When A Label Becomes A Lens with Dr. David Rowe

A single diagnosis can open doors to care, but it can also quietly close minds. When a label lands in a chart during the worst day of someone’s life, everyone downstream can start interpreting every behavior through that one lens and families pay the price in trial-and-error treatment, wrong medications and wasted months. We sit down with neuropsychologist Dr. David Rowe of United Assessment to unpack what “real assessment” looks like when the stakes are high and the clinical picture is messy. 

We talk about the practical difference between a brief psychiatric interview or biopsychosocial evaluation and a comprehensive neuropsychological assessment built on decades of norm-referenced testing. Dr. Rowe explains why psychology doesn’t have to be a soft science, how objective data improves diagnostic accuracy, and why good testing doesn’t just confirm a hunch, it helps rule out what isn’t true. We dig into symptom overlap that can even trip professionals up. We also zoom out to what we’re seeing nationally: rising acuity and complexity, more prior hospitalizations and medication trials, and a growing understanding of neurodivergence and autism. 

Dr. Rowe shares how he communicates an autism diagnosis to families as a framework for understanding a whole life story and building support that fits the person’s brain, not just the symptom list. If you care about mental health diagnosis, neuropsych testing, crisis stabilization, and finding the right level of care, this conversation is for you. 

If this helped you think differently about assessment and treatment, subscribe, share this episode with someone who needs clearer answers, and leave a review with the biggest takeaway you’re bringing into your work or your family life.

Transcript

Welcome And Guest Background

SPEAKER_00 0:00

Hello, folks. Thanks for joining us on Head Inside Mental Health, featuring conversations about mental health and substance use treatment with experts, advocates, and professionals from across the country, sharing their thoughts and insights on the world of behavioral health care. Broadcasting on WPVM 1037, the Voice of Ashville, Independent Commercial Free Radio. I'm Todd Weatherly, your host, therapeutic consultant, and behavioral health expert. With me today is a friend and colleague, Dr. David Rowe. Dr. Rowe is the Executive Director of Neuropsychology at United Assessment, a nationwide evaluation service offering comprehensive neuropsychological, psychoeducational, psychodiagnostic, psychosexual, sexual, forensic, and developmental testing for clients across the lifespan. Under Dr. Rowe's leadership, United Assessment has grown into a trusted resource for families, educators, legal professionals, and clinicians delivering data-driven evaluations that inform clear, actionable outcomes. In addition to this, United Assessment, Dr. Rowe serves as an assessment supervisor at Andrus Children's Center, an APA-accredited community mental health clinic, and holds faculty appointments with both Columbia University and the William Allenson White Institute, where he supervises psychological assessment and the child and adolescent program. A dedicated educator and researcher, Dr. Rowe teaches courses in child psychology, abnormal psychology, and psychology, and continues to conduct clinical research with a focus on novel pharmaceutical and behavioral interventions for individuals with severe psychopathology. Moving forward, Dr. Rowe is committed to continuing to build scalable gold standard assessment service that bridge the gap between clinical excellence and accessibility. Doc, welcome to the show. Thanks for having me, Todd.

SPEAKER_01 1:40

I really appreciate it.

SPEAKER_00 1:42

Absolutely. He's also like, I would add to the bio and fun to hang out with. Thanks so much. Solid conversation. One of the fastest, you know, one of the fastest minds I've ever I've ever run into. I'm like, hold on, let me see if I caught all those words he said on that. Like, I've just, you know, there are people gifted with the ability to speak quickly, complex terminology. Rappers seem to be one of them. And for some, you got like this gift for saying a lot of really dense content in a very short period of time. I I I'm in awe. The first time I met you in person, you were standing up. We all had to talk about what we did and who we are. And it's like, I'm Dr. David Rowe. And you're like, you sound like the guy at the end of the disclaimer message for a radio show. You're like, oh yeah, we did all that in like a second.

SPEAKER_01 2:32

Yeah. I almost went to auctioneering and then last minute, last minute I said neuropsychology.

SPEAKER_00 2:38

That's quite the divide there. Um

Why A Quick Diagnosis Fails

SPEAKER_00 2:40

I I think you could do a little bit of both, you know, if you get a little side gig, you know.

