E.55 The Complexity Of Crisis Mental Health Work With Cara Tirrell and Bill Dwinnells

In episode 55, Bill Dwinnells and Cara Tirrell are back (click here to find their first appearance) to discuss mental health crisis work. Interchangeably called many things, emergency services for mental health is a crucial part of our system. Bill and Cara describe the importance of this system, how it can lead to proper placement for treatment, the experience and stress that it can occur for both the clients and the emergency services worker. Cara and Bill also discuss how it lead to understanding more about the proper use of the suspension of civil liberties and how it is a delicate balance. They also describe how crisis teams coordinate everything from the "pink paper", to the interview, to the emergency department staff, to the insurance company, all the way to the proper service for the client's mental health needs.

We also discuss our own experiences, how this experience changed us, how we have developed invaluable skills, as well as the challenges for the current crisis team due to the pandemic and resource issues, while suggesting some ideas for those issues.

You can reach Bill Dwinnells' website here.

You can Cara Tirrell's website here. 

Transcript

Steve Bisson: 0:01

Hi and welcome to finding your way through therapy. I am your host, Steve Bisson. I'm an author and mental health counselor. Are you curious about therapy? Do you feel there is a lot of mystery about there? Do you wonder what your therapist is doing and why? The goal of this podcast is to make therapy and psychology accessible to all by using real language and straight to the point discussions. This podcast wants to remind you to take care of your mental health, just like you would your physical health. therapy should not be intimidating. It should be a great way to better help. I will demystify what happens in counseling, discuss topics related to mental health and discussions you can have what your thoughts I also want to introduce psychology in everyday life. As I feel most of our lives are enmeshed in psychology. I want to introduce the subtle and not so subtle way psychology plays a factor in our lives. It will be my own mix of thoughts as well as special guests. So join me on this discovery of therapy and psychology. Hi, and welcome to episode 55 of finding your way through therapy. I am Steve Bissonb so please go listen to Pat Rice on episode 54. It was an amazing conversation. I hope you enjoy it as much as I do. But episode 55 will be with Cara Tirrell and Bill Dwinnells. Cara and Bill are returning guests they came in in season two, one of the top downloaded shows so far in my what my five season career. But Cara and Bill will talk about emergency services, their own experiences, how can we help people in emergency services at this time and the different stressors that they have nowadays? Hi, everyone, and welcome to episode 55 of finding your way through therapy and also episode five of the YouTube channel finding your way through therapy. I am Steve Bisson. So joining us again after episode 21 and all the success but unfortunately your number three right now I'm just saying that you got to work a little harder. After episode 21. We were number one number one and then it started just dwindling. I mean, no, no pun intended. But I have build windows here and a half character. Well, we've talked about emergency service work in the past. And it was really fun. And I know a lot of people asked for them to come back. So here we are. So welcome, Bill. Welcome, Cara.

Cara Tirrell: 2:20

Thank you.

Bill Dwinnells: 2:22

Thanks.

Steve Bisson: 2:23

I hope that we don't have the recording issue that we had on the last one. That's why we are all in separate places. None of this like fancy going in the same spot thing. Right? It's good to see you guys virtually. Yes, yes. Nice seeing you guys. We saw each other on Monday. Anyway, we were face to face, which was really nice, too. But yes, I think it was really good to have that episode. I think a lot of people got a better glimpse of the work on emergency services. But in case someone missed episode 21 go back and listen to it. But still want to what let's start with you, Bill, how about you introduce yourself?

Bill Dwinnells: 2:58

Sure. My name is Bill Dwinnells. I am currently an emergency service director for one of the local teams. I've been doing emergency service work for about 26 years. Yeah, I cringe when I think about it. That's a long time. It's very long time. Other than that I can be found at my website, just my name builds wells.com. So I'll kick it over to Kara. Bill, you're not giving yourself enough credit you have not only are the director after all that experience, you have your own private practice. And you also created software that I think is cutting edge. So maybe you can put a plug in for that. I do have software that we use for managing the emergency services programs. I think right now it's used in about half the teams in Massachusetts. And you can find that at 508 tech.com. If you're interested in that, we clearly could tell who is into marketing and who forgot about their marketing skills.

