it, then [00:49:00] you’ll stop after say, 4 or 5 stories and say, did you guys notice anything about that? What was that like to do together?
And most of the time they have not noticed that they’ve done it. And I’ll say, did you notice that a lot of times your kid wanted to make the story really dark and you wanted to put a happy ending on it, or you didn’t like that? Oh yeah, I did do that. And so then you tie that into, well, as we’ve talked about, at this point they know some things about what the testing’s telling them because they’ve been watching it all along.
So you’ll say, we’ve talked about how she’s depressed and how she sees a lot of things really negatively, and you just don’t understand why she doesn’t think she’s smart or she doesn’t think she’s pretty. And then you are trying to tell her, no, you’re very smart, you’re beautiful at, all those things. You’re unintentionally making it so that she doesn’t feel hurt.[00:50:00] Dr. Sharp: That’s a good example.
Dr. Alison: So that’s a pretty common dynamic I would say. And sometimes for the younger kids, getting at often that very same thing, we’ll have them play together. So maybe I’ll just have the free play and I’ll try to get some toys that might pull for some of those family variables or attachment-type variables: So baby dolls, a Playhouse, dishes, food, and just see how you guys play together? Or a board game. Are parents going to get competitive and want to beat their kids? And then the kid gets really upset because they lost. How do you work around empathy there?
Another pretty common thing that I use in those sessions is the Kinetic Family drawing again. And sometimes I will do targets. So draw a [00:51:00] picture of everyone in your family doing something when someone is angry or when someone is sad. And you get to see how each of them views the family dynamics around that particular emotion.
Dr. Sharp: I could see that being really powerful.
Dr. Alison: Yeah, it really can be. And actually, for some families, I can’t do it because it would be too strong. I’ve actually had that before go wrong and had to back up and do something a little more symbolic or less on the nose, but sometimes you’ll have families draw. They draw the family when someone’s angry and they draw everyone in the room screaming at each other.
Or maybe everyone’s off in different rooms in the house. Well, somebody is angry and mom has gone off to the kitchen and dad has gone out to the garage and big [00:52:00] brother is upstairs listening to music and you see that anger causes people to separate and nobody supports each other through those things. So you just get to see.
And it’s really interesting to see, particularly with the anger one, when you just give the prompt, when someone is angry, who do they choose to make the angry person? Because the parents usually do the identified patient, the kid, and then the kid will do everybody. And it’s like, oh, well, what is this about?
Dr. Sharp: This is interesting.
Dr. Alison: So what you’re trying to do is bring some findings from the assessment into the room. Another thing that you try to do in that session is have families try out new ways of being with each other. I’ll say to families like, okay, part of what we’re going to do today is, I might ask you to experiment with some different ways of communicating. [00:53:00] Maybe it’ll work. Maybe it won’t. We’re just going to see what happens.
And so again with the projective storytelling task, I’ll say, okay, we’re going to tell some more stories and this time, if she says something negative, y’all go with it. And it’s interesting. Sometimes they can’t help themselves and they can’t do it. And so then I have to it ah, Nope. Wait, you tried to modify it. You tried to make it better. Let’s go with it. And sometimes it ends up that the parents get flooded themselves. I’ve had a parent who breaks down at that point.
I work with a fair number of families with intergenerational trauma, and that can be a really hard thing because as soon as they open that, they get flooded themselves. And then you stop and talk about it and you say, wow, it’s hard for you to [00:54:00] go negative because if you go negative, you’re going to go all the way because you’ve got all this stuff that you’re holding onto that you’re trying to keep bottled up.
And of course, you do because you went through these horrible things or of course you do because your mom when you were growing up was like this, so you talk about the parent dynamics around those things just like you would in a therapy session.
Dr. Sharp: Right. As you describe this, I’m just struck by how I’m guessing a lot of listeners are probably saying, I didn’t sign up for this when I became a neuropsychologist or a testing psychologist. I have a lot of questions around that. I’ll start with maybe easy basic ones, but at any point are you… I feel like I’m in a projective right now. I want to put structure into this session.