SPEAKER_02 2:44

Never too late. Never too late to be an auctioneer.

SPEAKER_00 2:47

Um, well, and and you know, in light in light of that, and you know, part of the reason why we know about your services, um, my team has used your services before or referred you out to folks. Uh and you know, every time that we meet families that are most of the time they're in crisis, a lot of times the person has a lot of co-occurring conditions, there's a lot of complexity involved, and everything else. That's that's that's part of where we live in the world. Those are the people that we meet, the families that are struggling to figure out what to do. And like, what do we do? I say, well, how about we get somebody to actually tell us what's going on? How about we get a really good assessment before we decide what treatment we're going to use? And I I think that people, it takes people aback a bit. It's like, well, you know, went to the hospital and he's got this diagnosis or she or whatever. You know, they've got they've got all this clinical history, but it comes from emergency care. It might come from outpatient care, it might be something a psychiatrist said, or something that a clinician was willing to hang their hat on. And then I have to go into explaining the difference between uh, you know, a social worker doing a biopsychosocial evaluation on a person who's just come into a center, they spent an hour maybe, and they did maybe a couple of assessments or asked some questions, did a biopsychosocial review. Out of that, some doc looked at it and they came away with a diagnosis. The difference between that and what I would call a true assessment, a neuropsychological assessment that's going to cross a lot of territory and even investigate specifically if there's indicators to do so. And I really have to tell families what the difference is in that. What is it like when you when you get a you know, a family that's come to you or a client that's coming to you that's looking for assessment, do you run into that? And what's your answer to that question? How would you differentiate what the rest of the world thinks of diagnosis and what real assessment looks like? What's well what's the answer to that question for you when you're talking to folks?

SPEAKER_01 4:42

That's a great question. I think that most people's foyer into diagnosis is like knowing somebody who just took a psych 101 class in college and is learning about the symptoms and the criteria and diagnosing themselves and their friends and their families. And the reality is like biopsychosocial is a really helpful tool. Psychiatric evaluations are a really helpful tool, but so much of it relies on subjectivity, which is to say it's inferential, it's impressionistic, right? And psychology doesn't have to be a soft science. And part of neuropsychological testing is bringing empirical data back to diagnostics. So when someone's doing a biopsychosocial, they're doing a psychiatric interview, they're meeting with somebody 15, 30, 45, 60 minutes, they're collecting a lot of information. Largely it's qualitative. And neuropsychological testing couldn't be more different. These tests have been iterated upon for decades. They've been norm referenced on tens of thousands of people that client's age. It's the best way we have in the field of psychiatry and psychology of arriving at an accurate, valid, reliable diagnosis. So we're testing for everything from cognitive disorders, attentional disorders, learning disorders to depression, anxiety, bipolarity, psychosis, disorder eating, OCD, trauma, personality disorders, autism, substance issues, the whole gamut. So when we get to the end, we don't just know what's going on for someone, we've successfully ruled out everything else. And to your point, when you're approaching somebody, especially when they're in crisis, more often than not, your subjective account of what's going on with them is not a good read on that person. You're seeing them at the worst moments in their life in an unfamiliar environment, oftentimes under enormous, tremendous stress. And then someone along the way may have assigned them a diagnosis, and that diagnosis gets entered into a chart, and then something really interesting happens. Everybody downstream starts looking at that person through that lens. And if the chart says bipolar disorder, we start interpreting that behavior as bipolar disorder. If the chart says borderline personality disorder, we start interpreting the same behavior very differently. If it says ADHD or autism or depression or oppositional behavior, that label starts organizing what we're looking for and how to help them. But the problem isn't diagnosis, because diagnosis can be enormously helpful as a heuristic to really again help organize someone's care. The problem is when a provisional explanation becomes an unquestioned fact.

SPEAKER_00 6:54

Does that make sense?

SPEAKER_01 6:55

Right.