Cara Tirrell: 4:00

That's one thing we do learn as clinicians to try to kick that in once we get into the private practice or starting our own business, which I have recently done. So I'm a year into a private practice. And Steve has helped me immensely. Bill has been a great mentor as well. I've had about a year of therapy, Terrell counseling.com You can call me at 588-347-7424. You can find me at Kara Terrell counseling.com online for my website. But just like Bill and Steve, I had been in crisis work probably for over 20 years, 15 years at Advocate psychiatric emergency services, where we all met and fell in love with crisis. And I have investigated elderly abuse for a couple of years at some different area. Council on Aging and some community based work as well.

Steve Bisson: 4:55

So the quick Math says that between us three there's 61 yearshave experience on ES.

Cara Tirrell: 5:01

Wow. Sounds about right. We're four years from now, Bill, you gotta retire. That's what I got from

Bill Dwinnells: 5:10

Four years. All right, I'll have to check my finance.

Steve Bisson: 5:12

It'll be 65. I mean, that's, that's a retirement. Oh, no, we're too young for that. 60 sounds so you still gotta pay? Last time, we talked about so many great subjects. And people really were interested in ES work. And one of the things that people asked me like, they said, Do you Do you enjoy es work that you like to do that stuff? And for me, it was always I miss it. But I don't know if I would go back to it. And that's kind of my answer. But I want to throw it to both of you and see like, because people really seem like, they're like, You guys are enthused, you seem to really enjoy it. But you know, maybe bill still in it. So might have a different answer. But how about you go first bill?

Bill Dwinnells: 5:50

Well, I mean, I've been doing it for so long. I mean, clearly, I love it. I really like doing emergency service work. It's it's very fast paced. There are no black and white answers, we always say that Emergency Services works in the gray. And that can be trying to figure out how to best serve the individual. Or in some cases, families, you know, what can we do to to help these individuals or families move along? How do we help them navigate the system, because the system itself isn't always very friendly. And if you don't kind of know where to go, who to talk to, or what to say, the truth of the matter is, it can be very daunting. And you know, these people are being asked to do this, while they're having some sort of psychiatric or some sort of emergency. They need help. So I really like being being able to be there. And you know, now I'm in a director's position. So I'm guiding other clinicians on how to get people to where they need to be, and to get them the services they need to be. And I think that's always, that's what's always really thrilled me about, about the job is being able to do that, despite a lot of the frustrations and, and barriers that we come up against on, unfortunately, routine basis.

Steve Bisson: 7:17

What about your Cara? I know you've been out of it now for about a year, right? Couple years?

Cara Tirrell: 7:23

Yeah.

Steve Bisson: 7:23

So how do you feel?

Cara Tirrell: 7:25

I would say similar to what you guys are saying is that there's something about being in a fast paced environment, every day is to every hour is different. You know, when you're in the ER, you're talking to the doctors, the nurses, the police clients, family making calls to the psychiatrists to consult, you know, it's very fast paced, you do have to be organized, you have to have great time management. And I think it's something that if anybody coming into the field, no matter what they want to do, I would actually say this is probably the best place to start to learn almost everything, diagnosis, people, you are consulting, giving clinical information, you're transitioning people through the their insurance, as well as determining level of care. So there's a lot of rich knowledge that goes along with it, you learn from everybody you work with, everybody has different styles. But the commonality is that you can think on your feet, you like that action environment, if you want to process things for a long time, this is not the place for you. This is kind of making decisions, giving directives to the doctors, like we said, and you know, they're looking to us for a lot of information, and resources. And that can be daunting, but it also can be very exciting. So as much as I loved it, and I 15 years, like I said, and you no longer in the rape crisis world and domestic violence, and I really liked working with the people there and making connections with people. I don't know if I could go back either. It's tough. It's a lot of work and Bill still in it. So he knows.

Steve Bisson: 8:58

And I think that what we were trying to do me and Cara here is to explain to Bill why we still love our work. But we may not want to do it for just what we used to do it for just saying though

Bill Dwinnells: 9:08

I welcome I welcome both of you back to emergency services at any time you waiting for you.

