Image: Podcast cover for Modern Therapist’s Survival Guide Episode 475 titled “Teens in Crisis: Before You Refer to the Hospital.” The background shows a blurred ambulance with emergency lights in motion. Text near the bottom reads “A Continuing Education Podcourse!”
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Before You Refer to the Hospital: De-Escalation, Safety Planning, and Wraparound Care for Teens in Crisis

Every therapist who works with teens knows the moment: a client’s crisis escalates, the room shifts, and the question of whether to call for a hospital evaluation hangs in the air. The hospital can feel like the safest, most responsible option – and sometimes it is. But the research tells a more complicated story about what actually happens for adolescents who get sent there, and what gets lost in the handoff.

Curt Widhalm and Katie Vernoy examine the iatrogenic harms that can accompany adolescent psychiatric hospitalization, the narrow role hospitals actually play in treatment, and what outpatient therapists (including solo practitioners) can do to keep teens safely in their communities when the clinical picture allows.

This is a continuing education podcourse.

Transcript

Click here to scroll to the podcast transcript.

(Show notes provided in collaboration with Otter.ai and Claude AI.)

 

In This Podcast Episode: Rethinking Hospitalization for Adolescents in Crisis

Curt brings the research and the framework. Katie brings years of LPS-designated assessment experience from community mental health, including the lived knowledge of what actually happens when a teen is referred for inpatient evaluation. Together they make the case that hospital diversion is a clinical practice, not a moral position, and one that begins long before the moment of crisis.

The episode reframes the inpatient psychiatric unit as a narrow medical stabilization tool, not a treatment plan, and walks through the concrete clinical infrastructure outpatient therapists can build to support adolescents and their families through serious crises without defaulting to escalation.

In this episode, Curt and Katie discuss:

“The hospital isn’t necessarily a therapeutic treatment partner. It is a tool that is something that happens for a very acute period of time to create medical stabilization.”

— Curt Widhalm, LMFT

  • What iatrogenic harm is, and why it shows up so often in adolescent inpatient care
  • What actually happens during a crisis evaluation, from the initial pet team contact through intake
  • Why post-discharge is the highest-risk window for adolescents leaving psychiatric inpatient care
  • The difference between chronic background suicidality and acute suicidality, and why that distinction shapes intervention
  • How clinician anxiety can drive premature hospital referrals — the “clinical liability hot potato” problem
  • Standardized risk assessment tools (C-SSRS, LRAMP) and how they support rather than replace the therapeutic relationship
  • Why safety plans need to be built from intake forward, not invented in the middle of escalation
  • What belongs in a comprehensive adolescent safety plan, and what definitely does not (no-suicide contracts)
  • Huckshorn’s Six Core Strategies for Reducing Seclusion and Restraint Use, translated for outpatient settings
  • Verbal de-escalation and environmental modifications parents can use at home
  • How to construct a mini Intensive Outpatient Program inside a solo or small-group practice
  • Identifying and engaging informal supports: extended family, schools, coaches, faith communities, occupational therapists
  • How language matters when a teen says “I want to die,” and why building vocabulary for distress is itself an intervention
  • Systemic barriers and health disparities that compound risk for Black, Hispanic, and lower-SES adolescents
  • Releases of information, HIPAA-compliant communication, and minor consent issues across state lines

“You are behavioral health professionals … we are closer to the medical doctors than we are to the lay people when it comes to the knowledge that we have in interventions.”

— Curt Widhalm, LMFT

Why This Matters for Outpatient Therapists Working with Adolescents

From years of LPS-designated assessments in community mental health, Katie names a dynamic that doesn’t always make it into the clinical literature: hospitalization is rarely the clean clinical decision it gets framed as. The very act of bringing in an outside assessor can itself rupture the therapeutic relationship before any decision is made about whether the teen needs inpatient care.

“There’s relational harm with a therapist, because the conversation goes from you and I are talking to now I’m going to have this person come in and see if you need to go away … the therapist is saying, you’re too much for me, and so I need someone else to come in and do something different.”

— Katie Vernoy, LMFT

Sometimes the reflex to escalate reflects clinician anxiety as much as client need. Katie notes from her experience that some clinicians refer to inpatient care because they feel out of their depth or want their client to be somewhere safe, not because hospitalization is the most clinically indicated response. When that happens, the cost is borne by the adolescent: relational rupture, dehumanizing intake processes, potential seclusion or restraint, distance from home and community, and a return to the same environment that contributed to the crisis — often with worse trust in mental health care than they had before.

This episode argues that outpatient therapists, including solo practitioners, have significantly more clinical range than the default-to-hospital reflex suggests. Doing this work well calls for:

  • Treating the inpatient unit as a narrow stabilization tool with a defined scope
  • Integrating standardized risk assessment from the beginning of treatment
  • Building collaborative safety plans with adolescents and parents before crisis hits
  • Engaging the family ecosystem as the environment in which the adolescent lives, not just treating the identified patient
  • Constructing wraparound teams of formal professionals and informal natural supports
  • Recognizing how access, identity, and structural barriers shape outcomes for marginalized adolescents

Continuing Education Information

Hey modern therapists, we’re so excited to offer the opportunity for 1 unit of continuing education for this podcast episode – Therapy Reimagined is bringing you the Modern Therapist Learning Community!

Once you’ve listened to this episode, to get CE credit you just need to:

Once completed, your CE certificate will appear in your profile and can be downloaded for your records.

Continuing Education Approvals

When we are airing this podcast episode, we have the following CE approval:

Therapy Reimagined is approved by the California Association of Marriage and Family Therapists to sponsor continuing education for LMFTs, LPCCs, LCSWs, and LEPs (CAMFT CEPA provider #132270). Therapy Reimagined maintains responsibility for this program and its content. Courses meet the qualifications for continuing education credit as required by the California Board of Behavioral Sciences. Please check with your licensing board to confirm eligibility.

Please check back as we add other approval bodies: Continuing Education Information including grievance and refund policies.

References Mentioned in This Continuing Education Podcast

 

Relevant Episodes of MTSG Podcast

Meet the Hosts: Curt Widhalm & Katie Vernoy

Picture of Curt Widhalm, LMFT, co-host of the Modern Therapist's Survival Guide podcast; a nice young man with a glorious beard.Curt Widhalm, LMFT

Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com

Picture of Katie Vernoy, LMFT, co-host of the Modern Therapist's Survival Guide podcastKatie Vernoy, LMFT

Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com

A Quick Note:

Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.

Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.

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Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):

Transcripts do not include advertisements just a reference to the advertising break (as such timing does not account for advertisements)

… 0:00
(Opening Advertisement)

Announcer 0:00
You’re listening to the Modern Therapist’s Survival Guide, where therapists live, breathe and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm and Katie Vernoy.

Curt Widhalm 0:15
Hey, modern therapists, we’re so excited to offer the opportunity for one unit of continuing education for this podcast episode. Once you’ve listened to this episode, to get CE credit, you just need to go to moderntherapistcommunity.com register for your free profile, purchase this course, pass the post test and complete the evaluation. Once that’s all completed, you’ll get a CE certificate in your profile, or you can download it for your records. For a curt list of our CE approvals, check out moderntherapistcommunity.com.

Katie Vernoy 0:48
Once again. Hop over to modern therapistcommunity.com for one CE, once you’ve listened.

Curt Widhalm 0:54
Welcome back, modern therapists. This is the Modern Therapist’s Survival Guide. I’m Curt Widhalm with Katie Vernoy, and today we have a CE episode with at least at the time of recording, we occasionally use artificial intelligence Gemini and ChatGPT to help us come up with creative names for our episodes, at least at the time of recording, today’s episode title is so incredibly long and clinical, I’m pretty sure it requires its own CPT code, because…

Katie Vernoy 1:28
What is this? What is this title?

Curt Widhalm 1:30
According to Gemini, today, we are doing a comprehensive analysis of outpatient interventions, wraparound strategies and de-escalation protocols to prevent adolescent psychiatric hospitalizations.

Katie Vernoy 1:45
Yeah, that’s not going to be the title.

Curt Widhalm 1:47
No, it’s not. So this is a continuing education episode, whatever the title may be. And check out our show notes over at mtsgpodcast.com and listen to the intro and outro of the episode to learn how you can get your continuing education through us and behind all of that beautiful peer reviewed jargon is a reality that every therapist who works with teens knows intimately, that heart dropping, stomach turning moment when a client’s crisis escalates and you find yourself staring down the barrel of a hospital evaluation. Now, let’s be real. Nobody wants to send their clients to an inpatient psych unit if it can be safely avoided. It’s disruptive. It’s terrifying for the family. Honestly, the sheer volume of paperwork involved is enough to induce a mild panic attack for even the most seasoned clinicians. We want to keep our kids in the communities. We want to keep them at home, we want to keep them in school and out of the psych ward. So today, we are translating a lot of heavy academic speak into practical skills for you, our modern therapist community, and we’re going to actually talk about what works when the stakes are high. We’ll explore how to build outpatient safety nets that hold weight, how to create wraparound strategies that actually wrap around rather than just entangling everyone in an endless thread of unread emails and how to deploy de escalation protocols that work better than just telling an explosive teenager take breath. So if long term listeners of our podcast know that Katie and I tend to take turns on leading some of the CE episodes, I’m going to be doing a lot of talking today, but Katie has also had some background in working in community mental health, particularly around these populations. So I have a lot of the academic references sitting in front of me. Katie has a lot of stories from her background. So Katie, can you just kind of frame a little bit of your experience where you’re coming from on this episode.

Katie Vernoy 4:04
Working in community mental health, I had a variety of different opportunities to work with teens. I worked with teen boys on probation, and then I also worked with intensive services programs, and throughout my time, maybe for 10 years, I was what’s called in California, LPS designated, which means that I was certified to be able to do initial hospitalization assessments. And so I would either within my own sessions or within other clinician sessions in the clinic or in family homes when we were doing more of the intensive service, home based services, I would go out and do the assessments to determine if the client needed to be taken to the hospital. So I’ll talk more about that experience as we go, but I’ve done a lot of these assessments, and I’ve also spent a lot of time with clinicians who are working with, with teens who at the very least had some suicidal ideation, if not suicide attempts, and big feelings. So.

Curt Widhalm 5:17
My practice, where I come from on this, is Real Honest Therapy. We’re based in Los Angeles, and we do comprehensive DBT with teens and their families. So we work a lot with clients who are needing help with emotional regulation type skills. So a lot of what many other clinicians consider high risk clients, and working in a practice like this really makes me take pause sometimes when I hear what other clinicians do. And so this is coming from a place to try and have everybody working towards the situations that end up helping teens based in research, based in what actually works and helping to at least spark for those clinicians who work, particularly in private practice. This is really where this episode is intended towards, that the experience that comes from Community Mental Health type agencies like Katie talks about has a lot of these kinds of protocols in place. This is to get the rest of us working in those private practice settings or agency settings, to kind of conceptualize what de-escalation protocols might look like. So we are also covering things that we’ve covered in bits and pieces in a lot of previous episodes, we’ll reference those in our show notes once again over at mtsgpodcast.com so you can listen in kind of varying branches off of this tree, more in depth on some of the things that we’re talking about today. The landscape of adolescent mental health is a lot of looking at severity and frequency of psychiatric emergencies. For those of us who work in private practice type settings, admittedly, people want clients who are the worried well, the ones who kind of need some help in adjusting to maybe some of the decode kinds of aspects of life, but a lot of research tends to look at the higher frequency, higher severity levels of psychiatric emergencies, and if we’re not prepared for those in a private practice setting, then we’re at risk of creating iatrogenic harm. And for those who do continuing education, you’re going to take a quiz afterwards. That might be a term that you see a little bit later in a quiz. I know the guy who writes the quiz. So iatrogenic harm refers to any injury, illness, psychological distress caused by medical treatment errors, negligence, rather than the natural progression of a client’s illness or a client’s presentation. It’s used in both the medical community as well as in behavioral health. So this is the harm caused by interventions. And is something that you should be aware about, because sometimes the ways that we escalate clients into the hospitalization system creates more harm and trauma in and of itself, and it becomes very destabilizing, and it comes at a particular risk within our field that I have been talking for the last several years, that our field is doing a lot better job about talking about things such as suicidality. It’s permeated a lot more conversations. It’s part of a lot more of the assessments that we’re doing when clients were coming in. Anecdotally, though, we’re doing a fairly poor job of follow through when it comes to walking the walk after talking the talk. While some of us are getting quite a bit better at asking about suicidality, it still brings up a clinician anxiety and responsibility that often gets kind of directed into this clinical liability hot potato where if clients have some kind of suicidality that they’ve expressed, if that feels difficult for a clinician, a lot of times, they will just escalate those clients to higher levels of care, including hospitals. And the point of this episode is seeing which clients actually need that versus those that need support in kind of living their day to day lives with kind of more chronic background suicidality, rather than the acute suicidality that is an intentional attempt to end their life in next several hours or days. So a lot of the research that I looked at here has been published since 2021. We’re also going to reference some of the episodes that looks at stuff in the background, but we are trying to intercept these crises before they culminate in the hospital admission. But I want to start this episode really kind of talking about that iatrogenic harm of hospitalization in and of itself, because there are a number of things that can go wrong, and I will talk about those, but not just to have me blather on and on about the background of this episode. Katie, you do have this LPS designation, so I’d like you to maybe start by talking about what actually happens from the clinical end that beyond, you know, for new clinicians who don’t have experience of this, when, when we call the PET team, or we send somebody to the hospital, they just, they go out the door, and then there’s a hospital, there’s a lot of steps that happen in between. So I’m hoping you can shed some light on that.