SPEAKER_00 6:55

Yeah, absolutely. When a person's if a professional comes and, you know, they see that the the evidence or the diagnosis is and suddenly they're entrained. Uh, you know, they're and I when my this is this is gonna be an interesting story for you, but when my first my first job, you know, undergrad and psych first job, um wilderness camp for adolescent kids, court referred, and everything else, we had a psychiatrist who was researching bipolar disorder. And suddenly all of our kids starting having a diagnosis of bipolar disorder. And they get and then they get put on the same meds and their clinical profile looks the same, and their treatment, you know, their treatment looks the same, or their you know, clinical documentation and how we're gonna access treatment for this person, what they're gonna go do after that, all starts to look the same for everybody. And suddenly it's a camp full of these kids. And it's like it's it's not it. You know, fast forward to another situation where I've got a person going into for a residential assessment, and you know, everybody said this about them. They've they've they're can they're they're they it's thought disorder, everybody knows it's thought disorder is everything else. They dig in a little deeper, and all of a sudden they discover it's like, look, this person's got pretty severe OCD. And while there it what looks like delusion is actually OCD gone awry. They live way far in their own brain. And it was like it changed their whole, the whole treatment approach that we had with the person.

SPEAKER_01 8:24

100%. There's so much symptomological overlap. I get people call me every day that say, Can you just do the gold standard test for ADHD? And I said I could, but the reality is inattention is symptomatic of a dozen different disorders in the DSM. So it could be development like ADHD, but it could be psychiatric causing cognitive interference. It could be anxiety or depression or trauma or OCD or anything that can compromise your attentional faculties. And if you're not going to be able to hold those variables constant, then you can't actually get a good sense of what's causing it. We're not there to invalidate someone's experience of inattention. I'm sure they're inattentive. We're there to evaluate the ideology of that inattention, what is causing it. So I think that uh I think that when your formulation is wrong or or quite frankly, even incomplete, we can end up delivering really good treatment for the wrong problem, right? And at the end of the day, you're never gonna get better if you're putting foot cream on a headache. You know what I mean? I don't know. Maybe you know. Maybe I don't know. I don't know. It could work, but we're trying, I suppose, if it's you know, no, no downside. But in this case, there could be in this case, they'd be colossal downside.

SPEAKER_00 9:31

And I think they end up throwing spaghetti at the wall, you know what I mean?

SPEAKER_01 9:34

So yeah, and trial and error is so painful for these for everyone, for the client, for the family, for the provider. When you're when you're when you're effectively having to adjust the neurochemistry, especially of the adolescents you worked with in the wilderness setting, that's a painful process, right? And for if you're doing trial and error with someone's treatment, it's exhausting in terms of time and money and effort and energy.

SPEAKER_00 9:57

Well, then you have to reset every time you discover something new. You know, the thing that you said about, you know, people going to hospitals or in their crisis situation, and and largely what's coming out of it is inferential, you know. Uh, in addition to that, the the inference is being made on self-report data. And if you're let's talk about thought disorder. Well, thought thought disorder has an impact on self-report, like the reliability of self-report from a person suffering from schizophrenia is questionable at best. At worst, it's all kinds of other things. And and so if you're walking in there making inferential diagnoses based on self-report, I mean,

Symptom Overlap And Mislabeling Risks

SPEAKER_00 10:40

heck, I, you know, many of the clients that we have can talk to you about parents are super frustrated because the clients came in, it's like, I'm okay and I don't want to hurt myself. And they walk out, and that's the first thing they do because they know how to say whatever it is they need to say, and they can walk out, or they're saying things that are completely immersed in delusion. When you are faced with clients like the complexity, this is I think I got a lot of listeners that would love to hear this answer, and I want to hear it from you specifically. When you've got when you're diving into something that feels complex, where do you start? Like as a di as a as a career and uh somebody who I respect a lot as a diagnostician, where do you start with somebody who's already presenting with a lot of complex behaviors?