Steve Bisson: 9:16

But I think it's important to think about all the stuff that we went through. So I remember one of the things that has really changed about my since I worked on a crisis team, when people call me nowadays, if the phone calls more than 10 minutes, I feel like I gotta hang up on them, or God, you know, call the police.I don't know if you've developed some of these things, but like, it took me a long time to say okay, yes, I can relax on the phone for 15 minutes and it's okay. If you guys have developed some of these little quirks around in your life because of our emergency work.

Cara Tirrell: 9:49

I would say so I think transitioning from you know, I did the crisis work along with working for the town for that 15 years. So I was still in that crisis mode, but dealing with people that was a more, like you said, a casual, I don't say casual environment, but a different environment where it's not immediate crisis. So it's always hard not to go right to treatment, or go right away to giving someone a resource and kind of sitting with what's going on. And then fast forward to being in private practice, that's a whole other skill set that you need to have. And what I kind of reassure myself about in that is that the crisis work we did, makes us a tune to what to look for how to assess someone very quickly. And then also to be able to give community resources, which I don't think a lot of private practice know about what's outside other than another therapist or a psychiatrist. But you know, I'm familiar with the food pantries in the area, I'm familiar with the emergency funds, the substance abuse prevention, treatment, things like that. So that has been an asset to go into this field.

Steve Bisson: 10:57

I think that getting all those community resources, and the assessment of quick, though, in a quick way, is just something that we do. And we're not looking at one of the things that I also kind of love about the work we develop is I don't look for a diagnosis right away when I'm working with someone looking for the quick one, just to get it out of the way. So thank you private insurances to get me paid. But otherwise, after that, I actually do the real work, which may take a week or two, but at least you know, you could do that in private practice. But I like the fact that people like why you came up with that quick and like, Yeah, cuz I don't want to waste my time on diagnosing I just don't care about it.

Cara Tirrell: 11:31

Right. That's something that you've taught me, Steve, I think that's a really, that's a big difference of being in the psych emergency world where you, you have a connection with having to provide a diagnosis because of the insurance. And also, depending on what you think the person needs as level of care, you have to be able to provide the clinical to either kind of upgrade their need or even down size their need. So you have to be able to do both of those things and advocate for your client. Right. And the least restrictive. Yeah, yeah. Outcome. Bill, what about you? Have you developed any quirks because of your work?

Steve Bisson: 12:09

yes,

Bill Dwinnells: 12:10

well, the two of you know very well that I've plenty of quirks.

Steve Bisson: 12:15

I thought we had an NDA on that.

Bill Dwinnells: 12:20

Yeah, I don't know quirks that I've developed. I think probably one of the one of the biggest quirks is I've been told that I under react to things. Because in emergency services, we're used to hearing these wild, crazy, heartbreaking stories. People are just like, you're always so calm. When they tell these stories. I'm like, because it you can surprise me, but it's very hard to shock me. At this point. I've had people say that I agree that within five minutes of talking to you, I can diagnose you with some general thing that okay, this is the general direction that we're probably going and we'll have to work out the nuances of it later. But yeah, I mean, I would say that's probably one of the biggest ones. And I completely agree with Kara and I, I know Steve has the same feeling that every single clinician coming out of grad school should do at least a year or two, on an emergency service. So that when they get to the point where they are calling for involuntary commitments, Massachusetts, it's called Section 12. I don't know if you have listeners outside of Massachusetts, but

Steve Bisson: 13:33

I would I

Bill Dwinnells: 13:34

nationally know that oh, sorry. You got the

Steve Bisson: 13:37

seven in South America, and I will hit every continent. All right. But

Bill Dwinnells: 13:40

people who are going to be signing these involuntary commitments, they really need to understand what they're doing. You know, and they really need to understand what what these papers say. Because I think sometimes clinicians without that experience, are very quick to sign these things and then get upset when the ES team lets them go.

Cara Tirrell: 14:04

Right, because it is a powerful document, like you're saying, you know, I've seen so many times where I said, it literally says on the section 12. You can't section someone for substance abuse and the police, police or someone else or a community member or a psychiatrist or sectioning, which means taking away someone's rights, really, and they have to be unable to make their own decisions, which still doesn't mean that you don't have to advocate for your client. That's what you know, when I worked with elderly especially, or children, or a vulnerable population, that's a big piece of that job. And to take that away without really understanding the document, like you said, is dangerous.