Katie Vernoy 11:23
Sure. I’m sure it looks different in different settings, and it’s been probably 10 years since I’ve been LPS designated. So there may be some things that are newer. But from my understanding of how this all works, the first step, if it’s a PET team or some sort of emergency team that comes to a home or a school or wherever the kid is expressing suicidality, that initial contact is one with someone they don’t know, most likely. I was able to do some of this with my own clients, or clients of my supervisees was when I was on community mental health, and so there was some familiarity, but most likely, you don’t have your best buddy that the client knows, on this PET team or on this emergency, you know, the crisis response team. And so there’s this new person that comes in, and potentially there’s, there’s relational harm with a therapist, because the the conversation goes from you and I are talking to now I’m going to have this person come in and see if you need to go away. And so I found for myself as an assessor, I would, I would create a relationship, I try to work through it, and oftentimes especially with clients who are not mine. And these were some of the clinicians, I think, who were hearing this and were feeling stuck. And so they said, Hey, Katie, come on in and help us try to sort this out, creating that relationship, creating safety planning, trying to determine, does this kid want or feel like they need to go to the hospital, or are they just feeling really out of control? And so there were times, most times like I was just getting ready to say that I didn’t say they’re ready to go the hospital. It was more I came in Pinchiter, let’s get a better safety plan. And so in my mind, there was a rupture there, because the therapist is saying, You’re too much for me, and so I need someone else to come in and do something different. So that’s the initial thing. And there’s also been times when I have said, Sure, go to the hospital. And this is, you know, whether it’s an ambulance, whether it’s, you know, law enforcement, like, there’s a lot of there’s systems that get involved. And we’ve talked in other episodes about how those systems might interact with folks in marginalized bodies, how they might interact with teens in certain areas of the the town that you live in or that you work in. And so there’s there’s danger that can come there, especially if you’re if the the teen that you’re working with doesn’t want to go to the hospital, but it’s clear they need to go to the hospital. Things can escalate, especially when you’ve got an adult-sized teen, and you’ve got emergency workers that may or may not be comfortable with the person that they’re having to take to the hospital. And then you’ve got the hospitalization itself, where you get to the hospital or the client, and potentially a family member gets to the hospital and another assessment happens, and so that at that point, the kid could just go home too, and they’ve been put into this system where they’re having to talk over and over again about suicidality. They’re having to try to express their self to someone they do not know. They may have been manhandled to a certain extent. They may be overwhelmed, lots of sensory information, those types of things. And then they get to a hospital and they’re told, okay, Go home. You’re fine. And you’re stuck as the therapist saying, Well, I thought they needed more structure, I thought they needed more supervision. I thought they needed this higher level of care. So I risked my relationship, and now they’re back home. So, so that’s the initial stab, and then if they do indeed go to the hospital, there’s, in my mind, I think of it as like a dehumanization. Now they, you know, we’re looking at risk. So take your shoelaces out. We’re going to check you for everything. Maybe we’re going to have you change your clothes into something that that is more able to be kept safe. Maybe you get put into seclusion or restraints. Maybe there’s, there’s different things that might happen once you get there. And I know this is, you know, this is something else that you want to talk to, talk to in more depth, but successfully getting to the hospital is a challenge and a very long period of time and a lot of very determined, potentially intense adults talking to you as a client. And then once you get there, the environment may not be great and may not even be that helpful. I mean, we’ve talked about this before, and we have another episode on suicidality in teens, and so I’ll definitely make sure we link to that in the show notes over at mtsgpodcast.com, but the process is not easy, and so it’s not a decision to be made lightly.

… 16:20
(Advertisement Break)

Curt Widhalm 16:22
And one of the things that you said before recording is the hospital isn’t necessarily a therapeutic treatment partner. It is a tool that is something that happens for a very acute period of time to create medical stabilization.

Katie Vernoy 16:42
Yes.

Curt Widhalm 16:43
Really thankful for you having put it into those words. Because for people who get their experience outside of the CMH, DMH system, that there’s a lot of times where it’s just kind of taught to refer to the hospital rather than they will provide all kinds of treatments, and they will have some sort of magical in the hospital box that will spit out this report of here’s all of the interventions that this client needs. When instead, my experience is a lot of times the discharge paperwork ends up stating, and I’m literally saying that this is what paperwork has come back to me as “released back to therapist who was being previously seen.” So there’s not some kind of magic box that happens in the hospital where there’s some new magic set of eyes that comes out and fixes everything.

Katie Vernoy 17:36
Well, and I think the other piece to that is depending on the client’s insurance, depending on the hospital, if they’re short staffed, it’s kind of holding them in a secure place until they stop being actively suicidal. Maybe there’s some some opportunities to change meds for folks that are not getting success with the current meds they’re on. And so it’s a place to make that change, and sometimes hospitals will do that. Some places have some decent treatment groups and things that help with all of this stuff. But my experience with a lot of hospitals have been it’s a holding place or a respite, and especially for kids in community mental health, sometimes it’s a respite from their community. And so I go off to this place, and it’s not perfect, and I don’t like it that much, but at least I get a break from my caregivers. I get a break from, you know, my enemies, or my or even my frenemies, you know. So I think there’s that, that element of I see it as a very specific use and certainly not a panacea for medical treatment or mental health treatment.