SPEAKER_01 11:20

You start with a clinical interview the same way you would if you were a social worker, a psychiatrist, a psychologist, because the most important thing you can do to start neurosite testing is build rapport. Everything in this field, everything in life, I would argue, is about relationships. I mean, this goes back 2,000 years to the philosophy like philosophical question, is there a self without the other? So I'm sitting there with them and I need to engage them in the conversation. I need them to be appropriately effortful, I need them to try their best and uh try to be open and honest and forthright. And sometimes there is a thought disorder. And that's why we don't just rely on subjective account, right? We also use objective and projective testing. So like a classic would be the Rorschach. It has contemporary standardized approach. And some people say, people still use the inkblot test? And I say, of course. Because you got to get tatted. Look, because we can evaluate aspects of thought and perception that can be so much more difficult to appreciate through self-report. Right. So like we're we're we're these these tests, again, have been validated. So we're looking for like distorted perceptions and reality testing. We're asking, does this person repeatedly perceive things in ways that are poorly anchored to the world around them? We're looking for disorganized reasoning. We we're asking, do responses that they're providing contain illogical relationships, contradictions, implausible combinations, breakdowns, and like ordinary reasoning? And we can see that through even something like the inkplot test. And we're not even doing a singular test. We're looking for convergent validity, which means we're doing more than one test. That way we know that when we get to the end, we have the highest statistical likelihood of accuracy, right? And the same thing can be said of a bunch of other different variables, loose or kind of uh idiosyncratic associations. Does this person make connections that are unusually difficult to follow or very highly personalized to them? Communication disturbances, boundary and integration problems. You know, we even have the question: what's the duration? What's the severity? What's the frequency of these behaviors? One unusual response means very little. A repeated pattern of significant disturbances is much more clinically meaningful. Does that answer your question?

SPEAKER_00 13:27

Well, yeah, and I, you know, I think you I was about to ask this question, and then you answered it anyway, or at least I think this is the answer to this question. Like, what's the difference between the doc and this in the hospital that's walking in 20 minutes, writing some things down, looking at the biopsychosocial review uh uh assessment that the per somebody else did, and then coming away, you know, making some inferences and coming away with a diagnosis. What's the difference between that very erroneous system, oftentimes, uh as evidence would indicate, and what you're talking about? And I think

Starting With Rapport Plus Data

SPEAKER_00 14:00

that the difference is is that you said, I I need to have I need to have a relationship with this person. I need to have their trust, I need to have a connection to them. And their their aim is not to do that when they walk in that room.

SPEAKER_01 14:13

That's it. We have very different goals and we're trying to answer very different questions, right? Any psychiatric hospital uh doctor, any psychiatrist working in an inpatient unit is asking, what's happening right now? Is this person safe? How do we stabilize them? Right? That's like their their primary goal. As a neuropsychologist, I have the luxury of asking, of first of all, of the luxury of time. And secondly, I have the luxury of asking them who is this person when they're in crisis and when they're not? How did they get here? And what best explains the entire developmental and clinical picture. At the end of the day, we're trying to do the impossible. We're trying to construct an explanatory model of a person, right? And the the distinction is important because families, like as I said, arrive asking, does my child have ADHD? Do they have a thought disorder? Is this autism? But the better question is you know, what is happening here? Why is it happening? And what does this person need?

SPEAKER_00 15:12

Yeah. As opposed to approaching it with a diagnosis in mind already, as you say, you know, like it's got that's gonna flavor everything you see.

SPEAKER_01 15:20

When all you have is a hammer, everything looks like a nail. That's true. That happens when all of a sudden everybody has a bipolar diagnosis sometimes. Not to cast this person.

SPEAKER_00 15:28

Right. Well, and the other piece, and I think that it it it's entirely it's entirely possible that you know forming a therapeutic alliance with the individual answers this question as well, which is you know, when we see people in crisis, uh a lot of times it's like, hey, you know, we were talking about this video, they need to stabilize a bit before we can really, you know, because all these all these big, you know, loud symptoms are screaming so loud, everything that's underneath it is is muted. We can't see it. A hundred percent. When you've got, you know, I I know that you get clients, even though you're not doing most of you're not doing assessments in a residential setting, I know you get a lot of clients that are in a lot of distress, they've got a lot of symptomology going on, even if they're not in the hospital, they probably could be in a residential treatment environment where they're gonna get very substantial care, clinical care. When you're encountering someone who is highly dysregulated and highly symptomatic, what's the approach that you take? You know, I I know that you're trying to get a relationship, you know, trying to also get a really good read on this person. What's the approach that you take in getting to that place where you feel like you can get in underneath the surface and figure out what's going on?