Bill Dwinnells: 14:42

We'll have people call up and be like, Well, why can't you just section them? And you know, I've I've worked with a lot of law enforcement over the years and talking to them this section 12 This involuntary commitment. It's more powerful than an arrest warrant. Because even if Officer arrest you, they have to charge you with something in 24 hours or let you go. Okay, a section 12 I can hold you for three days. And I don't even have to tell you why. Yeah, you know, so there's that. So I think, knowing that because I don't want to take away anybody's civil liberties without a very clear cause. I think sometimes that might be what makes others in the field feel like I'm under reacting to stuff. That's like, I can't issue a section for something I think they might do. Yeah, just like, I can't pre arrest somebody. Because I commit a crime.

Cara Tirrell: 15:38

We'd all be in handcuffs,

Bill Dwinnells: 15:40

I'll be in handcuffs.

Steve Bisson: 15:42

Speak for yourself.

Cara Tirrell: 15:44

I'm speaking for you. That's a good point, bill is that it is hard to explain to someone who's not in the field or even in a different field, why that just isn't on a whim or so, you know, can be done, like you said, if someone's concerned because someone's not eating, and therefore that would cause some could they could die from that eventually. But that's really not what the crisis is, it has to be really an immediate safety issue. Right,

Steve Bisson: 16:14

right. And I think that what I would throw at you is like, sometimes people jump to that section 12. Way too quickly. Yeah. And then some people under use it also. And I had a conversation with someone that's going to be on episode it was on episode 53. Go back J ball. And Caitlin D. J. Ball works at the core response in Framingham, Massachusetts. Caitlin has worked at Westboro behavioral like them at the same time. But one of the things that we talked about in our last podcast was that how people are unwilling on a social work level, to sign a section 12 and a turned to the police. Who said And again, I'm not saying this about every police and every social worker. But some police have a high school diploma and they're like, oh, no, we'll turn to your high school diploma and doesn't work with mental health to decide if there's a section 12 here. And then we're saying that's pretty unfair, too. I figured I'd ask both of you, I thought it was a good point to make here.

Bill Dwinnells: 17:08

I encourage any police department to call whoever their local emergency service provider is, because one of the specs of emergency services that I do think it's underutilized, especially for the police, is a consultative service. I mean, under Section 12 Very clearly states I have or have not consulted with the local ESP screening team. So if the police or any social worker there, or anybody who can sign the section 12 has a question called the ESP. All right, that doesn't necessarily mean we're going to give you the answer you want. But at least then you've talked to somebody who you know, quite frankly, I mean, this is what we do all day, every day. Me and my team, the other teams throughout Massachusetts, we know exactly what a section 12 is, we know exactly what the criteria is, and what doesn't meet criteria.

Steve Bisson: 18:02

I'm gonna stop you for a second. So let's pretend someone doesn't live in Massachusetts doesn't know what a section 12 is. involved. What would why would you describe it?

Bill Dwinnells: 18:09

It's a paper for involuntary commitment. You know, I know when I was a California, I think they call them 5150s. Right. Right. Also very famous Van Halen album. But they've also been called Pink papers, involuntary civil commitments,

Cara Tirrell: 18:28

Because they are on pink paper. Just FYI. most of the time, unless it's copy,

Steve Bisson: 18:33

yeah. And then we talked about the three main criterias, which are danger to themselves danger to others, or lacking judgment that will cause bodily possible harm to themselves. Okay, but let me amend that a little bit. Well, that's kind of where I wanted to go. So you got you got the gist?

Bill Dwinnells: 18:51

It's very specifically suicidal, not they're going to hurt themselves, right? suicidal, homicidal. And both of these things have to be imminent. So if you tell me you're going to kill yourself next week, I cannot section you for that. Right. If somebody else next week, I can't sanction you for that. I can report that to the LAM warning that's different. But I can't section you for and same thing with the psychosis. You have to be so psychotic that you are in and again, the key word here is imminent danger, not just because you're psychotic. There are plenty of psychotic people wandering around in society today. 99% of which are not dangerous. They're psychotic, but they're not dangerous.