Dr. Alison: I’m not spoiling it. I’m not […] you at all. I promise.
Dr. Sharp: I’m trying to be sensitive. So are you going through [00:55:00] and actually answering the questions that they put forth at the beginning? Is that happening in a structured way?
Dr. Alison: After the family intervention session, yes, that’s the next step. You’re actually answering those questions. But to your point about what people sign up for, I think you’re absolutely right. It’s very helpful to have a background in family therapy to do this model. I’m pretty biased and I would say it’s helpful to have a background in family therapy to assess kids at all.
Dr. Sharp: I would agree.
Dr. Alison: Yeah, that’s my bias. But like I said, this session is usually the hardest one for my fellows. I have become more comfortable with it over the years because for families, much more so than I work when I’m doing this with an individual, like I do with adolescents, with the families, I usually feel like as long as I get them interacting, we’re going to get something out of it because you’re going to see [00:56:00] something.
And sometimes it’s not at all what I expected. Oftentimes, I’ll see that families are maybe much more supportive and healthy than I expected that they would be. And what we end up doing in that session is just praising them. Look at all these things that you’re doing right. You guys are struggling in these ways, but you have this really nice strength to build on. And sometimes that is really helpful for families to hear.
And sometimes it goes wrong in ways that you didn’t expect. So like I said, sometimes an activity ends up being too intense for somebody and I have to back off and say, okay, let’s play instead. Here are some puppets or here’s UNO cards or whatever it is. You back off of the emotional intensity.
Sometimes they end up ramping up the intensity. I’ve done ones where I’ve had somebody had to leave the room because it got too [00:57:00] intense for them for one reason or another. And then, you say, okay, you need your space when you’re ready, come back. They come back in and you say, okay, what happened there? What was so strong for you? And then does this happen at home?
Dr. Sharp: In real life? Yeah, absolutely. So just structure-wise, structure-wise again.
Dr. Alison: And I appreciate that because I’ll wonder that’s how we’re projective on me. I tend to just go off on all these tangents and I don’t know, maybe I just like to listen to myself talk, but you’re keeping me on track. That’s important.
Dr. Sharp: Thanks for the reframe. I don’t know. It’s funny how these things work out. I’m just thinking of folks who might want to put this into practice somehow, with a new process, I just want to know, like, how does it work? And so, as do you do the family [00:58:00] intervention session, is that an hour? Is it two hours?
Dr. Alison: 1 to 2 hours.
Dr. Sharp: And then after that is when you go through it and answer the question. So that would be like the next week?
Dr. Alison: Yes.
Dr. Sharp: Okay. And is there data being presented there or is it really just answering the questions? Are you writing the letter?
Dr. Alison: It totally depends. Yes. The letter comes afterward. The next step is the summary discussion session, what probably a lot of people would call a feedback session, and you are going to systematically go through and answer those questions.
You structure it in, again, I know Dr. David talked about the level 1, 2, and 3 types of information. How congruent is what you have to say with how they’re already thinking about their kid. The hope is that through the process, you’ve started to shift that understanding a [00:59:00] little bit, and you have either nothing or very few things that are level three. So you’re not going to come at them out of the left-field with much of anything, if at all.
Dr. Sharp: In case people don’t remember, can you describe levels 1, 2, and 3 just briefly so that we have some context for that?
Dr. Alison: Yes, absolutely. So this goes back to the therapeutic assessment process is helping people reframe the way they think about themselves and their families. So level 1 information is findings from the assessment that are congruent with the way they already think about themselves and their family. So you say something like this to a parent and you say, yes, that’s exactly right. That you got her. That’s her. Yes.
Level 2 information is a little bit of a shift but it’s not too hard for them to take in. And that’s the kind of thing where you get the reaction like, oh yeah. I [01:00:00] never thought of it that way before, but I can see that. An example of that educating people that depression sometimes shows up as irritability. A lot of times that’s a reframe that’s pretty easy to take in. It’s just new information that, oh, wow. I never thought of it that way before.
