94 Transcript

Dr. Jeremy Sharp Transcripts Leave a Comment

[00:00:00] Dr. Sharp: Hey you, welcome back to the Testing Psychologist podcast. I’m Dr. Jeremy Sharp. This is the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. My guest today is a good one; Dr. Michelle Friedman-Yakoobian is talking with us all about early identification and assessment of schizophrenia spectrum disorders and psychotic disorders.

Michelle got her undergraduate at Cornell University and her Doctorate in Clinical Psychology at the University of Massachusetts in Boston. She’s currently a licensed clinical psychologist and the Clinical Team Leader for the CEDAR Clinic, a clinic in Boston that specializes in the early identification, assessment, and treatment of adolescents and young adults on the psychotic spectrum.

She provides services for families, agencies, and individuals in this realm. She also presents at [00:01:00] schools and other community youth agencies to raise awareness about advances in early detection and treatment of early signs of psychosis. She is also the Director of Psychology Training in the Prevention and Recovery and Early Psychosis Program. Clinically speaking, she’s been interested in this area for a long time and has conducted a lot of research in this area as well. She authored a book called Everything you need to know about schizophrenia back in 2000.

And what else? My gosh. Michelle is also an Instructor in Psychiatry at Harvard Medical School at the Massachusetts Mental Health Center, Public Psychiatry Division of the Beth Israel Deaconess Medical Center.

I think that’s it. What a resume.

Michelle has a lot to say today. I think it’s a fantastic interview. I hope you will tune in and [00:02:00] take a lot from it.

Before we get to the interview, I want to let y’all know that I’m recruiting again for my Advanced Practice and Beginner Practice Mastermind groups. These are group coaching experiences that are so powerful. You get to be in a group of 5 other psychologists right at your stage of practice with their testing practices, and you get the benefits of spotlight attention on your problems and questions that you have but you also get vicarious learning from the group in this group coaching experience.

So if you are interested in joining an Advanced Practice Mastermind; this is for those who are consistently making over $75,000 in their practices, or if you’re interested in the Beginner Practice Mastermind which is really aimed at those just starting out with testing in the practices, jump over to the testingpsychologist.com. You can search under the consulting tab and find information for both of [00:03:00] those groups and you can schedule a phone call and we’ll talk through whether either of those groups could be a good option for you.

Without further ado, here is my interview with Dr. Michelle Friedman-Yakoobian.

Hey everybody, welcome back to another episode of the Testing Psychologist podcast. I’m Dr. Jeremy Sharp, and like you heard in the introduction, I am so fortunate to be here today with Dr. Michelle Friedman-Yakoobian. Like you heard, Michelle has a ton of experience in this area that we are going to talk about and she’s doing some really important work, so I’m excited to talk to her.

Michelle, welcome to the podcast.

Dr. Michelle: Thank you so much for having me, Jeremy.

Dr. Sharp: Yeah. Thank you. I [00:04:00] I am always starstruck when I reach out to these folks who are doing such important things and you actually say yes to come on the podcast. And you are one of those people. You get this cold email and actually agree to come and talk to a stranger. So first of all, thanks for that. I really appreciate it.

Dr. Michelle: It’s really a pleasure to be here and I really enjoy your podcast.

Dr. Sharp: Oh, awesome. I appreciate that as well. I’m so excited to talk to you because this is a topic that we, I mean the Facebook group and the community at large, it’s so important and something that has a lot of mystery to it for a lot of clinicians, I think. So I’m really excited to dive in. I would like to start though; I’m curious how you got interested in this whole realm of schizophrenia, schizophrenia spectrum, and psychotic disorders. How did this come to be so important in your life, in your career?

[00:05:00] Dr. Michelle: It’s a great question. I started getting interested in working with individuals with schizophrenia and learning more about it in college. I was fortunate to have a really dynamic and compelling abnormal psychology teacher who himself did some research on schizophrenia and what was called schizotypy- schizotypal personality disorder or certain kind of thinking. 

I became initially just really fascinated by the idea of what the brain could do and the idea that the brain could play tricks on a person, make you hear things that aren’t really there, make you see things that aren’t there, confusion about what’s real and what’s not.

And so at first, it was really an academic interest. And then I had a really nice opportunity to do a summer internship in college [00:06:00] at Columbia Presbyterian or the New York State Psychiatric Institute, and got some exposure to working with folks there. And eventually, post-college got to work at a schizophrenia research unit within the New York State Psychiatric Institute.

And then I started interacting with patients and families and found that it was a group I really, really enjoyed working with. I found their stories to be really compelling and really noticed that a lot of folks within the field may feel less comfortable working with people with psychosis. It feels like an unknown. It became an area really wanted to specialize in.

And so then I went to graduate school in University of Massachusetts, Boston. And when it came to the point of going on internship where I [00:07:00] did this at the Massachusetts Mental Health Center, which I’m still connected with, they were just beginning to start an early psychosis program. I had really focused all my training on working with folks with psychotic disorders, mostly schizophrenia adults, but when we moved into the realm of early psychosis, I wound up learning more about working with teens and young adults.

Currently, over the last about 10 years, I’ve been the Director of the Center for Early Detection Assessment and Response to Risk. This is a program that aims to identify young people that are experiencing the very earliest signs that they might be developing psychosis. The idea is trying to catch people in the possible prodrome psychosis, really earlier intervention, and that’s where my focus has been primarily over the last 10 years or so.

[00:08:00] Dr. Sharp: I think that’s the part that is so interesting to a lot of us too; being in the assessment world, trying to catch those kids, adolescents and young adults relatively early, it’s so important but it’s also really challenging I think for many of us. So it sounds like you got on this path relatively early and just followed it and have been doing it for a long time now. Fantastic.

Tell me, just a little bit, for those who might be in the area, and this could be relevant, what does the CEDAR Clinic do specifically? What kind of services do you offer over there?

Dr. Michelle: The CEDAR Clinic is located in Boston. We serve young people who are between the ages of 12 and 30 who are beginning to develop signs that suggest they might be at risk for psychosis. Most often this means [00:09:00] what we might call attenuated psychotic symptoms. So a person may be experiencing more subtle changes, maybe hearing voices they know aren’t real or having a concern about something that they know their mind might be playing tricks on them about, and some change in functioning that’s been happening.