Steve Bisson: 19:42

Yeah, you want to make your point. I didn't know you were trying to Yeah, I

Cara Tirrell: 19:45

was gonna say just to be to clarify, too, and when we're assessing for suicidality, I think a lot of Steve's work with some of the podcasts in the different treaters is talking about suicide. suicidality as a baseline. feeling, you know, and talking about normalizing that and not going immediately to, you know, pathologizing it or saying that you're immediately in crisis if you have those feelings, and the way we assess that. And Bill, you do it more recently, but we assess by finding out if someone has a plan, is it something that they have access to? Do they have guns in their house? Do they have swallowing a battery is not probably going to kill you. But you have the intent to do that you have the plan to do that. And then we assess what the danger level is. So there's a couple different aspects as well, it's not that someone is suicidal, and tells you I want to kill myself. Those are sometimes people have hopeless feelings. Sometimes people feel helpless, scared, but they would say, you know, we talked about people, babies, somebody would say, Well, I would never do that, because I have two children, or I would never do that. You know, it was very rare. I thought in the years that I was at psych emergency services, that someone really had the intent and the plan to kill themselves. That didn't mean people didn't say that. But there was few and far between whether I saw maybe a letter that was very specific, you know, the hairs on the back of my neck plus the clinical clinical judgment, but I knew that person was could not be safe at home. You know, you just, again, with your instinct and assessing that.

Bill Dwinnells: 21:21

Well, I think you bring up a really good point, Kara. If you're going to do emergency services, you need to understand that when the individual sits across from you, and they say, I'm suicidal, I want to kill myself. That is the beginning of the conversation. It's not the end. You don't just sit there. Oh, you're suicidal. Okay, in the hospital, you go. Now that just like you said, occur, that is where you start the conversation, it prompts other questions, to determine plan intent and means, but also, what's driving this? Is there something driving this that I can help mitigate? Is there a service out there that you don't know about? But I do, because that's my job that I can connect you with, that can help alleviate or mitigate these feelings. So I think that's what I like to remind, especially when I get new clinicians in that just because they said they're suicidal. That doesn't mean the whole encounter stops right there and I put them in the hospital. That's where the encounter truly begins.

Steve Bisson: 22:26

Right. And I think I'm going to say, again, finding your way through therapy, Kara Terrell build windows, we're talking about emergency service work and how it goes. One of the things that I also would add to that assessment of suicidality. I've said this multiple times, I'm going to say it again, you need to ask the right questions. So there's passive suicidality versus active suicidality. There's also an the difference between the two is passive suicidality, if something happened to me, I wouldn't mind or something like that versus active. I'm seeking this mean by doing this thing in order to get to that end, that's more active. And it's also kind of like telling truthfully, I've worked outpatient pretty much throughout my career since I got like, since I started in 2003. Yeah, how many people I've worked with that are passively suicidal, that are in the community survived? And I've never done anything. I've never sectioned them. I've never done anything else around that. And I think that that's the other part that people will understand about, yes. My client says he's suicidal. What's the plan? Well, no plan. What are they going to do? They're not seeking it per se, but they don't want to live? Okay. Well, I don't know if that's meets criteria for something that we call section 12. In Massachusetts, or for me, I think maybe a good way to think about since is more international, taking away civil liberties. So I don't know what you guys think. But

Cara Tirrell: 23:44

good point. The other piece to talk about is also past history. And I think we should also talk about an important pieces. If someone has a successful Suez suicide, a completed suicide in their family that also lends itself to a higher risk when you're assessing for something, if they've had past intent, if they've had made past self harm. Those things are all aspects that we have to assess. And just to your point, and I'm sure Bill still doing this. When I used to go into the ER, I have a set route I went for, I'd always you know, find out who the referring person originally was, contact them. Look at the medical reports, because that's the advantage of being in the ER that someone has been medically cleared. Look at the substance use history, look at the contacts and collaterals that you need to contact. So doing those assessments beforehand gives you some more information so that when you do go in to meet with the client, you have some background information. So you do the assessment and then you follow up on more aspects of it. And sometimes if someone comes in where they're impaired, or their substance use, and they made an original statement of wanting to hurt themselves, well through three hours later when they sober up. Sometimes they say you know, I know I said that, but that was because of this, this, this. Now I don't feel like that. And of course, we have to collaborate it, we have to make sure they're safe and those type of things. So it is really hard to explain to a lay person, yes, they are suicidal, but we're not going to place them in a hospital against their will. So that's a really hard concept, I think to talk about to way, a normal person.