SPEAKER_01 16:43

Uh honestly, time is everything. Giving people time, giving people attention, giving people what they need in that moment. Uh again, people are usually unfamiliar settings and they're very, very distressed, and they need a calming, reaffirming, and patient approach. Uh, at the end of the, and and you said it perfectly, which is they can be really, really behaviorally dysregulated. And behavior tells you what's happening, but doesn't tell you why it's happening, right? The the symptom is like the smoke, not the fire. And we're trying to figure out what the fire is. So we do testing on it's true. We do testing inpatient, outpatient, uh, we do testing in residential facilities all over the country, testing people's homes. We do testing anywhere anybody is and where they need it. Um and what we tend to find is when we have, again, the luxury of being able to do testing during a moment of crisis, when people are inpatient, it helps to inform the stabilization process. So sometimes people erroneously believe that you have to wait until someone's stabilized to do testing, but that doesn't actually make a lot of sense. Then you're doing trial and error during the most important part of the process. First of all, you don't want to miss it. Right. You don't miss it. I mean, first of all, we get a good sense of the way in which this uh acuity is affecting the person, how it's dysregulating them, how it's impacting their functionality. And then two, we want to get an understanding of, for example, is this bipolar one with psychotic features or is this schizophyll disorder? Two very similar disorders in terms of behavior, two very different treatment approaches. So at the end of the day, we want to be able to get good clinical information so people can make informed clinical decisions as soon as possible. So as long as they are being appropriately effortful and we have validity indicators built within the algorithms of the test themselves, um, we're able to kind of move ahead with testing and give a lot of good information to that inpatient team. So they can inform medication considerations, therapeutic interventions, behavioral controls. I mean, I I've seen people in crisis. Treatment placement. Treatment placement, you know, what level of care do they need? I mean, there's there's times where people are are inpatient and it has a greater iatrogenic effect than than it should, which is to say

Testing During Crisis And Placement Fit

SPEAKER_01 18:55

maybe they're they are experiencing paranoia or a thought disorder or a delusion. And by virtue of being locked up and getting 15-minute checks and having a camera in the room, it's making their condition worse, not better. Right. And we need to be able to consider all of the factors. And a neuropsychologist, a good neuropsychologist, can help you with all of that.

SPEAKER_00 19:11

Yeah, I I tend to think of residential treatment very often, though not all of them are this way, they can they can feel like pressure cookers. Um and there are some people who need that kind of intensive level of approach because you got to get to the root of it and and and they benefit from those kinds of treatment environments. And then there are others who just like there, it's too much. It's just way, way too much.

SPEAKER_01 19:34

Oh, there's nothing more important than fit. Fit is everything. Yeah. It's the same as getting a personal trainer, right? You you you want to make sure that somebody's not going to push you too hard to where you hurt yourself and not kind of push you light enough to where it's a waste of your time and money, right? There's a there's a lid for every pot, especially in in treatment, and that's why we say, you know, you don't have to find every modality that works for you. You have to find one that works for you. Same with mindfulness practices, the level of care, all those kinds of things.

SPEAKER_00 20:03

Well, now let's let's let's broaden ever so slightly. You know, let's let's um because I I'm pretty interested in the the kind of the metadata here. Um I would say that as a for the company that you've built and the approach that you take, um, you've got a you guys are all over the nation. I know a few other c you know psychologists or clinical psychologists that are out there doing assessments and they travel the country and they hit this and that, and they may work with programs and so on, but I think you've got broader reach than anybody I know. So that means that, you know, in in some of the ways it makes a good consultant valuable to a person because they've been everywhere and they've seen enough, they've seen placement and they've seen enough conditions and they know what they're doing, they know who to find, etc. When you're doing assessments, what are you seeing on the metadata? Like, are you seeing more acuity out there? What are you encountering with the people that are coming to you for assessment? Like, what is the what has been the and and you know you're probably on the on the side of treatment as well because you're seeing people in residential environments and everything else? I think that our our our field at that is treatment field for for primary mental health conditions, co-occurring substance use conditions has done a pretty significant shift in the last five, say, ten years. What would you say that shift is towards? What is it that has caused the shift? Do you agree that it has shifted? You know, like what is your what are you seeing us going right now in the world of mental health care, assessment, treatment, et cetera?