And we offer a very comprehensive assessment including the structured interview for psychosis risk syndrome which is the gold standard for assessing for clinical high risk for psychosis. We talk with individuals, families, providers, we offer detailed second-opinion assessment reports. And then for a portion of folks that come in for a consultation or comprehensive evaluation with us, we may also offer some treatment as well. So we have a small [00:10:00] coordinated specialty care program where we can offer an array of services from individual therapy, family therapy, psycho-pharmacology. We offer school and work coaching services and some school support and advocacy as well.

Dr. Sharp: Wow. So y’all are really doing a lot there it sounds like to help folks. Are you busy?

Dr. Michelle: We’re quite busy, yes.

Dr. Sharp: I would imagine.

Dr. Michelle: And we’re lucky. We’re one of the first programs of its kind in Massachusetts and there’s a time where the SAMHSA has put in a lot of investment in developing programs like CEDAR. So it’s an exciting time for us to be able to reflect on what we’ve learned over the last 10 years and think about how to support new programs in other areas of the country in getting started as well.

Dr. Sharp: Oh, that’s fantastic. It seems like a huge need. I’m not [00:11:00] totally well versed in the availability of these types of services in other states, but it seems like it’s a huge need pretty much everywhere.

Dr. Michelle: Yeah, it’s definitely growing. There’s been 21 new centers that have been developed in the last year or so around the country.

Dr. Sharp: Okay. That’s great. Well, I would love to just dive right into it honestly, because I feel like there’s so much to chat about in this topic. So maybe we could start with the basics, I suppose, or what I would say are the basics. You can feel free to correct me at any point in this interview. That’s my disclaimer with all of my interviewees that I will ask some dumb questions and you can feel free to steer me in the right direction.

I am curious, would it be fair to start just with what do we even mean when you’re talking about psychotic disorders and when do they start to show up, maybe is a good place to start?

Dr. Michelle: Sure. [00:12:00] The best way that I like to describe what psychotic disorders are or the symptoms, psychosis is a symptom. It’s not a disorder within itself. So it can be part of a number of different diagnoses. Psychosis at its core makes it hard for a person to tell what’s real from what’s not real.

One of the most common psychotic symptoms that our patients experience is trouble with their ears and eyes playing tricks on them. So hearing noises or voices, hallucinatory experiences that are generated from their brain versus something in the environment.

Another very common psychotic symptom is something called delusions, which is a really fixed, false belief doesn’t fit in with a person’s cultural experience that a [00:13:00] person holds onto despite there being lots of evidence that it’s not real, but feels very, very compelling to the individual.

Another psychotic symptom involves just trouble with thinking and thinking organizations. So folks that experience psychosis may find that it’s much harder to explain what they’re thinking or understand what other people mean in certain situations. And speech might get confused.

I’m sure a lot of listeners who do evaluations where psychosis might be a question, will pick up on circumstantial speech, tangential speech maybe kind of person winds up making up words as well. And those are things that can show up as well.

Dr. Sharp: Okay. Since you brought it up, can you talk about the difference between circumstantial speech and tangential speech or [00:14:00] disorganized speech? I hear all those terms and I’m sure I learned it at some point, but there’s one problem in that…

Dr. Michelle: I will do my best; listeners can write in if I get this incorrect and correct me. I usually use the word circumstantial to describe speech where the person talks around a lot of details before getting to the point; where tangential speech may be, a person starts on one topic, switches to another topic and never quite gets to the point as well.

Dr. Sharp: Okay.

Dr. Michelle: Both I would say are versions of disorganized speech as well, but sometimes when sitting with someone who’s experiencing what we might call thought disorder in schizophrenia, you might be sitting there and the words make sense, but you don’t understand what the person is trying to get at. And can feel really lost. And that’s a [00:15:00] pattern of speech that can show up for folks experiencing psychosis.

Dr. Sharp: Got you. Thanks for indulging me with that.

Dr. Michelle: And also, just to clarify, in the CEDAR Clinic, we see folks that are experiencing milder versions of these. One thing that really distinguishes what we would call psychotic symptoms from attenuated psychotic symptoms or risk for psychosis symptoms has to do mainly with insights. So folks that come in to CADAR Clinic, may be having their ears playing tricks on them, they’re hearing noises and may might even have voices that are talking with them but they’ve always maintained insight that the voices are not real.

They’re product of their mind. They’re worried about themselves or at least an ability to wonder if this is something their mind is playing tricks on them about, or whether it’s something that’s real. When someone has had a prolonged period of time where they believed it’s real, then we would say they’ve reached [00:16:00] the structured interview for psychosis risk syndromes, would say that they’ve reached what we would call full psychosis.

Dr. Sharp: I see. Yeah. I’m so glad that we’re digging into this because that seems like the hard part, those attenuated states that seems really challenging. And I think that’s probably a lot of what the audience sees in our practices because, I don’t know, if someone “fully psychotic,” I think they get people’s attention pretty quickly and end up seeing a psychiatrist or maybe hospitalized or whatever might happen that higher level of care, but we’re really working with those folks where there’s a question, that’s why they’re being assessed.

Dr. Michelle: Yeah. Actually, I think, as testing psychologists who have a real opportunity often to connect with young people before the diagnosis is clear, we do get a [00:17:00] fair number of referrals from testing neuropsychologists and where folks are just beginning to have some changes in their thinking and it’s not clear what’s going on, but it is starting to affect their functioning. And it’s really great opportunity for us when folks do reach the CEDAR Clinic because that’s what’s all about. We’re trying to catch people in that period of time.

And remember you asked about when this comes on, it’s usually around teens to early twenties, is the general age of onset of psychosis. And so a lot of these young people that are early teens maybe just starting to experience some changes in their thinking and it’s not clear what’s going on. And when folks do reach treatment early and it’s identified early, there’s real opportunities to increase resilience and build up. The whole idea behind CEDAR Clinic is trying to help people [00:18:00] to address symptoms early on to prevent them from getting worse and leading to disability that can come with the development of psychotic disorders as well.

Dr. Sharp: Sure.

Dr. Michelle: Another thing that can really show up in a lot of these kids that are presenting with clinical high risk symptoms is a change in cognition. So an associated feature of psychosis, about 90, I could be making this number up, but I’m pretty sure I’ve come across studies that indicate about 90% of individuals who experience psychosis do experience some cognitive changes associated with the onset of illness. So that includes trouble with memory, attention, processing speed. And for that reason, a lot of folks who come into CEDAR, one of their chief complaints is a change in cognition. And that can certainly lead to a referral to neuropsychology.