Bill Dwinnells: 25:24

I think a little Steve, you can rein me back in if this is a little off track. But I think we we talked about this in the last podcast, we did that there, there's still a lot of Magical Thinking about what an inpatient unit is going to do. And what has to be done in an inpatient unit, we've seen countless times that the vast majority of services that you can get inpatient, you can get outpatient to, you don't necessarily need to be on on an inpatient unit to, to get your meds looked at, to get some social services put in place, all the emergency teams in Massachusetts, can connect you with a very wide variety of services, probably more than we really have time to go into here. But all my brothers and sisters who are still in emergency services, they have not that you guys aren't my brother and sister,

Steve Bisson: 26:19

but I was gonna point that out. But I was gonna say

Bill Dwinnells: 26:23

they have a very wide variety of things that they can do. So, you know, the goal, really, it isn't that we don't want to put people in patient. We don't want to put people in patient who don't need to be, you know, there is a section of the population that yeah, they do need to be inpatient, and we'll take care of that. But not everybody who has a negative emotion needs to go into, into an inpatient unit. Right?

Steve Bisson: 26:46

When that'd be the whole population. Really?

Cara Tirrell: 26:48

Yes, I was just gonna say, normalizing all these different feelings, especially now I couldn't, you know, I kudos to you, Bill, because I know it's, it's a tough job right now, we had a tough job years ago, and I can't even imagine, you know, the complications, and how complex it is now. So I just remember how much it went into it. Nevermind, if there was a child, and we'd have to make a DCF report, or it was an elder, we have to make an elder at risk report, or it was someone who might be vulnerable and, and have a disability, we'd have to make those reports as well, while we're filling out another 12 page paper and trying to kind of get it all done within two hours, really, if that we have seven more people waiting.

Steve Bisson: 27:31

And I think it's a good shift to do too, because I would love to hear more about, again, Bill, you're the only one who's in it. But I certainly get reports from a lot of people since the pandemic, less beds available, more borders in the ER, a lot of more acute stress and acute needs in the community. It really has shifted, it's always been kind of difficult, as Kara pointed out, we've seen it ourselves. But I would say that in the last two and a half years, the acuity and the borders in emergency rooms, has gotten significantly higher, particularly for mental health services. How is that shift? Kind of like? How did es work has How have they dealt with that shift?

Bill Dwinnells: 28:13

Well, I mean, the last two years have been extremely trying for the entire population, not just Yes, work. Things were complicated, obviously, because of COVID. So a lot of the community services that had been in place, out of necessity had to shut down, either because their own staff were sick, or because they just couldn't take the chance of infecting their staff. And even today, we're still seeing the results of that. I don't like to blame everything on COVID. But it did make a very huge impact. You know, people weren't getting the services they needed, which then caused them to go into crisis. And then what's their first thought oh, I'm gonna go to the ED. So now the ED gets overloaded. But the EDI've said this numerous times before, if, if you want psychiatric assistance, the ED is not the place to go. And this is no, I have complete respect for everybody who works in the ED the nurses, doctors, and so forth. This just isn't what they signed up for. They're there for medical things. But there's some people there who were there for like psychiatric nursing and stuff like that. But even they, this isn't really what they do. Know, they're really just kind of a holding place until you move on to the next level of care. So when they start getting overwhelmed with folks like this, it becomes very difficult for them. You know, as the emergency service team I come in, and we're trying to move people along the system, but the rest of the system has the same problem. Their staffing is down because of COVID. There's a staffing shortage across the board all industries at this point. So I have friends who are intake directors of some of these hospitals. And they have, physically there are enough beds, they don't have the staff to open the unit, either because of COVID, or they just, you know, they just can't hire. In some cases, there are empty beds, but there's no one to staff, the unit, the beds that can be staffed, they're overwhelmed. Because every step of the system right now is bottlenecked. Once one person moves, it can move forward one space, but that's it. And the problem is you get well in the hundreds of people who are waiting for beds or placements of places. So that's, that's the problem. What have we been doing to try to mitigate that a lot of the e ss have been doing the e ss and some of the inpatient units have been doing some really exciting out of the box thinking there, we've seen a tremendous increase in the number of virtual partial programs, where somebody can attend the partial program virtually, it's usually nine to one nine to three, depending upon the program, where they can attend groups, virtually, it's not as exciting as doing an in person. But because it's virtual, they can actually have more people. So they're actually able to service more people. And they can schedule time to meet with a doctor who can review their medications, and do things like that. As both of you know, a lot of times people would be sitting in the ED with no treatment whatsoever until they got to the inpatient unit. One of the things that we've been able to do with one of the local hospitals is create a virtual partial program that they can start while they're in the ED. So the time they're spending in the IDI is not wasted, untreated time.