Curt Widhalm 18:46
So I want to give a little bit more background on the hospital stuff so we can get to talking about what we can do in more of our outpatient settings. You were talking about the kinds of kids and the potential traumas that can happen as part of the process of coming in. And there is a 2022, article from Stewart, Semovski, and Lapshina called “Adolescent Inpatient Mental Health Admissions: An Exploration of Interpersonal Polyvictimization, Family Dysfunction, Self-Harm and Suicidal Behaviours.” And it talks about the high ACE scores that kids who are coming to the hospitalization already have. So we have a particularly high vulnerability to re-traumatization through this process, and it often comes to a rigid, often punitive structure of an acute care environment. There are some studies that they cite, that indicate that between six and a half percent and 29% of inpatients in child and adolescent psychiatric units experience seclusion or restraint during their stay. And we can go on a whole side rabbit hole of how controversial those are is actually. effective therapeutic treatments. But this can create even more emotional damage, even more physical injuries, diminished self efficacy and deeply entrenched lifelong distrust of the mental health system. So the impacts of all of this are incredibly high. And it comes with also that the paradoxical literature that says that the then highest risk for future attempts is in the handoff coming out of the hospitals, and that’s why we’re talking about this is kind of from the backward steps first is because there’s a lot of times where clinicians will get a call from a social worker at a hospital and say, We need to have this client who to have a session within X number of hours of discharge. And then it’s kind of with, Okay, here’s your client. They’ve also got a psychiatrist someplace and go do therapy. This is where we need to really look at where the problems that come out of these kinds of handoffs end up being some of the highest risks. And these risks in some studies, such as an editorial by Nordentoft, Caine, and Webb. This is in 2021 called “Mortality risk and related adverse outcomes following discharge from inpatient psychiatric care.” Talk about the dramatically increased what they call hazard ratio, so the risk of completed suicide across all diagnostic categories upon discharge, and they highlight that adolescents diagnosed with schizophrenia have an 8.9% chance of completing a suicide within six months after being hospitalized. So there is this risk of further traumatization that ends up happening, and particularly when it does show up with certain diagnostic categories. So we have these iatrogenic harms that can happen through this process. It can be about you referring clients in. It can be about the people on the other end. And this doesn’t even start to look at the myriad of other covariates, such as baseline depression, engage in services, family situations. So now we’re talking about a loss of autonomy as a piece of this too, and all of the trauma and coercion. So all of that background being said is one of the places that I do have my qualms about a lot of the ways that our mental health care system works, a lot of the discussions I have with families that we serve in our practice is referring clients to the hospital too early, and that’s the big point that I want to be able to convey in looking at where the level of symptoms are and being able to be responsible with that. So when you have clients who are presenting with moderate symptoms, difficulties in school, work, social life, most of us are going to be thinking about that as, okay, this is working with adolescence. This is, you know, our day to day kind of work. But when those symptoms start to increase in distress, we’re starting to see some of the red flags. They’re not even quite red yet. They’re pink flags. They’re maybe flags that we’re looking at with rose colored glasses. So all the flags just look like red. But this might be where we start to see some despondent thinking. I wish I didn’t have to deal with things. You might start to see some non suicidal self harm. Reference some of our episodes on non suicidal self injury. But this is where I see clinicians getting uncomfortable and then referring to the hospital, rather than increasing the level of intervention in an outpatient type setting that can end up really just exacerbating a lot of what we’ve talked about already.

Katie Vernoy 24:20
It’s interesting, because when you spoke at the beginning of the episode saying that a lot of clinicians don’t want their clients to go to the hospital, my first response was, Are you sure about that? Because this specific dynamic around feeling uncomfortable, feeling out of your depth, I think is fairly common. I think in in other settings, especially my experience with community mental health, there were times when clinicians just wanted clients to be somewhere safe and not have to worry about them, and so they didn’t necessarily, weren’t as necessarily, as discerning in that referral. They use the opportunity to say, hey, I need this person to get more care, so I’m going to try to send them to the hospital right now. And it’s hard because working with kids and teens, even, you know, in my practice with adults who have really big, deep pain, and potentially not the language to discuss that pain. And the only thing that comes out is whether it’s self harm statements or I wish I was dead. I wish I wasn’t living. Those types of things, if you can’t sit with the pain or the discomfort, or frankly, the liability of not knowing what this client in front of you is going to do, hospitalization can seem like a nice way to take care of it, especially if you think it might be helpful. Too often you were talking about iatrogenic harm. Sometimes it’s just a holding space. It’s not even necessarily actively harmful. It’s just time away. And maybe that helps to de escalate things. Maybe it puts things in a different perspective. But I do really worry about the harm that can happen in the escalation of symptoms, where someone comes back out and is potentially just better at masking the deep pain because they don’t think anyone’s going to actually understand it or be able to sit with them, they’re too much.