Level 3 is where you are starting to get into people’s defenses. So level 3 information is something that does not fit with the way they see their kids. This is me trying to tell an anxious mom of an anxious girl that her daughter does not have autism. Without doing this process, an anxious mom will say, no, you didn’t get it. You don’t. That’s level 3.
And so for level 3 findings, you can either, if there’s still level 3 by the end, hopefully, there are some things that may be started out as level 3 at the beginning, but you’ve worked with it and now they’re up to level 2. [01:01:00] When you get to this summary discussion session, if you have level 3 information, you can either be very careful about how you present it and go slowly and watch for those defenses and work through them at the moment or you can just hold them back and not present them depending on how relevant you think it is.
Dr. Sharp: I see. Thanks for that. I really like how you tied it to real-world examples. That help. Oh Gosh, our time is flying and I’m aware of that.
Dr. Alison: It’s me rambling. It’s it’s me.
Dr. Sharp: No, this is such good information. It’s great. Honestly we went in a direction that I was not expecting. This is not at all what the process I thought the process was going to look like. So this is great.
Dr. Alison: This is a level 2. We’re having a level 2 moment here.
Dr. Sharp: This is a level 2 [01:02:00] moment for me. So if I’m keeping track of my mind, we’ve gotten through maybe six-ish weeks of these meetings. I am curious what the rest of the meetings look like for the additional, I guess 4 to 6 weeks.
Dr. Alison: Oh, yeah, probably not that many. When I call parents 2 to 3 months, that’s assuming that we’re probably going to miss a week or two in there because that’s typical. So after you’ve had your discussion with the parents and you’ve presented your findings and answered all of their questions, you have a session with the child, and you present results to the child.
The main way that we do that is through fables. We write each child an individualized fable that takes some of the findings [01:03:00] from the assessment and turns it into a metaphor for their life. And then it’s a therapeutic fable for them. With some kids, you may also talk to them about test results, and then with some kids, you may just only give them the fable.
Dr. Sharp: Okay, so my first thought is, are there fable templates out there or are you writing a fable every time? That seems really funny.
Dr. Alison: Yes, I am.
Dr. Sharp: Oh my gosh. That’s remarkable.
Dr. Alison: To be honest, I love it. It exercises completely different muscles than anything else in my work. And so I love it because of that. You use something that the kid has given you for inspiration. So I usually have a metaphor ready to go because I’ve done those performance-based assessments. And so they’ve already told a TAT story about something or they’ve already drawn a picture of [01:04:00] something. Most of the time that’s where your inspiration comes from.
There are tons of examples out there. On the therapeutic assessment website, therapeuticassessment.com, if you go to the section where all the articles are, sorry, the bibliography, I think section, there are links to several articles and some of them have examples of fables in the article.
Dr. Sharp: I got you. Nice. I’ll definitely link to that. Do you have, just off the top of your head, a general fable?
Dr. Alison: Yeah, I was just about to say that we [01:05:00] published a case study. Dr. Tharinger, Dr. Finn, myself, and Dr. […], we published a case study that walks through the whole process with a kid and it has her fable in there.
And so for her, the fable was based on one of her Rorschach responses. So one of the Rorschach responses was something was breathing fire and her presenting issue was that she was having these meltdowns. And so we thought of the breathing fire as a self percept for her. And so [01:06:00] when we did like, if you could be any animal, what would you choose to be? She said she would choose to be a unicorn.
And so the fable that we wrote was about a unicorn that would breathe fire and nobody could understand why she was breathing fire. And then the unicorn family went to see a wise owl in the forest, I’m often riding myself into the fable, and the owl helps them understand that the family can learn to not be scared of the fire and to work on their relationship and doing things together and responding with empathy and that will help the fire get smaller and less scary.