[00:19:00] Dr. Sharp: Sure. The times that I’ve dug into it in the past, it seems like executive functions are the thing that takes the hit with psychotic disorders. That’s such a good point. So just being on the lookout for that as we’re going through our assessment.

So let me back up a little bit and ask, I think we all get questions about true childhood schizophrenia or psychotic disorders in kids. Can you just speak to how often that actually happens and the likelihood of seeing a kid under, let’s just say under 12, that truly has schizophrenia?

Dr. Michelle: The likelihood of a kid under 12 with schizophrenia is pretty low. And it is really hard to distinguish and it’s certainly not my area of expertise. In the CEDAR Clinic, we see folks 12 and up. [00:20:00] Until recently, we saw 14 and up. So most of my training really was with adults. And as I’ve worked with younger and younger kids in the CEDAR Clinic, I’ve needed to learn a lot about child psychology and how to distinguish.

We have a new child psychiatrist that’s joined our team who’s really helpful in teaching me about distinguishing developmental concerns from psychotic symptoms. The younger a kid gets, the harder it really is to distinguish whether experiences are part of developmentally normative or just slightly developmentally delayed fantasy and play and imagination versus what might be a true perceptual disturbance, a change in true psychosis as well. So I don’t know if I have an exact answer for you. I can give you an example of [00:21:00] a case that we saw recently where we have real debate and we’re not sure.

Dr. Sharp: Sure. Let’s dive into it.

Dr. Michelle: I recently saw a 13 year old who was referred to us by a Developmental Medicine Clinic in our area, and which is interesting because they see developmental disorders, but the reason they referred this kid, now I want to make sure I make it de-identified enough that the person wouldn’t recognize themselves.

Let me just say, this person was complaining of some perceptual changes, seeing some things often when waking up and going to sleep, which we would not generally think of as clinically notable for psychosis. This is actually something…. It’s hallucinations when waking up or going to sleep are actually pretty common [00:22:00] not necessarily a disorder, as well as reporting seeing some things changing on the wall that were concerning to him and had showed up in school. He also was beginning to complain and worry about ghosts and had a lot of preoccupation with ghosts.

Now again, this is a 13 year old with a long standing history of expressive and receptive language difficulty, never really had friends, has always been bullied, has had a lot of learning difficulties and behavioral difficulties in school.

So I met together with a psychiatrist to do the 6th interview and in my mind, his description of the perceptual changes was infrequent enough that it wouldn’t [00:23:00] necessarily meet criteria on the SIPS. Or what we would look for is experiences happening that are new and getting worse, and they’re happening at least once a week in frequency.

Dr. Sharp: Good to know.

Dr. Michelle: For him, it was happening like 2 or 3 times, so not as notable. What was notable is he was genuinely quite afraid of spirits. He was afraid of talking about spirits and giving them power. He was very afraid which to me, coming from an adult lens was like, gives me these thought or there’s some family history of psychosis that maybe this is something that’s notable.

The child psychiatrist that was working with us is really thinking, well, this is a kid who’s never been able to understand language or speak language very well. He’s very developmentally young, 13 year old. We’re really on the cusp of where imagination and [00:24:00] suggestibility is still very much going on and could be influenced by an online peer group that talks about ghosts and how things work. It could he be influenced by video games he’s watching and movies that he’s seeing.

And that’s really somewhere where I, honestly, my hunch is we’re going to offer some services for this kid to provide a little bit of support that might increase his resilience. But it may be that what’s going on for him is really not psychosis and it’s really more or clinical risk for psychosis. So we certainly wouldn’t diagnose psychosis based on this level. You can still wonder, there’s a part of him that thinks it might be in his mind, that kind of thing.

Dr. Sharp: I see. I’m so glad that you are giving this example. I feel like that is a very representative case from my practice at least, and probably a lot of other folks too, where it’s like, [00:25:00] well, all those factors. It could be a developmental thing. There’s maybe some influence from TV or video games or peer group. It’s vagueish, like the “hallucinations” are not obviously bizarre. I’m just glad that we’re talking about this for clarity and it’s validating too. It’s not very clear cut.

Dr. Michelle: Another tricky situation that’s been confusing that shows up sometimes it’s where we’ve maybe gone on the other end where a kid with some developmental concerns has like a very rich internal monologue with imaginary friends from TV shows. You can see and hear and talk to but at the same time it really seems very, it’s a thing that the kid does for fun versus something that [00:26:00] seems like is showing up and really disrupting functioning in a way where, again, that’s been a tricky confusing situation.

I think in both cases, they’re good referrals for us to be able to do some more in-depth assessment and see what our thoughts are but those are tricky ones. I don’t think there is a hard and fast rule and I definitely don’t feel like I have tremendous expertise with the younger kids and really teasing that out.

Dr. Sharp: Sure. Yeah, that’s fair. I think I picked up somewhere along the way, I can’t say specifically where, this idea that if the perceptual disturbances or hallucinations, whatever, if you’d like to call them, if they’re negative or unwanted, then that’s not good. And that’s maybe more of a sign that it’s a psychotic disorder but if they are pleasant or positive, then maybe we’re okay. I don’t know if that’s right or not, but somehow that got stuck in my mind at some time.

Dr. Michelle: Yeah, that’s interesting. [00:27:00] I wouldn’t say it’s necessarily hard and fast rule. There’s definitely patients that I’ve worked with who have schizophrenia, that have real fluctuations in their voices and hallucinations, and actually often a sign of folks getting better is that the voices become a little more positive and neutral.Not that it doesn’t mean they don’t have a psychotic disorder, but that they’re feeling better.

One big difference, I’d say as a clinician working with folks around how to cope with voices, one of the goals as a psychologist doing therapy would be to help a person to, when a person is hearing voices that they feel are real, that they feel are powerful, that they have to listen to them and do what they say, that’s the most functionally disturbing [00:28:00] combination.

And so one of the things that we’re often doing in therapy with young people is trying to help them develop a different stance towards their voices, where they start to see them as less powerful. They might do experiments to try out ways of either listening to them or not listening to them when it’s not convenient and having those voices have less power and influence over the choices of what they do during the day so that they can make more valued based decisions about what they’re doing.

Dr. Sharp: Got you. That makes sense. Well, let me see. I wonder if we could zoom out and back up just from an assessment perspective, we start with an interview most of the time. What sort of things might be showing up in that interview? I don’t know if you call them soft signs or something else but just red flags that might tip us off. Like, [00:29:00] hey, we need to really pay attention to this and consider a psychotic disorder as part of the picture here. Sorry, I’ll give you some more context. Let’s say the person is not necessarily coming in with that as the concern. Does that make sense?