SPEAKER_01 21:37

Uh so I will say that as a as a like a proud statistician and diagnostician, I try not to make like, you know, subjective conjecture on trends without appropriate data.

SPEAKER_00 21:49

My job is to make you step out on a limb here.

SPEAKER_01 21:50

So I I'm happy to kind of share anecdotally. The thing that we're encountering is acuity, like certainly, but I think an even better word is. Complexity. Acuity and complexity are both very much on the rise. We're seeing young people who don't come to us with one clean problem anymore. They arrive with four or five diagnoses, with multiple medication trials, with previous hospitalizations, school failures, school refusal, significant family systems distress, like years of treatment. And sometimes those diagnoses are correct. And sometimes we then have to reconstruct their developmental history and do comprehensive testing, and we realize that those diagnoses don't fully explain a person. But in terms of trends, we do see an enormous amount of overlap. We see ADHD with anxiety. We see autism with OCD. I mean, I will say that there's been a lot more recognition of autism, especially in people assigned female at birth. It's not that necessarily the prevalence rate has gone up, but that the incidence rate, which is to say like the acknowledgement of it, the diagnosis of it. Um, because we understand it a little bit better. And that happens over time. Um so more and more people are understanding what neurodivergence means in our society. It's becoming easier to talk about, more normalized. So people are are wondering about themselves. And I think that that's a really wonderful thing. More and more patients are asking questions and are invested and interested in learning. Um and I think that's a that's a good trend to go with the kind of more scary trend of increased acuity and complexity.

SPEAKER_00 23:22

Yeah, and uh since you since you hit the neurodivergent topic, let's let's I just recently and I went and uh presented at the autism research symposium. Uh and and the the thrust of mine was not only is there, you know, a a care continuum that you want to be careful to observe, you also want to assess properly and everything else. And finally, because we're because our sophistication around this topic has increased, you can't treat ASD the way you treat mental health. Looks like borderline, it's not. And if you treat it the way, you know, which is why you get this phenomenon where you've got some kid on the spectrum, and they could walk in and write a book and teach a class on CBT or DBT techniques and everything else. Like they are expert, but they couldn't use a DBT skill to save their life. They walk out dysregulated, they walk out overwhelmed, and it it it doesn't land for them because the modality doesn't address their need. When you're when you're doing this assess when you're doing the assessments and you're you're finding people who are on the spectrum or on the divert neurodivergent spectrum, I know that part of the work that you're doing is also communicating to families in a way they understand. Like, what is it, what's the message like to a family who finds their finds their child or a loved one, and maybe it's an adult that's on the spectrum, um, and you know, trying to figure out what that means to their life? Like, how are you talking to families about this?

SPEAKER_01 24:55

Yeah, it's a great question. I mean, first and foremost, we have to help them understand their historical experience. Most of the time, by the time I'm doing an evaluation and we're the ones giving the initial autism diagnosis, it's not for three or four-year-olds, it's for 23 and 24 year olds, right? For people who are who are who are functioning well through society, maybe they transitioned to early adulthood and went through that very sensitive developmental change and they were no longer able to function. Maybe it's that point where the demands of life in terms of increased complexity, relationships, you know, vocational demands exceeded their capacities and then they didn't know what to do. Maybe they had friends through their cohort from, you know, K through 12, and they were in structured opportunities for social engagement like sports, and then they transitioned to college and they they couldn't figure out how to make new friends and and that they couldn't hit the ground running like they really wanted to. But the reality is when people find out that they might have a developmental disorder, right? They might have like an autism inspection disorder, you really attempt to try to provide like a framework, a lens through which to interpret their history the rest of their life, which is to say maybe you weren't able to able to get your needs met, right? Maybe you struggle to feel like you fit in or really struggle to feel like a you know a person at all. And when that happens, all those things can aggregate, all those little traumas can aggregate and internalize into kind of a a significant, you know, relational rift. Does that make sense? So it ends up being you know, so when people have things like they come into us for depression, they come into us for anxiety. And we see that, and obviously we want to treat them for that, but maybe there's a foundational reason why they're experiencing that depression and anxiety. I know that if anybody isn't getting their needs met, especially their social needs, they're gonna experience depression and anxiety because people on the spectrum, just like people not in the spectrum, want what everybody wants mostly, which is to love and be loved. And when you're not getting that, you're gonna feel anxious, you're gonna feel depressed. You might develop some caratological symptoms, right? I mean, there are people who become very, very internalized and say, the world rejected me, I'm gonna reject it. I want everyone to leave me alone. It might become very externalized. The world feels like it's constantly rejecting me, I'm gonna constantly seek