Curt Widhalm 26:27
Also just in that emotional dysregulation that ends up happening is we are sending our patients into a hospital environment. You had illustrated the LPS system, but for a lot of families where the parents are concerned, they’re taking their kids to the emergency rooms, and some of that process ends up not happening in their community, but it ends up where they’re going into an environment that is incredibly stressful, and they’re witnessing potentially other patients who are going through their own medical or psychiatric episodes at that time, and that, in and of itself, can lead to higher levels of dysregulation. Now for a lot of children and adolescents, not every hospital is going to have the available facilities to be able to work with child and adolescent patients, and so they might be going to hospitals that are only able to service adults, and even those facilities that do have child and adolescent psychiatric beds, also called capped beds, in a lot of the research, children are more likely to be admitted to hospitals that are far away from home than they are to hospitals that are nearby. And there’s an article in the BMJ, the British Medical Journal, from 2023 by Holland et al. So this is looking at the British medical system rather than the American medical system, but they found that kids who are sent to at distance admissions, so far from their home communities due to local bed shortages, often have stays that are 15 days longer than the average stays of inpatient cap admissions when they’re in their home communities. So now they’re being further isolated away from their home. They’re coming back with further shame in re entering back into their school system, because now they have a reputation of having a psychiatric episode. So these are risk factors that we want to be able to consider when it comes to the myriad of issues that are coming up with these patients as they’re coming out of the hospital. So there’s a lot of logistical nightmares. There’s a lot of risks that outpatient therapists, private practitioners need to be equipped to think about and to be able to have de escalation protocols to manage, even when it comes with clients who are seemingly having recently been stabilized, because during these handoffs is when there is the most risk. The second half of this episode here is really now taking, how do we take these frameworks that do largely exist in a lot of community mental health systems that are more team oriented, are more geared towards having these kinds of assessments already in place, and translating that to some of the attitudes that we have in private practice, so that way, we can make the recidivism back into the hospital, hopefully as avoidable as possible. Now this is going into every kind of attitude, with the possibility that a safety plan is probably going to be needed to be in place, even if they’ve already recently had one done in the hospital, you don’t want to risk having something fall through the cracks whenever there’s handoffs from one provider to another. This is illustrated a lot in the medical community. It’s also illustrated a lot in behavioral health. This is when the risks really arise, and you can’t just assume that everything has been done in ways that make sense to you and your practice. I also really want to give a shout out at this point to Katie Keets May, who is another DBT practitioner. I follow her on social media. I’ve met her a couple of times. She’s presented at therapy reimagined conference before, but…

Katie Vernoy 30:41
And she was on the podcast.

Curt Widhalm 30:42
She’s on the podcast, yeah. So she had a reel recently that was talking about, for a lot of clinicians who are really relational in their work, which, admittedly, I am very much relational a lot of our work, that that oftentimes, when it doesn’t become the intervention that prevents clients from escalating. That if you’re waiting for times when clients are then agitated already, and now you’re having to create a safety plan when they’re agitated, and you’re shifting how you work with them at the same time that that ends up being a recipe for disaster. And so her recommendation, my recommendation, is, come in with plans and come in with a lot of evidence based assessment tools in order to be able to have comprehensive plans so you’re able to recognize patterns of intent, ideation that will be able to provide a clear lexicon if you end up needing to hand off clients to somebody else. So we’re talking about Columbia Suicide Severity Rating Scale, LRAMP, for interventions that can focus around suicidality to do from the very beginning of treatment, rather than just waiting for crisis.

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Katie Vernoy 32:05
You’ve highlighted the difference between community mental health and private practice, and I think this is one where being able to learn from Community Mental Health might be helpful. And I think this is what you’ve done in your practice. So I think I’m just saying what you’ve already put in place, but having what community mental health clinicians think is way too much paperwork at the beginning, that does have some of these types of assessments, having a structure around safety planning from the first session and normalizing conversation around risk and safety, whether it’s harm to self, harm to others, those types of things, or even abuse, neglect, that kind of stuff, depending on where you’re where you’re located, and what type of treatment you’re doing and what population you’re serving, I think there’s something to be said about having that systematized, and there are also limitations for some of the systemization that you’re talking about. And I just want to mention one thing, when safety plan has been put into effect, it seems that the the teen is not able to comply, work within the safety plan. Hospitalization happens, and then they come back out. The biggest challenge is, theoretically, insurance coverage during the hospitalization, because you, as a clinician, depending on how you operate, can’t necessarily keep in touch with them for the time that they’re in the hospital, and so sometimes the hospitals don’t want it, but that may be more so that they don’t have that double billing, double dipping, that then nobody gets paid. And sometimes it’s for other reasons, not wanting to have confusing, different messages, but you’re also having to re engage with the client after three days, five days, 11 days, 15 days, whatever it is. And so being able to have that language around safety as well as the relationship around safety. That needs to be built into the relationship. Then, then you can come back there in that same space, but if you re-engage with a client in a totally different role, when they return from the hospital, I think it’s hard to get them re-engaged.

Curt Widhalm 34:32
For what I want to cover in the rest of this episode, I’m not I’m gonna acknowledge you and move on. I think we can go into that quite a bit. So we’re wanting to talk about some of the things that can be in some of the safety plans. And I’ve seen safety plans that range from do more good to very comprehenisve safety plan, literally, they just say, do more good things, accumulate positives. So, they don’t necessarily identify stressful points and ways to avoid. But some of the comprehensive treatment teams that we’re going to want are going to include psychiatric team members that may or may not be able to communicate with you regularly, and I’m really talking about this episode, as far as from the idea of the solo practitioner, there are practices like mine that have multiple clinicians in them that have some of these things already in place. But even for group practices that aren’t necessarily thinking about this that some of the safety plan stuff that we should include is, particularly for children and adolescents, is incorporating parents into the safety plan and talking to them about how to talk with their kids when things seem to be escalating; so verbal de escalation procedures, Hey, let’s turn the lights down. Let’s talk more in down regulated version, using neutral tones, using simple concrete language, deliberately avoiding confrontational or authoritarian stances that can help to reduce the need for escalation, and in particular, if they are families that, through their own means, engage in physical restraints with their own children, not necessarily starting at that as an intervention, but trying to use verbal de-escalation techniques earlier. For some of the client sorts of things, is setting up environmental modifications, even upon discharge from the hospital, that having quiet rooms designated, designated in houses, If there’s a space to be able to say this is the kind of quiet room to go to, and having a calm place for kids to go and to be able to work through their feelings, particularly for those with neurodevelopmental disorders such as autism spectrum disorder, profound sensory sensitivities, getting a physical space where they can avoid triggering stimuli. I’d also like to cite Huckshorn’s “Six core strategies for reducing seclusion and restraint use.” Now this is an article from 2005 but it does highlight some ways that working with these kinds of kids helps to systematically reduce our reliance on higher levels of care. And part of what we’re really hoping to lean into with a conversation like this is working on our own attitudes towards organizational change of how we intervene with higher risk kids. In multi clinician practices this starts with leadership. In solo practices, this is even looking at our attitudes towards if I need to build a team in the next 12 hours, who am I going to call to have, I’m going to work with this kid who’s going to work with the parents, because both of those are levels of intervention that are needing to be in place in order to work on changing the home environment, changing parents’ attitudes towards us. We’re not just treating the kids, because I’m going to cite approximately a million kids who’ve been through my practice before, who state I’m the one doing all of the work. It’s my parents who need therapy. That that becomes part of your treatment response. I’m already in the middle of this, but again, if you’re taking a CE quiz at the end of the episode, these six items might show up. So second on Huckshorn’s list is data informed practices. I know that there’s a lot of our audience that bristles from time to time at evidence based practices, but this might be a time where you use what works in the research, because it works. Having some of those standardized assessments in place, having some of those tools readily available so you’re not just relying on your relational aspects. The third is for group practices, and however this makes sense in your solo practices, is having workforce development and Huckshorn’s suggestion around the article is literally about don’t use restraints when you don’t need to, but rigorous training and de escalation. Fourth is use of specific tools to assess risk factors for aggression. In other words, use evidence based practices to identify what are the likely triggers that are going to create more aggressive stances. Fifth, elevating client roles in making choices regarding their care. Now, this article is 20 years old now, but this is still very foundational. And this might seem like incredibly common knowledge now, but a lot of times, what seems to work with clients is asking them, hey, what do you think would work in this situation? And then helping them to make that part of the plan, and particularly for kids and adolescents, a lot of times, they know exactly what they need, not always, but they know exactly what they would need. I need my parents to stop following me around the house. That’s why I throw things at them, is to get them away from me. And then I end up in the hospital because they’re not following their job. And then six is post incident debriefing. So when there is some of these escalations to a higher level of care or to a response within the safety plan, is to then review with the client, once things have calmed down, what happened and why and how it was part of the safety plan that they were involved in making.