Dr. Michelle: Yeah.

Dr. Sharp: What sort of things might pop up that we should pay attention to and assess a little further?

Dr. Michelle: Well think I’m actually curious about, I might have some thoughts, but I’m curious about whether there might be any routine questions about like, do you ever feel like your mind is playing tricks on you? Do you ever feel like it’s hard to tell it’s real from what’s not real or anything like that standardly tend to come up in interviews for most people or would that be unusual to have those as part of the questions?

Dr. Sharp: You know, I can speak for our practice. I think there are a [00:30:00] lot of folks doing a similar thing where I’ll talk with the parents first and unless it’s really obvious the parents aren’t saying anything about those symptoms. Where it does tend to come up is when I have the kiddo or the adolescent complete a self-report measure and I ask questions about hearing voices or seeing things that aren’t there, and whatnot, and sometimes a little more subtle questions. And if those get tripped, then I’ll dive in and ask more of course. It’s screened with maybe a self-report checklist, let’s say.

Dr. Michelle: Which assessment do you tend to use to look for self-report around voices and…

Dr. Sharp: We just do the BASC and then if the kid’s old enough, then a personality measure, so it’d be like the MACI or the maybe the M-PACI [00:31:00] would ask about those things.

Dr. Michelle: Perfect. I think self-reports are really useful. One thing I can send you and post to the, if you have like a show notes item…

Dr. Sharp: Yeah, definitely.

Dr. Michelle: There’s something called the Prodromal Questionnaire-Brief.

Dr. Sharp: Okay.

Dr. Michelle: It’s a 16-item questionnaire that was developed by Rachel Loewy and colleagues. It’s a nice little screening tool. It’s taken items from a larger questionnaire and they identified the items that were most predictive of who would meet on the SIPS for clinical high risk for psychosis. And it asks about a variety of experiences. It’s pretty quick to do, I think you can do with kids as young as 12. It asks yes/no if you had this experience. And it also [00:32:00] asks if yes, how much does it bother you.

Dr. Sharp: Nice.

Dr. Michelle: And it’s not a hard and fast thing. It’s not like if people score on this, it means I have psychosis. There’s certainly a false positive rate and a false negative rate but it’s a discussion starter. And I do think a lot of kids that might be experiencing these symptoms may be very reluctant to talk about them unless they’re asked or unless they see it in a questionnaire. So some kids have said to us that sometimes it’s really helpful and non-stigmatizing to realize that their experience is an item on a questionnaire because if it’s an item on a questionnaire, then they can’t be the only ones that have this.

Dr. Sharp: Sure.

Dr. Michelle: And I do feel like it’s a good starter. And again, on that, someone could say yes to every single item and not have psychosis. They could be really really obsessional, [00:33:00] anxious, like really thinking about like, oh, this could be true and say yes to everything or they could say no to everything and have psychosis and be thinking like, no, I’m not sharing my information with this person at all. But I do feel like it’s a nice discussion starter to have some screening tool or something you ask, especially within a help-seeking population and folks coming for testing or help-seeking. There’s something going on that bothers them that I’m wondering about.

Dr. Sharp: Yeah. Well, so let me ask you this, would you recommend screening any assessment client that comes through the practice? Is it worth it? Is it to that level or…?

Dr. Michelle: Yeah. I have some colleagues who are much more knowledgeable about me than this and have really been wrestling with this question because there are pros and cons to screening everybody. Assessments like the Prodromal Questionnaire, BRIEF, or the SIPS Assessment are definitely not designed for the general population. And we wouldn’t go into a school and just do an assessment with everybody and [00:34:00] expect to necessarily find that useful. But within a health-seeking population, I think it can be just a useful tool.

I think a lot of times the folks that come to us in CEDAR, and especially have also worked for many years in a first episode psychosis program called PREP, lots of folks who wind up in an early psychosis program who developed psychiatrist disorder will describe seeing a number of clinicians along the way who may have diagnosed depression or ADHD or anxiety and they just didn’t tell those people about some of those early experiences they had.

And so a clinician who asks is going to be much more likely to be able to notice, but it’s important not to overreact to any yes; someone saying [00:35:00] yes to every item on the PPP does not mean they have psychosis. Even if they meet the criteria for being at clinical high risk for psychosis, it doesn’t mean they’re going to develop psychosis. In fact, studies of folks who meet the criteria for being at clinical high risk suggest that between 10 and 30% actually develop a psychotic disorder. That’s way less than 100%. So these folks that are experiencing attenuated psychotic symptoms, they’re experiencing distress, they need treatment. They would benefit from help, but it doesn’t mean they have schizophrenia or will ever have schizophrenia.

Dr. Sharp: Sure. That’s such a good point. I know. We keep coming back to that, which is worth emphasizing that whole zebras instead of horses thing, right?

Dr. Michelle: Maybe in getting back to your question, I’m curious about what might be some things a young person might say that would pique your interest that you’re wondering about might be [00:36:00] psychosis that would be leading you to ask more?

Dr. Sharp: Good question. I’ll give the range of responses that might fall under that umbrella.

I get a lot of kids on the maybe less severe end that say things like, I hear my name all the time when there’s somebody there, something like that. Maybe at school, in the hallway, or maybe at home they’ll say that they hear somebody calling their name or something like that. All the way up to, I’ve had kids who will say at nighttime, I’ll see ghosts or I’ll see shadows or I’ll see, let’s just say demons coming out of my closet when I’m trying to go to sleep but at night or something like that. I’ve had older teenagers who were driving who will say things like, I’ve seen things jump out in front of me in the road when I’m [00:37:00] driving. Let’s see. I’m trying to think what else. I don’t know. That’s just a sample.

Dr. Michelle: That’s a really helpful example. So maybe it’d be helpful for me to think about some follow-up questions that I might ask. So the kid is having his name called in the hallway and around. That experience is not super uncommon but one of the things that I would want to know is, is this happening a lot more often than it used to? How does he respond when he hears his name being called? Is he thinking like, oh, I’m just mishearing something else? Or is it that he’s actually more and more hearing, it’s a voice saying his name or he is turning around, he’s looking, is it causing some disruption in functioning? Is it causing some distress? Are there any other ways his ears might be playing tricks on him as well? And [00:38:00] depending on some of the answers to those, I’d be a little bit more thinking that it might be something along our lines and that kind of phenomenon.