Steve Bisson: 31:56

Emergency Departments can be overwhelmed, they probably like that. Yeah.

Bill Dwinnells: 31:59

So I mean, that's been fantastic. We've been making a lot more increases to our emergency medication evaluations we've been using, I can tell you, my team has been using crisis counseling a lot more. So we'll help you bridge. If you know, you're going to have an appointment with a therapist and four weeks, my team will Bridger will see you every single week for the next four weeks until you're able to get to your regular therapist and other creative situations. You know, I mean, that's just the tip of the iceberg. But people, people have been very creative. Across the board, I hear my colleagues making all kinds of really interesting, out of the box thinking as to how to address the needs of the people in their communities. And it's very exciting.

Cara Tirrell: 32:50

I want to add a few points to that Bill, because I think when you do work in emergency crisis work, I think it goes a lot of it goes against all everything you learned in your master's program of how treatment should should be conducted, how, you know, confidentiality should be happening, how interactions with people, I remember the issue about the boarding is going into the ER and saying, I need to have a private room to talk to this person. And believing that that's one of the basis piece of doing any type of interaction in a clinical way or a professional way is that I need to have confidentiality, I need to give this person dignity, I need to do this. But meanwhile, the reality is there's five boarders sitting on beds in the hallways, and I have to do an assessment with five people around us. And that was that was tough to do professionally. But also, just logistically, that's a tough one. And when someone is in the hospital for the psych issues, to your point is that's all consuming for those medical professionals, you have to have security, you have to have constant connection with the calling the emergency services team and finding out when they're going to be there. During the box levels, the tox screens, the blood alcohol level, doing constant medication, if someone is withdrawing and going into with withdrawing or detoxing, there's all those things plus the medical piece as well. So that's when we have that I'm just referring to when we used to work at MetroWest Medical Center Framingham there was just one corner that used to be the psych part we had kind of like a little closed off area. And then we had like a closet that we could do our assessment in and there's two of those like three to four of us sitting in there making phone calls, you know, consulting, things like that. But it's almost laughable that this important issue is still not given the space they need not giving the money they need, not having a place for people to go because it does feel almost endless when you know this person needs to know a certain level of psychiatric care. And you really can't refer them anywhere. If there's no beds in the whole state, it feels very impotent you feel, you know, that's a stressor that I'm sure you and your staff feel all the time. And I can't imagine what it's like now, because we felt it five to 10 years ago.

Steve Bisson: 35:18

Right. And I think that that's kind of something that if I was someone, and I know we're not doing an infomercial by any stretch here, but if I was someone listening to this, I'm like, I'm 24. I wonder if I want to go to ies, I think we're doing a really piss poor job on selling.

Unknown: 35:32

That's just my, the best time in my life. Right. So I think I've

Steve Bisson: 35:37

barely touched on it. And I think it might be important because I honestly from the bottom of my heart, and I think now I can finally look at a camera and say, probably the best time of my life. I really truly enjoyed my work, no jokes, I learned that I didn't want to work with this population. And this population, which I had no interest whatsoever, suddenly became a population I work with. So for me, I want to be able to I make no money, people going to ies or not, that's not the point. But for me, it's like I said, we said earlier, we tell people go do ies work for maybe a year or two, in order to really figure out some stuff. So maybe might be important for us to kind of like discuss out loud, why would someone do es work? What are they going to discover? Why do they want to eat spaghetti next to the bathroom in an emergency room instead of something else?