Katie Vernoy 41:05
I like those. I think there’s some additional stuff I might add, if that’s okay?

Curt Widhalm 41:09
Yes.

Katie Vernoy 41:10
Looking at the ways in which suicidality or big feeling self harm is addressed in society, as well as how it’s addressed within a clinical space or within the family, I think it’s especially important. And maybe this is part of the debriefing, maybe this is part of planning. But if every time after a hospitalization, the client describes that level of despair or that level of agitation, safety plan goes b-b-b-b-b-b, and all of a sudden they’re either safety planned up, whatever that looks like, or back in the hospital. I think that can be very problematic, and so I started talking about this earlier, but I think maybe a couple minutes on this might be helpful; really trying to understand the motivation behind what is happening that’s causing those types of feelings, understanding the feelings themselves, and maybe getting more comfortable in talking about suicidality, whether it’s the clinician or the parents, to be able to say, it sounds like there’s some really big feelings going on, or this really sucks, or this is overwhelming, and speaking to the dynamic versus: Oh no, risk! Oh no, risk! Because I think if the client doesn’t have language to describe the depth and overwhelming nature of their feelings, ‘I want to die’ is a close substitute. And so taking that at face value initially, I think, is where harm can start. And so being able to sit with that and really dig in and help develop a language so the client can describe my feelings are really big, and I’m overwhelmed, and I want to express how deep these feelings are, but I don’t actually want to die right in this moment versus I can’t handle it anymore, and I do want to die, and this is I need help to not die right now. So to me, that element of stuff that is very clinical, but it’s also really distress tolerance for the clinician and for the parents is hugely important.

Curt Widhalm 43:40
When I’m talking with clinicians, and this typically ends up being earlier career clinicians, whether they be associates, even within my practice, or it ends up being people who are freshly licensed, looking consulting with me, I have to remind them that you are behavioral health professionals, and there’s a lot of things that we end up deferring to people with more advanced degrees than us, just by the structure of where we feel like our MFT or CSW or PCC licenses, or any of the myriad of other alphabet licenses out there that you have listeners, I see you too, that we are closer to the medical doctors than we are to the lay people when it comes to the knowledge that we have in interventions, and some of that is empowering. Some of the knowledge that we have from our studies and our research and our experience and our consultations continue to get consultations on stuff, because when we put stuff like this into work, we see tremendous amount of successes. For example, programs that use the six core strategies that we had mentioned earlier show monumental progress. There was a four year study involving a Connecticut Valley Hospital that demonstrated an 89% decrease in annual restraint hours and a 24% reduction in workers compensation medical costs by just changing their attitudes and their protocols when it comes to how they intervene. Again, this is stuff that in 2026 might seem like this is good practices, because this was not good practices 25 years ago, and putting these things in place helped change how we do that. And that’s the intention of conversations like this is continue to change our attitudes and how we work with this part of the system, so safety plans: don’t have no harm contracts. We’ve talked about that in other episodes, just other things that might appear on your quiz. They should include personalized warning signs, physiological triggers, independent coping skills, that they can use, healthy activities for distractions, responsible social supports that can be contacted during an urge, and letting those responsible people know, hey, I might reach out to you for one of these moments where I really need somebody to talk to, because if they’re just listing people and those people aren’t prepared, that’s another recipe for disaster, outlining explicit steps to access professional help or emergency medical services, and rigid, verifiable plans for lethal means restrictions, so securing firearms, medications, sharp objects, et cetera. I want to also talk about really more in depth, engaging the family ecosystem as part of this in hospital diversions. So both in coming out of the hospitals, but also when we see the warning signs before a first hospitalization ever happens, adolescents don’t exist in a vacuum. They tend to have families that they’re anchored to, and as I’ve mentioned a couple of times before, they might be a reflection of the broader family ecosystem. And so doing individual therapy alone is clinically short sighted, and that’s where you need to look at how your attitudes towards the family change needs to be a part of keeping the kids out of the hospital as well.

Katie Vernoy 47:27
I wanted to comment on that because you had mentioned earlier about having a whole treatment team and being able to identify folks you’re going to call up in the next 12 hours to be able to do some of this work, and that may be necessary, and most likely is but the 12 hour timeline, I think, is something that you know, I know dramatic effect.

Curt Widhalm 47:50
It was a dramatic effect.

Katie Vernoy 47:53
But to comment on what I would do in private practice, in that space, in my solo private practice, is start with me being that clinician, and then potentially reaching out and getting more folks involved as the need becomes more apparent. So it’s not something where you have to have someone on standby to do parent work. You can start with family work, and potentially you’re doing multiple sessions a week on your own, which is why being in solo practice can be a harder, a harder challenge for this, because you don’t have other clinicians, you don’t have folks to offload other thing, you know, other responsibilities to and so It becomes a big lift, but I’ve found doing family therapy, doing one on one therapy, having coaching calls those types of things, while not sustainable for me, is something that I would do if the need arose within solo practice before I was able to pull together a team.