Usually, folks who come into CEDAR Clinic might have that, but they might also have some additional things going on too.

Dr. Sharp: Okay. I see.

Dr. Michelle: The person that’s seeing demons coming out of their closet when they’re going to sleep, some of the questions I ask, how old the person is. Are they 10 or are they 18? Would make a really big difference to me.

Dr. Sharp: Okay. How so?

Dr. Michelle: Just around imagination, hypnagogic, and hypnopompic hallucination kind of experience. Is it within the context of a fear of the dark [00:39:00] and we are seeing things in shadows and that kind of thing? I feel like, in an 18-year-old, I’d be a little that had this developed new, or in the last year? I would be a little bit more concerned for that being potentially associated with psychotic symptoms, just that it’s new, it’s emerging. They didn’t have the sphere of the dark and now all of a sudden this is happening.

I’d want to know if they’re really awake when they’re seeing these or if they could be in the middle of falling asleep or waking up. Because again, those pens of hallucinatory experiences aren’t uncommon and aren’t associated with psychotic illness. Anyway, I want to find out what they do. So if this kid was setting up traps to trap the demons in his room or keeping the light on or staying up all night, I’d be a lot more [00:40:00] concerned about psychosis than someone who’s just saying, yeah, every once in a while I see this shadow and it could be my cat, or it could be a demon. I don’t know. That thought crosses my mind, but I don’t think about it too much.

Dr. Sharp: Right. Okay.

Dr. Michelle: And then what was the last one?

Dr. Sharp: Well, I had one example of a kid who would say that things would jump out in front of him while he was driving. So we could run with that, but I thought of other examples that are actually a lot more common. One that comes up a lot is like the angel demon kind of thing. I have voices in my head, one’s telling me, “do it, do it” and the other is like, “no, don’t do that,” that kind of thing. And let me see. I had another example, but now I lost it. So we can run with that too, but that comes up a lot.

Dr. Michelle: Yeah. The angel demon one, that’s interesting. [00:41:00] Is the person indicating whether they’re actually really hearing it through their ears? Does it feel like a separate person? Is it more like parts of themselves deciding what to do? How do they imagine the pros and cons of a situation? I don’t know what maybe a person you have in mind might have said, but it…

Dr. Sharp: Well, this is validating because those are some of the questions I try to ask. Like, is it your brain talking to you? Is it your conscience? And often so far, anyway, that’s what these kids have said is like, oh yeah, it’s just different parts of my brain arguing back and forth.

Dr. Michelle: Yeah. So it’s a way that the kid is explaining their thought process and that there’s different things [00:42:00] of them, which I would not see a psychosis. What I might see as more psychosis, a lot of kids who do hear actual voices may hear voices telling them to do things and they may or may not be things that the person wants to do. Often one of the things that comes up is that the voice feels it, or the voice, or sometimes it’s even just a strong thought that feels really foreign to the person. It feels separate from their own thoughts. They can really distinguish, this are my thoughts and this is the random thought that shows up that talks to me, or the voice that talks to me.

And it doesn’t feel like them. It feels separate even if it’s coming from inside their ears or outside their ears, there’s a sort of separateness that is more common, but it often can tell the person to do things that is actually pretty common. Anywhere from, do things like, get up and go to school today.[00:43:00] Brush your hair this way, wear this outfit too, attack this person. All those things can show up and are not uncommon among voices that will show up for person.

But the angel demon thing is really not something I’ve seen that much show up. Maybe it’s cultural. I don’t know. In Boston, folks are less likely to describe angel and demon and they might name different parts of themselves or something like that, but it’s interesting. Not that exact thing, but often, I’ve had folks say, I heard a voice and it told me to do this thing and it was really annoying, so I did it. Or it’s really annoying and I’d never do it, but it says it and it’s really frustrating.

Dr. Sharp: Yeah. I got you. So you tell me, sometimes I’ll ask kids if the voice, one, is it your voice or is it somebody else’s voice? [00:44:00] Does it sound like somebody else? And then if they say, oh, it sounds like somebody else. I’ll say, well, is it a grownup or is it another kid? And then they’ll say whatever. And is it a man? Is it a woman? And just trying to dial it in a little bit. And it makes sense I guess, but like the kids who end up saying it’s a grownup male, mean voice that tells me to hurt myself. It’s like, okay, then that seems significant but I don’t know if that’s actually.

Dr. Michelle: On the SIPS is kind of a change. So experiences that are new or getting worse in the last year seem to be more predictive of risk for actually developing psychosis than experiences that have been just there throughout life. There’s a whole community of folks that hear voices who are not part of the psychiatric community. [00:45:00] Their voices don’t cause dysfunction. They call like voice hearing groups or voice hearing network, and voices that are just there. They are in the background. They’ve been part of life forever. They’re not causing dysfunction. Generally, as a clinician, we wouldn’t see as being a target for treatment.

Dr. Sharp: Oh.

Dr. Michelle: So the voice would need to be causing some real trouble and dysfunction for a person in order to be notable in need a treatment.

Dr. Sharp: Yeah. I get that. Just out of curiosity, what can you attribute that to this benign voice hearing? What can drive that for people?

Dr. Michelle: There’s a whole network. It’s really interesting. I can also maybe find a post to the show notes of the Hearing Voices Network. Some of the folks who have done research on cognitive behavioral therapy for voices have learned a lot [00:46:00] from talking with individuals who identify as voice hearers who don’t experience dysfunction because of their voices.

And one of the biggest differences is that folks who hear voices that are not particularly problematic for them feel like they are in control, not their voices. They don’t have to listen to their voices when they don’t want to. It’s not convenient. They don’t feel like they’re powerful. They don’t feel like they have to do what they say and they can concentrate on other things. Those are some of the biggest differences to identify.

And there are a lot of different theories about where those voices come from. There is some thought this may be an experience that of course another population has whether or not they are… that may not necessarily be in need of treatment. And then there’s a whole group of folks who hear voices for whom it’s very disruptive.

Dr. Sharp: Yeah. I see that. That [00:47:00] sounds like a distinguishing factor for sure. The onset and the dysfunction element. So I’m thinking about, just to maybe clarify and really nail down, from an assessment perspective, you mentioned the SIPS, you mentioned the Prodromal Questionnaire. What does your assessment process actually look like? From start to finish, what are you doing with folks?