Rising Complexity And Neurodivergence

SPEAKER_01 27:10

validation. Maybe they turn to substances to self-medicate, like so many people with depression and anxiety. And then it becomes a complicated clinical picture. So if we can understand that they have this foundational developmental disorder, then we can really kind of help them reinterpret so much in their life to have a better relationship with their past, kind of shore up their resources, have a have a kind of make better decisions in the present, and and you know, as insipid as it might sound, have a brighter future.

SPEAKER_00 27:36

Psychological conditions, uh, you know, the best analogy I can think of is it's like an ecosystem. You know, it's like you've got this factor over here, but it's influenced by this factor. If you remove this factor, these factors there's there's all these pieces that are interdependent on one another. And when you're you know sussing it out and you're figuring it out, you want to find the drivers, of course, but you also it's like in through your life you've done all these things. You know, a family came to me just the other day and they were like, Well, he he was in the hospital for two months. I said, Well, if you didn't have a mental health condition before he went in the hospital, he does now. Um because that environment is just not one that's I mean, it's not supportive, it's not it's not a place where you're actually getting care. You're safe, you're keeping you from doing any harm to yourself or anybody else, but you know, largely at the end, they come out of this experience and they're highly traumatized. Now, you know, I send them to you and you're doing an assessment on this person, it's like, okay, well, now they have a they have a trauma disorder based on an experience they've had with a hospital, in addition to whatever condition that caused them to get there. So we have to add that into the mix, and all of a sudden you've got this picture uh and you've got a treatment that's got to complement all the various pay pieces and be able to address them in the way that they need to be addressed.

SPEAKER_01 28:50

I will say, just to come full circle back to the beginning of the conversation, that's why I'm so passionate about like assessment for neurodivergence. Because you can't assume that uh that a young person on the spectrum just presents with anxiety and depression, emotional dregulation, all these kinds of things, and in that it can be conceptualized the same way as like a neurotypical young person presenting with the same symptoms. The symptoms might look the same, but the mechanism underneath them may be very different. And when you're doing a biopsychosocial, when you're doing a psychiatric interview, it's very difficult to see those things, if possible at all. Like most good clinicians, they know a mood disorder when they see it, they know an anxiety disorder and they see it. OCD is misdiagnosed 40 to 50% of the time. And as soon as you start having personality or trauma or developmental issues, it gets very cloudy very quickly. And neuropsych is the best way of kind of disambiguating those things. But that distinction really matters because it it helps to formulate treatment. And again, you know, at the end of the day, the goal here isn't to make an autistic person less autistic, right? The goal is to identify what's causing suffering, what's interfering with someone's functioning, and how we can help that person build a life that works for their brain.

unknown 29:58

Right.

SPEAKER_01 29:59

Um the value of testing over and above the kind of standard forms of assessment in in treatment.

SPEAKER_00 30:06

And I'm gonna say something that um I I'm curious to see your reaction to, which is uh the the DSM is not very good at pass. Um not touching that with it. As in there's a there's a bucket, you know, and I'm gonna and and I'm gonna keep pitching, oh, they've got this symptomology and that symptomology, they've got anxiety and they've got depression. And I keep pitching these things. And if I put enough things in the bucket, it weighs on the scale of a diagnosis, and the diagnosis pops up. Um and as a as a I'm not saying it's not a useful mechanism. I'm saying that without training and insight and experience, it can lead a person to just do it, just throwing things in the bucket, watching whatever it is that rises, checking the boxes, putting the diagnosis down, etc. Without a person, and that's why we've gotten to where we are with with people on the spectrum where they've been diagnosed improperly, treated improperly. And you get to a person like you who's like, all right, I need to form a relationship with this individual. I need to look beneath the surface of what we might see these farmer diagnoses being having been. I need to, I need to really form a picture of what has gone on in their lives and how it is that we can come up with something that's going to help them lead a better one. And so I, you know, there's a real like gift to doing good assessment. The the person who's doing it has got a gift for being able to get to the root of it. Um, and that is something that I think that you're accomplishing, which I'm grateful for, which just leads me to this question how did you get into this? Where did it, where did you start?