Dr. Sharp: I like it. This is so interesting to me. People who’ve been listening and even someone who’s only [01:07:00] listened to this episode can clearly tell I enjoy structure and predictability, but there’s this part of my brain, I mean, this is really interesting to me to be able to exercise that other part of my brain to do something like this. It’s so intriguing.
Dr. Alison: A lot of the times I go into the part where I’m going to write the fable and I’m thinking, oh gosh, I have no idea what I’m going to write for this kid. Maybe they didn’t give me anything really salient in their projectives or maybe I’m just not sure how I’m going to resolve the story, for example. We want to stay away from like, oh, they all lived happily ever after because that’s not going to be the reality for most kids. You want to try and put an ending that’s hopeful, but realistic to the fable.
So sometimes I’m like, boy, I don’t know what hopeful, but realistic looks [01:08:00] like for this family. And I usually just find myself, if I haven’t gotten something ready-made from what the kid has given me, I often find that it’ll just pop into my mind when I’m doing something else. This is one of those things that like, you can’t always force, you have to just maybe just think about the kid and the findings and let something come, which is like not helpful at all. I realize. But that’s often the way it comes about is just sitting with the findings and thinking about the family and not forcing it, but letting it come that way. It’s a creative process. That’s where those different muscles come [01:09:00] into play.
Dr. Sharp: Yeah. I like the possibility of that. I know that you wanted to touch on research around therapeutic assessment for kids. That may be a nice thing to close with just to put the cap on everything that we’ve talked about.
Dr. Alison: Absolutely. There’s a small but powerful emerging literature on therapeutic assessments, specifically with children. There’s been a lot more research done, which Dr. David talked about for adults, but there have been some in kids. And some of the things that have been found is that therapeutic assessment can result in a decrease in problem symptoms for the kid, which again is maybe our [01:10:00] main target, but it also can decrease psychopathology in parents, which is not what people come to an assessment for.
Dr. Sharp: That’s a remarkable thing.
Dr. Alison: Again, if you think of this as a family intervention and then also knowing that often the apple is not falling far from the tree, and so if there’s something that you’re looking at in the kid and trying to help with the kid, you going to end up helping the parent as well. There’s also been some research specifically looking at family system variables, so conflict, communication, and parent perception of their child, and we’ve seen improvement in all of those things.
So there was also a study that was done I think, Dr. JD Smith was the lead author on that one, that looked specifically at all the different components, which one was the most helpful and they found that [01:11:00] the family session was often the most helpful which I think if we think about it, it’s not that surprising, but that’s not true for everyone.
Different families will have a light bulb moment at different points. There has been more than one family where I felt like the primary agent of change was the fact that I said both parents needed to be there. And one of the parents often dad, is totally checked out. And so just by saying, nope, dad needs to come. We’ll be flexible with his schedule. We’ll figure it out. But this needs to be a priority.
And sometimes these are kids who are in a lot of distress, suicide attempts, they are in legal trouble or they’ve been hospitalized for one reason or another and it’s like, okay, this is really serious.[01:12:00] Dad, give me an hour of your time. And sometimes that’s huge for the kid.
Dr. Sharp: I could totally see that.
Dr. Alison: So the meta-analysis that was done on TA in general, that posted Hansen in 2010, they looked specifically at children and they actually found a large of excise and it’s pretty comparable with other empirically supportive interventions that we look at in kids.
Dr. Sharp: That’s great. That’s always the question. When you start talking about things that fall outside people’s comfort zone, it’s like, well, what does the research say? And it’s good to hear.
Dr. Alison: It works.
Dr. Sharp: It works.
Dr. Alison: Yes it does.
Dr. Sharp: Yeah. Well, and I think that’s a nice way to close the loop and come full circle is that again, you are a classically trained [01:13:00] neuropsychologist, you’re working in a hospital, you’re doing this model and it’s working. That’s a really powerful testament to what it can be and the validity of it.
Dr. Alison: And on that note, can I also maybe talk just real quick about things that anyone can do. So even if you’re not using this full model, which, like I said earlier, I don’t always use this full model. You can take pieces of it. Almost always, I’m using parent questions and then using the questions and levels 1, 2, and 3 as a way to present results.