Curt Widhalm 48:56
And really what we’re trying to describe here is creating almost kind of a mini intensive outpatient program. That without having kind of the institutional overhead of an IOP, this is something where it’s kind of conceptualizing, how would you be able to accomplish, once again, things that are going to show up on a quiz, but the things that you’re going to want to look at fall into family centered psycho education and medication management. Now this might not be stuff that you directly provide within your practice, your group practice. This might be with the role of a psychiatrist, but providing the family with a comprehensive, accessible information about the child’s diagnosis or the adolescent’s diagnosis, the rationale behind medications, if they’re there and if it falls within your scope of practice, you can say these are antidepressant medications. I’m not a doctor. Talk with your doctor more about them, but these are traditional side effects that you might see. This is a traditional amount of time. For more comprehensive information about this, talk with the doctor. But really trying to demystify the illness. We have a somewhat recent episode this month about when families don’t accept the diagnosis. But this is also part of continuing on with the conversation, as far as this is how a diagnosis presents and shows up, so that way the family can start to understand and hopefully have better empathy for it, have better reactions, be able to understand why they’re making some of the changes that they need. Second is individualized case management and peer support. So this is not just you being the only support for the parents, but also referring to support groups, other caregivers navigating similar crises, that lived experience piece is huge for not just the kids, but also the family members, and having those peer led interventions does show significant evidence in improving Family Centered skills. It gives problem solving. If we hold ourselves accountable, we don’t know everything, and sometimes families are going to learn some of the tricks of the trade from other families there. And it also reduces caregiver isolation and can help to reduce stigma.

Katie Vernoy 51:32
And places like NAMI are good places to go the National Association of the Mentally ill.

Curt Widhalm 51:39
Third is measurement based care. And this is actually kind of tracking, whether it be individual or continuous family assessments, and conducting regular feedback sessions to adjust your treatment dynamically. So a lot of places use measurements such as the PHQ-9 and the GAD-7 to be able to kind of monitor depression and anxiety symptoms, but making sure that you’re getting regular feedback, so that way you know where to lean into needing to get measurable improvements. Fourth, referring to multifamily skills groups, frameworks like DBT, where multiple families can also learn some of the skills themselves. This addresses some of the kids concerns about parents, but also helps to increase a lot of all of the wonderful things that DBT does, and it helps to foster a community of shared healing and accountability, because kids see their parents being held accountable. Parents are also learning a lot of the skills that are out there. And fifth on this list is relational conflict resolution; and so family therapy. And there’s a lot of models out there, but being able to help resolve some of the parent-child relational traumas improve family cohesion and and facilitate healthier coping strategies. If you’re finding yourself in this position, you’re probably the one who’s the architect of the wraparound team that you’re kind of making, and this is where thinking about who might be able to fulfill some of these roles, helps to think ahead of time. Who’s a doctor that I’m going to refer to for higher acuity adolescent medication management, who’s a family therapist that I can work with. Do I have NAMI on my list already? Who are where are places that people can get DBT skills? That’s stuff that you can kind of put together now and have that in your back pocket. So that way is we mentioned earlier, you’ve got that stuff kind of already there.

Katie Vernoy 53:53
And we did do an episode on creating treatment teams and private practice that we’ll link to in the show notes over at mtsgpodcast.com.

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Curt Widhalm 54:03
This is really kind of the space where, as the architect, you’re probably the one who’s going to be facilitating some of the conversations, whether it be email chains, whether it be trying to find a magical 15 minutes where all of these people are available for a video call to kind of check in, but knowing that the team is all communicating is something that really helps to make sure that kids and adolescents in these situations don’t fall through the cracks. You’re probably also the one who’s going to need to most vocally push the initial integrated plan treatment, the specific needs and strategies that are for the action steps of each member. Now, most often this is going to be when there’s multiple therapists involved. You know, we know that the doctor is going to do the doctor things. We know that the support groups are going to do the support group things. But a lot of times where the problems kind of arise is, what does the family therapist do, versus what does the kids individual therapists do? And does the kids individual therapists have recommendations for the parents? Does that get filtered back into family therapy? So you want to be able to figure out some of those steps as up front as best ahead of time. So you’re not kind of building that plane as it flies as much as needed.

Katie Vernoy 55:29
So I want to jump in here, because for a while I worked in wraparound, which was specifically around keeping kids safe with with a team wrapped around them. And so I like what you’re saying. I think that there’s additional pieces that are important to add. Making sure that even though the doctor is going to do the doctor thing, the support group is going to do the support group thing, there are people within the child or teen’s life who play a big role, but may not have their marching orders. For example, getting to the school, making sure the school has a full understanding of of how to support this kiddo, and determining if there’s changes that need to happen through, you know, the United States and some of the places, 504, IEP plans, and looking at where else is this kid interacting? Are there coaches? Are there religious leaders? Are there youth group directors? Are there folks who are pivotal that need to be involved with the family, and especially the kids permission in trying to create safety and create that plan around how do we move forward after something like this. And so I really liked the wraparound idea, which was there were wraparound team meetings, sometimes weekly, sometimes once a month. It just depended on kind of people’s availability and those types of things. But finding out that Uncle Joe can be very helpful in this way, and actually lives with the family, but you’ve never heard of them because, you know, so far, he’s not been involved in treatment. I think it’s those types of things really looking for resources and identifying, how do those resources show up? What are they agreeing to? What psycho education did they need to be able to support this teen in having the accommodations in the different settings, and building the strength, the tolerance to move through what’s going on. And so it can be really fascinating, especially when you’re working with the kid, with the family, to identify these resources to make things better, because you find out all kinds of stuff that maybe weren’t didn’t feel relevant when they first popped into treatment with you.