Dr. Michelle: So within the CEDAR Clinic, assessment starts even with the point of a phone call to the clinic. So we have a licensed clinician who handles all of our referral calls. Her job is to find out a lot more about, she’ll ask some questions to get a sense of what’s going on for the person and whether a more specialized assessment in our clinic would be a fit for them.

Even at that point, some folks will call up and say, I’ve just been diagnosed with schizophrenia, been in the inpatient [00:48:00] unit. That would already be someone that would not be a fit for CEDAR Clinic because it’s clearly have already a psychotic disorder. And Megan, our referral coordinator, will provide resources and information where that person might go instead.

She also, as part of the assessment, will try to get a sense of, just a little bit about what’s been happening for the person, whether or not it seems like the person is still able to tell what’s real from what’s not real, what kind of impact it’s having. So she’ll ask anywhere from 10 minutes to 40 minutes of questions of their referring clinician or provider or will often talk with the family or the individual themselves before they come in. And we’ll make some recommendations for treatment if it turns out it doesn’t seem like that person’s a fit.

Dr. Sharp: Okay.

Dr. Michelle: Once they come into the clinic, we do a consultation [00:49:00] which involves, usually a team. The way we do it in CEDAR, we have a team of people. We’re in a process of trying to figure out cost-effectiveness and it’s not the most cost-effective way to do things, but we’ll often have a psychologist or a licensed clinician along with, often we have a number of trainees that are within the clinic, so we’ll often have a trainee join in and sometimes a psychiatrist as well.

Sometimes we have the psychiatrist meet in a separate meeting and we do initially gather information with the person and their family together, just introductions, get a sense of what they’re looking for, what they want to talk about all together in terms of questions and what they’re hoping to get out of the evaluation. And then we’ll split off where we’ll meet with the young person with the symptoms separate from the family.

So we’ll have some of our team meet with the family to get a really [00:50:00] in-depth and developmental history. Find out more about the parents’ or the family member’s concerns. And with the young person, we’ll jump into doing the SIPS interview.

We start with background information, we find out about their current social and role functioning, we try to find out a little bit more about what’s on their mind, when problems started. So a little more open-ended interview. And then we got into a lot more specific questions, initially around where we’d be checking for attenuated, positive symptoms of psychosis. So specifically questions around unusual thought content, paranoia, grandiosity, perceptual abnormalities and disorganization and speech.

And there’s a lot of very specific questions about whether or not folks have had these experiences before. If they endorse that we ask follow up questions to get a sense of how long [00:51:00] they’ve been happening? How often they happen? Whether they’re call causing any distress dysfunction in the person’s life. That’s the first part of the SIPS and that’s the main part that is used to determine whether or not a person meets for a clinical high risk for psychosis syndrome as well.

We also get information about family history of psychosis, general functioning. We do some assessment around other comorbid symptoms like anxiety, depression. We often see a lot of comorbid autism spectrum, attention, executive function difficulties. So we’ll ask some questions around that as well if that’s showing up.

That’s good main initial assessment. We gather a lot of records and talk with collateral contacts of whoever the person and or their family provides permission to talk to. [00:52:00] We use that as part of information gathering.

And then sometimes we may recommend an additional follow up assessment with our psychiatrist. And sometimes we’ll gather information, we’ll put together a report that provides some recommendations for treatment at that point as well. And then we have a follow up meeting. And then at that point we may decide for someone who seems to be meeting criteria for clinical high risk or psychosis, who seems to be really in need of treatment, right now they don’t already have a provider in the community that they’re working well with, we may offer some additional services like therapy and family therapy and school coaching and other kinds of things as well.

Dr. Sharp: I see. I noticed you didn’t say anything about projectives in that process.

Dr. Michelle: It’s not a standard part of our assessment. We do have some capacity and because I saw some [00:53:00] questions about projectives in the notes you sent me prior to today, I asked my colleague who knows a lot more about it. Odds on projectives. So we do occasionally offer some more in-depth testing. It’s not the standard, it’s something that we offer sometimes above and beyond. If someone comes into the clinic, usually we’ve determined they meet criteria for us, but we’re still a little confused about diagnostically and what’s going to be the best course of action, we may do that as part of a more in-depth testing battery, but it’s not something we do standardly.

Dr. Sharp: Got you. Can you speak to the, and I don’t want to get anybody in trouble here, but can you speak to the rationale in not including any projectives as a standard part of the battery?

Dr. Michelle: Yeah. What the field has gone to for this field of identifying [00:54:00] individuals at risk for psychosis, which stems from, our group has been part of a large research study how the North American Prodrome Longitudinal Study, there’s folks around the world to do this work. The assessments that have been identified to use for identifying people at risk for psychosis are not projectives. They are interview-based assessments that do require the young person to be able to tell you about their experience which has pros and cons to it. It just is the standard. Projectives have not been part of the standard for the field.

I did ask my colleague, I said, what do you think about, I know we sometimes offer the Rorschach and part of the rationale for offering the Rorschach for some of our individuals is partly because there’s an interest in that. Partly because we have a variety of trainees that are [00:55:00] applying for internship and need to do full battery assessments in order to be competitive for internship. And so some of the reasons that we’ve offered that has really been to give them a good experience and the patient interested in that and we’re figuring out what to offer but it’s not standard. Her thought was that the Rorschach can be helpful as an additional tool among many but in and of itself can’t be used to identify psychosis risk or psychosis.

Dr. Sharp: Got you. Thanks for talking through that. It’s obviously a point of debate I think in the field that I don’t know a lot about, so these are very naive questions.

Dr. Michelle: Yeah, she did send me a paper and I can also post that to the show notes if you’d like, that looked at a group of individuals with psychosis and individuals identified as being at clinical high risk in a group that was not psychotic [00:56:00] or at clinical high risk on the Rorschach. If I’m remembering what she told me correctly, you could distinguish the non-psychotic folks from the folks with psychosis or clinical high risk, but you couldn’t distinguish the clinical high risk from the psychosis on the Rorschach.

One of the things she was just saying anecdotally is that some of the referrals we get, maybe if folks that were told they have psychosis based on just the quality of their responses on the Rorschach, not necessarily using the scoring system, but just anecdotally looking at that, her feeling was that, that really is not a good practice. She felt like that was not necessarily accurate or connected with what our more in-depth assessment would find in terms of a person’s risk for psychosis or meeting criteria for psychotic illness.