SPEAKER_01 31:44

Well, you you also gave me so much to address there before. Oh, yeah. I'm terrible. It's terrible. It's so rich, but the DSM is really interesting because it does allow for a lot of misinformation, a lot of self-diagnosis. Anybody can look up the DSM and say and identify with the things that they're seeing. Um I mean, what comes to mind is like to paraphrase Churchill about democracy, the DSM is the worst form of you know government, except for all the other forms that we've tried. Um, it's the best that we have. Um and it's and it and they they spend an enormous amount of time validating. I mean, the first DSM disorders included homosexuality and nostalgia, right? So like we're on DSM 5 revised, like these disorders that have that have remained are empirically validated disorders. And the issue is so often that there's uh a co-option of clinical language. People on the street love to say I'm depressed and anxious. And rightfully so. The world is a sad and stressful place, but they mean I'm sad and I'm stressed. When I say somebody is depressed, it means they meet five out of nine criteria for major depressive disorder in the day. Right. So that's when people say I'm depressed, and their friends say, I don't know, take a shower, you know, go on a run. It's not really capturing, that's not a it it they don't necessarily mean depression, and that's not a real treatment recommendation, right? So I think that kind of disambiguating uh kind of like a colloquial usage of our of our clinical terms and what a psychologist means is really important. Um so in terms of how I got into it, um, they don't let you try therapy. They don't let you like try it out to see if you like it. There's no sample where you get to be someone's therapist and see if you like it. Um so you don't get to do it until you're in a PhD program for psychology, which means you've committed to therapy for the rest of your life in terms of time and money and energy and all the things you you put into it. And I sat down and I was a therapist for several years, and it was not for me. It is

Autism Meaning For Families

SPEAKER_01 33:45

such important work. Uh all my friends are therapists and they they are help people transform their lives. Um they love doing it. They love doing it. And and you know, there were definitely moments where I felt like I really made a difference. Um but I used to kind of glibly say that when I was a therapist, I used to sit, wait to have a gut reaction, and then try really hard not to tell somebody what I think they should do. And now my job is to collect as much information as humanly possible about somebody and then tell them exactly what I think they should do. Uh you know, now I bring the horse to water, right? My job is to say, the water's full of lithium and you're a really thirsty horse. It is not my job to make them drink it. My job is to kind of empower people with data, which is much more egosyntonic for me. Right. I like more information. I want to be able to make informed decisions and I try to help people do that. Whether or not you're a client or a family or a clinician or a consultant, my job is to try to get everybody on the same page and at least have one set of mutually agreed upon valid data.

SPEAKER_00 34:51

Yeah, your job is to bring them to the water. My job is to convince them to drink it. That's correct.

SPEAKER_01 34:56

Exactly. That's exactly right. And then the therapist's job is to treat them your water. Exactly. Just give it the water into horse's mouth.

SPEAKER_00 35:02

I know. I get it. Like I'm telling you, this water is going to taste really good, I promise you. Just give it a minute. Exactly right. David, it has been I again, I just enjoy hanging out with you, and I I enjoy hearing your insights about the field. Um, I enjoy having you as a person out there doing really solid work because I think we need more of you. Um, so this has been Head Inside Mental Health, Todd Weatherly, your host. I've been with Dr. David Rowe with United Assessment. Um, seek him out if you need uh good diagnostic work for mental health or co-occurring disorders. He really does know what he's doing. Thanks for being on the show. Thank you, Todd, for having me. We'll look forward to being with you next time. Be well.

DSM Limits And Career Path

SPEAKER_02 37:12

Need to find my way home, I want I feel so lonely and last in here, I scale me. I feel so lonely and last in here, I scalp me on, need to find my way home, I want it, I want I feel so lonely and last in here, scale we are, I need to find my way home, I'll find my way home.