Curt Widhalm 57:47
And a couple of things to not overlook is one for clients who might have sensory needs, the role of occupational therapists as part of the treatment team, because if there is a biological or a sensory component that ends up being something that contributes to escalating behaviors, having somebody on your team to be able to address those because that falls within their specialty, is an incredibly helpful piece of a treatment team that we can often overlook. The other thing that I’ve come across is sometimes kids who have been out of school for a lengthy period of time and have a hard time reintegrating back, is being able to participate in alumni groups or group therapy with other kids who have also been stepping down. Because there’s sometimes such a difficult time relating to other kids who have not been through this kind of a system before, if they’ve been hospitalized, that further isolates them and makes them lonely, and that becomes another risk factor that I have heard kids say before, I am escalating my behavior so I can get hospitalized again and be around other kids who understand me. So having peer support from other kids with some of the lived experience is also something to assess for.

Katie Vernoy 59:12
And as you’re saying that, I think making sure that you’re spending enough time right off, right off the bat, right when, when this this kid goes to the hospital trying to determine what environment they’ll be returning to and which needs to shift in the environment. Because I’ve also had kids want to go to the hospital as a respite for their life. And so if there’s, if there are ways to try to address some of those things and have a softer landing, make the environment more sustainable for the kid, that can be very helpful as well.

Curt Widhalm 59:51
So in the last few minutes here, I want to just cover some of the legal issues that you might want to consider that you would need to hopefully have in place. Especially if you’re working with the decentralized treatment team, you’re going to want to make sure that you have releases of information to talk with everybody in varying practices. And this is a difficult paperwork burden, and it might be something where you just have a stack of ROIs pre-printed out with your treatment team. That’s part of your document packet here, but making sure that you do get that permission for everybody on the team to be able to talk.

Katie Vernoy 1:00:31
One of the things that I’ve done for psychiatrists, attorneys, different folks who I speak to a lot is I actually within my electronic health record have release form specifically to them, so it’s a click for the client. And so becomes very easy. So there’s, rather than printing them out, you might also be able to send them here the four people that are on your team that you can just go, click, click, click. And you’ve got those that pretty quickly.

Curt Widhalm 1:00:58
You should also make sure that all of your communication is set up for HIPAA compliant communication, so when you are sending emails back and forth to people that you are covered on that end of things. I also want to highlight here, if you’re in states where minors can consent to their own treatment, such as California, that allows for minors, ages 12 years and older, to consent to outpatient mental health treatment autonomously, you. And there’s caveats to that. This is not a law and ethics workshop, but for those clients who are autonomously consenting to their own treatment when it does involve having a treatment team, when it does involve potentially escalating up to the hospital, you do have to go through a decision making, processing about the confidentiality that arises in those situations. And at that point, I would encourage talk to an attorney, or talk to somebody who’s versed in the laws and ethics in your state when it comes to treating minors in these particular situations. And I want to close out here by just kind of talking about there are going to be systemic barriers and health disparities in community care. When we work in private practice, in this kind of a wraparound model, there are a lot of barriers that people from a lot of marginalized backgrounds and vulnerable populations end up running into. There can be a lot of stigma and negative beliefs regarding mental health treatment. Those are the ones that are usually most cited. Lower SES families are going to face a lot of logistical and systemic issues and potentially even cultural obstacles that end up compounding upon each other. And there are studies that demonstrate that black and Hispanic adolescents exhibit not only significantly lower rates of accessing mental health care, even after controlling for socioeconomic and health statuses, but that they’re also more likely to be rushed through this system faster and so potentially creating all of the traumas and everything else that we mentioned earlier in this episode. So those are things that we want to make sure that we are taking into account here when we are setting up our treatment team and our access to care as well.

Katie Vernoy 1:03:26
I think it’s important when you’re working with specific populations to understand the resources. I know for myself, I was surprised moving into public mental health, community mental health, that how much I felt like it was case management or social work, and even in my private practice, knowing what resources are available for folks of different socioeconomic status, of different diagnoses, or folks that are on disability versus not, I think it can be very helpful to know what you can access and and provide those resources to families when it’s appropriate, because helping someone to logistically move through the system and streamline that for them can make the whole thing less iatrogenically harmful.

Curt Widhalm 1:04:15
So this is kind of a bird’s eye view and framework of how to set up these teams, how to end up working. I know that this might not be quite the here are the individual interventions that you do with an adolescent or a child in order to keep them out of the hospital. But I’m going to maybe summarize that point as do good clinical work, and part of that do good clinical work is the individual interventions that build on safety plans, build on following through, but it’s also building the community around these clients in order to help be able to shape their environment and to be able to make sure that everybody is helping to contribute. Because this is one of those times where it is really about it takes a village. So my final thought on this, and Katie, if you have final thoughts too, is, don’t stay isolated as an individual, private practitioner. Have kind of idea that if you need to serve in kind of this architect role, What is your community kind of being able to provide? And if you don’t see these clients frequently, like practices like mine do, check it once a year see who’s still practicing. People move away, people retire. People’s caseloads get full. But it’s also a good way of staying networked and not so isolated yourself, but it really is within kind of the broader aspects of the clients that you work with and the care that you provide them.

Katie Vernoy 1:05:47
I think my final thoughts are for the clinicians, this work is challenging, and when the world is chaotic as it is right now, it can be even more challenging, but both because it’s harder on our clients, but also because we’re weathering a lot of the same chaos and discomfort that they are at the same time. And so I’m going to to amplify, yes, don’t stay isolated. Make sure you know who your team is, but also make sure you have your own therapy if you need it, make sure that you’re in consultation, that you’re working on yourself, and your ability to sit with really hard things and knowing when you need to step away and take a break or do those types of things. Because if you can’t show up for these kids, and that isn’t an option on the table, the kid is in your practice, the teen is in your practice, and for me, the young adults in your practice, then you have to be able to step forward and do the work. And so more and more, it becomes apparent that, yes, our job is hard, and it’s our responsibility to have those self assessments and those resources to stay capable and helpful for our clients rather than falling into another adult that has potentially harmed them.

Curt Widhalm 1:07:11
Check our show notes. Listen to the intro outro if you want to get continuing education for this episode, you can find our references over at mtsgpodcast.com. Follow us on our social media to continue to engage with us, and until next time, I’m Curt Widhalm with Katie Vernoy.

… 1:07:28
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Katie Vernoy 1:07:28
Just a quick reminder, if you’d like one unit of continuing education for listening to this episode, go to moderntherapistcommunity.com, purchase this course and pass the post test. A CE certificate will appear in your profile once you’ve successfully completed the steps. Once again, that’s moderntherapistcommunity.com.

Announcer 1:07:46
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