Dr. Sharp: That makes sense. I hear you. I did want to [00:57:00] ask you about the… you mentioned different diagnoses and things you might screen for. Autism certainly makes sense. The one I really wanted to ask about though is OCD, especially when you were talking about “powerful thoughts” that could be hallucinatory. Could you talk through that, like how you might separate OCD from maybe a prodromal?

Dr. Michelle: Definitely. And one thing I should add in terms of our standard assessment, we give them a lot of self-report batteries, a lot of self-report questionnaires as well that include screenings for depression, social anxiety, OCD, trauma, borderline personality disorder symptoms. I’m sure there’s others we do that I’m forgetting about, but we do a lot of self-reports related to that to try to get at whether or not we should do more in-depth assessment around that as well.

OCD is really interesting. OCD is an area where, [00:58:00] one, my training was all in working with individuals, adults, a lot of adults with psychosis and then adults with first episode of psychosis. And then when I moved into the CEDAR Clinic and working with folks at risk, there were a few areas that I feel like I really needed to learn a lot more about how to treat. One of them was OCD. There were tons of folks showing up with OCD symptoms that seemed to be overlapping with clinical high risk symptoms.

And in addition to that, there’s a lot of overlap because OCD requires that a person is insight. And so does clinical high risk require that a person is insight, can tell it’s real from what’s not real. So you got real overlap then. There are folks we have in the clinic that I do think have both, some of the differences, but I’ve also, part of my work in CEDAR, I’ve done a lot of [00:59:00] connecting with the OCD Institute that is at a nearby hospital in Boston as well to say, what do we do with this overlap? And it’s been very interesting because sometimes folks, depending on what lens someone’s coming from, you could call it OCD, you could call it clinical high risk.

Some of the biggest differences, like we definitely wouldn’t call really clear textbook OCD-like person comes in, they are worried, they are dirty all the time. They are washing their hands all the time. No matter how much they wash their hands, they never feel clean. They’re worried about germs constantly. I would not see that as….

That might happen if someone who’s also hearing voices that have started and they’re brand new in the past year. And then I would say, okay, it seems like that person is experiencing both. But where it gets trickier, we’ve had, let me think about some [01:00:00] examples. We’ve had folks, both in our first episode psychosis programs and in the clinical high risk program where some of the symptoms are more subtle, they’re around thoughts.

So we had, oh, I can think of a good example. There’s one person we saw who was so, okay, person that we’ve seen who is just really, has a lot of thoughts about being a good person and like a person and I said anything that bothered anyone, lots of checking about, did I bother somebody with what I said? Am I being a good person? That in and of itself to me sounds a lot like OCD. There’s a professional thought the person is doing rituals [01:01:00] to try to neutralize the worries about that bad thought. So this person developed things like touching his chin or asking did I offend you or writing a sentence. Those are all examples of really what seem like very clear cut rituals that fit into OCD.

But then on top of it, we’ve had folks, and to some extent I’m making up details again to protect confidentiality or combining people, but where on top of that, they felt like their thoughts were being influenced by an outside force. That didn’t feel like them and felt like was coming from some external being that maybe was God or spirit, maybe not. Felt outside. That’s where I’m starting to think like I don’t know. That feels a little bit outside of just OCD. Person had a lot of disorganization in their thoughts where they were just [01:02:00] literally stuck where their family would find them stuck for hours, immobilized.

Again, starting to think about like there’s some thought disorder that seems to be emerging on top of that. It seems like we’ve got a little bit of both in that case. Some of these folks, this is a really interest of mine because some of these folks are really hard to treat, especially when they’ve crossed over into psychosis because people who specialize in OCD don’t want to do exposure and response prevention with someone who might have psychosis because they’re, I don’t know if there’s actually any research on this, in fact, I’ve taken some steps to look at whether there is any research, I wasn’t able to find any but there is definitely a thought amongst clinicians that I’ve interacted with who treat OCD, that if someone might have psychosis, that it would be dangerous to do exposure and response [01:03:00] prevention.

I don’t know if anyone’s ever researched that. I haven’t actually found research or any clinical evidence, but it’s an interesting thing because exposure and response prevention, of course, is an evidence-based treatment for OCD. And so there are a variety of folks that I’ve seen who have really bad OCD and psychosis, but for some folks the psychosis gets better, but they’re disabled very much by OCD and they just go on with very disabling OCD because nobody wants to try exposure and response prevention.

Dr. Sharp: Oh gosh.

Dr. Michelle: That’s an interesting area that I’ve been interested in. I have this fantasy of getting funding to do a study that we would actually look at, can we do particularly like an a acceptance and commitment therapy based intervention for folks with co-occurring [01:04:00] psychosis and OCD.

Dr. Sharp: I got you. That would be really interesting.

Dr. Michelle: Yeah. But that’s an area I’ve wound up learning a lot more about, and we have a substantial number of folks in our clinic with co-occurring OCD. A substantial number of folks that have come in where we’ve said, I think this is really OCD and not clinical risk for psychosis as well. And so lots and lots of overlap.

Dr. Sharp: Got you. A tricky job.

Dr. Michelle: Yes.

Dr. Sharp: Well, before we totally wrap up, I know our time is getting close, as always. It has gone by fast. I hoped we might touch on treatment and recommendations. So what happens after the assessment? Let’s say you’ve identified someone as high risk clinical.

Dr. Michelle: What’s really neat is, and this is a really emerging field, people are very actively studying interventions for folks at risk for psychosis. And there is some promising research that [01:05:00] a variety of treatments can be helpful in reducing symptoms as well as potentially delaying or preventing psychotic symptoms from developing. So some of these treatments that have some research support include, there’s some support for CBT being helpful. There’s some support for family-focused treatment being helpful. So teaching families and plans together about symptoms, about strategies for coping with stress, practicing strategies for improving communication, improving problem-solving can be really helpful.

There are some studies that suggest that low doses of antipsychotic medications can be helpful, but those are not considered standard of care. So a variety of side effects that antipsychotic medications can bring. And so the field generally would not recommend using antipsychotic [01:06:00] medication unless other treatments are tried first and the symptoms seem to persist in a way that’s really continuing to cause trouble for the person.

Dr. Sharp: Oh, I see. And is that just for high-risk folks or those actually diagnosed with…

Dr. Michelle: That would be for clinical high-risk folks. For folks with a psychotic disorder where the symptoms seem real, they’re causing seriously disorganizing symptoms for the person, medications always the first line of treatment.

Dr. Sharp: Okay.