I do that even in my one-hour multidisciplinary clinic consultations. It’s incredibly flexible and it’s a real good way to get parents thinking about what they want out of this. You can write a fable [01:14:00] at the end of any type of assessment. They actually did a study just looking at children’s fables at the end of a standard neuropsychological evaluation. And there were various improvements just from adding the fable on. And really just going back to those core values: collaboration, humility, respect, compassion, openness, and curiosity.
I think for me that any of us who maybe struggling with imposter syndrome sometimes, those values and these lens are really helpful because you don’t have to know all the answers. You’re going to collaborate with the family to say, okay, I know about this test. I know about the psychometrics of this test, I know about developmental milestones and I know about diagnoses, but I don’t know your kid and your family. So we have to put our heads together. I’m not responsible for coming up [01:15:00] with all of the answers. We’re going to do this together.
Dr. Sharp: Right. I love that approach. It just makes sense to me that we can’t know everything. Are there any resources specifically around pediatric therapeutic assessment that you want to point people towards?
Dr. Alison: The website that I mentioned, the therapeutic assessment website does have a bibliography and many of the articles in the bibliography are looking at kids. So there are a number of case studies in there and there are also some of the studies that I mentioned, a lot of the articles have PDFs linked right through the website. So you can read them from there.
In Our Client’s Shoes by Steve Finn is an amazing book. And it’s about therapeutic assessment in general, but there is [01:16:00] some child-specific stuff in there. The case book. What’s the official title of it, a Collaborative Therapeutic Assessment Case Book and Guide. So that’s Steve Finn, Constance T. Fischer, and Leonard Handler. There are several child cases in that book. I know there’s at least one adolescent in there too. Those are excellent resources.
The therapeutic assessment website also has some videos that people can watch and it links to different pieces of training that are offered in this model. I really encourage anybody to go and take training, even if you don’t think that you would be able to use the full model, because it will really help you understand the background and values and how can you incorporate some of these things into your practice no matter what you do?
Dr. Sharp: Sure. Yeah, I think that’s a nice takeaway that yes, this full model is out there, and [01:17:00] it would be amazing to be able to implement it. And if not, there are so many components that you can integrate into your current model that will make a big difference and just move in that more collaborative direction.
Dr. Alison: Yes.
Dr. Sharp: Well, Alison, this has been enlightening, fascinating, and educational for me. I hope that the audience would think the same.
Dr. Alison: I hope so too. I hope we didn’t meander too much.
Dr. Sharp: I don’t know. I think there’s a lot of good info in here. Just to hear about your points.
Dr. Alison: There are tons more I can talk about. I’m really passionate about this model. And so I could talk about it all day if you let me.
Dr. Sharp: Well, careful, you might set yourself up for a part two podcast. So watch that. No, this is great. I really appreciate it. Thank you so much for the time to talk through this.[01:18:00] Dr. Alison: Thank you so much for the opportunity. Thanks for inviting me.
Dr. Sharp: Okay. Thank you for tuning into this interview with Dr. Allison Wilkinson-Smith. Hope you found it as enthralling as I did. This world of therapeutic assessment is so interesting to me. I just see so much value in trying to incorporate these principles into our own evaluations. Even if you don’t go full bore into the TA model, there are just so many positive qualities about this approach that I hope we can integrate into our “normal evaluations.”
Like I mentioned, there are a number of resources in the show notes that I think you will find useful. So check those out and stay tuned. If you have not subscribed to the podcast, I would love to have you on board. In Spotify, you just hit follow, in iTunes you actually hit subscribe. That just makes sure that [01:19:00] you don’t miss any episodes that come up over the next several weeks. I’ve got some great content and fantastic guests coming up. So, I hope to have you join in, subscribe and get each of those episodes as they come out.
All right. Everybody take care, stay healthy, and we’ll talk to you next time.