Dr. Michelle: The real opportunity in identifying people really early because they have this insight. So the folks who come into CEDAR Clinic who need our criteria, they’re worried about themselves. They know their mind is playing tricks on them, and they’re worried about themselves. So there’s a real opportunity to help them to develop strategies for better distinguishing what’s real from what’s not real, for helping them figure out what’s important to them, what their values are, and to do [01:07:00] things that matter to them and have the symptoms get in the way less for them.

That’s real kind of acceptance and commitment therapy language. That’s really the orientation that I tend to work from within the clinic. Real opportunity for just tweaks in services they get at school to make a big difference for folks. I had a kid I worked with a number of years ago who was really bothered by hallucinatory experiences. He would have to leave class because he knew they weren’t real. He met our criteria but they were just really distracting to him. By just monitoring his symptoms over a few weeks, we noticed that when his sleep was disrupted, it really made those symptoms worse. So a simple accommodation.

And he was often staying up really late to finish his homework and then he was getting even more behind in school because he was missing class. So a sleep accommodation around making sure [01:08:00] he slept at night and would get an extension of homework if he needed it, made a huge difference for the frequency of the hallucinatory experiences he had. And that was a school accommodation that was actually really easy to do.

So those are some things that can make a difference. Within our clinic, we do offer coordinated specialty team and there does seem to be certainly within the area of psychosis. People with schizophrenia coordinated specialty care where you have a variety of services being offered by a team that talks to each other is the standard of care. That really does seem to be the recommendation for treatment. And this hasn’t been as well studied yet in clinical high risk, but there is evidence suggesting this might be a good way to go in clinical high risk as well.

We have a team that works together. So if someone’s getting family therapy and individual therapy and psycho [01:09:00] farm, we’re all meeting together at least once a week to share information, make sure we’re on the same page, and coordinating services as well.

Dr. Sharp: Got you. That’s great. I’m just thinking geographically, refining resources seems hard. And I wonder how you go about that if you live in an area that maybe is not an urban area or has a lot of providers who are skilled. Are there other options or are there tips or tricks to find folks who could help this area

Dr. Michelle: We’ve been thinking a lot more about, I am also lucky to be part of, there SAMHSA has also invested in a number of mental health technology transfer centers, of which I forget how many there are around the country, but all regions of the country are represented and I’m part of the Northeast, no, not the [01:10:00] Northeast, the New England region, which is the seven, I think it’s seven states in New England. And part of our mission is thinking about how to provide access to quality training and care across the region.

So that’s an area that we’ve been actually thinking a lot about, some things that have been emerging. Because of that, there’s also an organization called PEPPNET, which I can put a link to. I forget exactly what it stands for, but there’s something with psychosis and technology and training that’s involved in that. Where there have been attempts to consolidate lists of centers that specialize in early psychosis treatment and assessment, there are a variety of training resources that have been made available. Lots and lots of webinars have [01:11:00] popped up recently.

Our center’s been involved in wo webinars. I did a webinar on ACT for early psychosis a few months ago, but there are lots of webinars that are coming out, so clinicians that are interested in learning more. It’s actually a good time. There’s a lot of resources that are available and pretty easily accessible for free like recordings of all these things are available.

Dr. Sharp: That’s great.

Dr. Michelle: An area that our center is really interested in learning more about but haven’t yet is telemedicine. And that seems like a real opportunity for being able to expand the access to services. Things like, we’re on a Zoom call right now. It’s such a wonderful technology. It’s like almost being in the same room. And I’m hoping in the next few months to years that we’re going to develop a better system for using these technologies to allow our services to be a lot more accessible to folks that might not, [01:12:00] even within the Boston area, we have folks who don’t have access to transportation that can help them to get here. Even if it’s 45 minutes away, let alone if they’re on the western part of the state and it’s two hours away.

Dr. Sharp: Yeah, it’s so true. Well, it’s great to hear that those efforts are moving forward. I think we’re just going in that direction as a field.

Well, let’s see. Gosh, we’ve covered a lot of ground and I really appreciate all this info you’ve shared with us. If folks are interested in learning more about the kind of work or contacting you, what’s the best way to do that?

Dr. Michelle: So definitely going to the CEDAR Clinic website, which is www.cedarclinic.org.There’s lots of information there and definite ways to reach me to reach the CEDAR Clinic with questions. [01:13:00] I can also post my email and information that people can contact me directly. Additionally upcoming new initiative we’re going to be offering in CEDAR that’s just not fully formulated yet, we don’t have it on our website just yet, will be some opportunities for remote training.

So if folks are interested in learning more about providing therapy for individuals at clinical high risk or treating early psychosis or family treatment of early psychosis, acceptance and commitment therapy, starting a clinical high risk per psychosis clinic, there are going to be opportunities for courses and consultation that we’ll make available through our website and folks who are interested, they can check us out for that information as well.

Dr. Sharp: That’s fantastic. Very cool. Well, Michelle, thank you so much [01:14:00] for chatting with me today. This is super informative. I’m sure people are learning a lot. I’m just grateful for your time. I appreciate it.

Dr. Michelle: I’m really happy to be part of this. This has been fun.

Dr. Sharp: Great. Well take care and do good work.

Dr. Michelle: Sounds good. Thank you.

Dr. Sharp: Thank y’all for checking on my interview with Dr. Michelle Friedman-Yakoobian all about early identification of psychosis. Learned a lot as always, I’m so fortunate to be able to do these interviews and speak with all these experts here in the field.

Like I said, at the beginning of the podcast, if you have any interest in group coaching experience, I would love for you to shoot me a message and let me know that. I am recruiting for my Advanced Practice Mastermind and Beginner Practice Mastermind. The next cohorts will be starting in late September. These are amazing groups. [01:15:00] Both groups are just wrapping up over the summer. Again, it was just a fantastic experience.

It’s group coaching. You get 5 or 6 other psychologists at your same level of practice, specifically around testing, and you get one-on-one time as well as vicarious learning from the rest of the group. And it could be super powerful. I had a lot of fun this time around. Next time, I think will be just as good. So if you go to thetestingpsychologist.com/consulting you can look for some options there for either the Beginner Practice or the Advanced Practice groups. Those links are also in the show notes along with all the resources that Michelle mentioned during our interview.

Thank you all for listening as always. Stay tuned, subscribe if you haven’t already, and I’ll talk to you next time. Thanks. Bye bye. 

Click here to listen instead!

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.