Cara Tirrell: 36:28

Well, if you like smelling shit on the walls in the airport, this poor attempt to put coffee grinds and a little bedpan next to, you know, the bed to try to, you know, mitigate the smell, and you could still eat a pizza, then you're there in bed. But seriously,

Steve Bisson: 36:43

but I heard I hear that if you spread feces on the wall, as a psychiatrist, I could say off the top of my head, give you a section 12. And

Cara Tirrell: 36:51

I know exactly what you're talking about. And then some won't. So think about that as your perspective changes when you're in the you know, you're within this department is your what regular people would think is an emergency or a horrible situation is almost the norm. So you do have a different perspective. But I think the best part of that was I loved going in and having a case that would include talking to the police talking to I love that part of the investigatory piece of it. So you had to deal with lots of different professions, you had to do things very quickly, which I found very exciting. There was never a dull moment, even if some of the cases tend to be similar in some ways. None of the days were ever the same. I love my colleagues, obviously, we always had a good time, because we did have a lot of things in common. And we did try to support each other in this times. The professionalism that you get that you gain is part is outstanding, because you learn so much. I remember going into my master's program. And so many people had just gone from their bachelor's right into their masters that had never worked in the real world. And I thought you're missing out because some of these things you want to implement, like, I went to Leslie so there was a lot of expressive arts and things like that. And I said, How would you do that while someone's urinating in the corner while you're trying to talk to them? You know, I think about all these things, but the real life experience, kind of with the professionalism and the knowledge that we do have melded in a really, you know, almost a perfect way. So you learned a lot. But you also, you were right in the action, you were doing everything that you needed to do, and not only to talk to the insurance companies, which is that's a tough job in itself, but doing bed search. So you're connecting with people that are intake workers, you're then talking to the nursing staff at all the different hospitals in the whole state. You know, that's pretty impressive.

Bill Dwinnells: 38:49

I would definitely agree with that. I think Kara hit on a really good, good reason to do ies aside from the clinical experience, because you're going to see every diagnosis in the DSM five, walk through your door, probably in about two years and probably see it multiple times. And it's it's very different reading about somebody with a psychotic disorder versus having somebody with a psychotic disorder sitting in front of you. How do you engage them in a meaningful way? You know, because that's really the key of what we're doing. How do I engage this person in a meaningful way? I don't have three or four sessions to develop rapport with this individual. I've got about 10 minutes, if that probably closer to five because if I can't develop rapport, they're just going to tell me to go off and get out.

Cara Tirrell: 39:36

Have you ever heard anybody say that to you, Steve or bill

Steve Bisson: 39:40

about what set me off? I have a board in my office.

Cara Tirrell: 39:44

That's all days. But that doesn't faze us and that didn't faze us so you didn't hurt my feelings. You didn't make me feel less as a clinician. I reveled in it. You know, I I would say you know, this is more of a challenge or I'll use this humor or this, this irony to develop this report, like you're saying, I think,

Bill Dwinnells: 40:07

you know, and it's important to remember that that's one aspect. Because right after you have that conversation, you need to go to a doctor and have the same content, but a different way of talking about it. Yes, which then translates into the same content, but a different way of talking about it to the insurance company, you really develop the skills of how do I talk to other professionals? In a way, you know, how can I relate to this person who's having this emergency right here, and now where I need to be relatable. And five minutes later, I need to have this conversation with other professionals that I need to, in some ways, ease their anxiety that I know what I'm talking about, and have developed an effective plan, I can communicate that in a professional manner, regardless of what just went on in the exam room. Or, as I said, we're big focuses on community now, I mean, it could be what just happened in this person's house, that I now need to communicate to another professional. Because a lot of times, that's what, that's what it really is, especially talking to doctors, it's managing their anxiety about the case. Because what the doctors don't usually admit to is they're looking to us as the experts.

Cara Tirrell: 41:31

How many times we've gone into the ER, and they say, What do you want to do? And I'm thinking, me, me, okay, well, here we go, this is what we want to do. And to your point, you do have to have that ability to switch. So you've talked in rapport building communication to whatever the person is presenting at. So they have to be very flexible, you have to have different styles, we see kids from zero, and we see all the way up to 100 year olds, so you have to be ready to see a five year old kid, talk to their parents do the assessment, call their teacher, then, like you said, present to present in a clinical manner, which is a lot of diagnostic terms, and using some you know, assessment and really utilizing your knowledge of kind of that book stuff that we learned, so that you can present it so that person will accept it and agree to your plan, or at least be able to consult with you on that. And then we also have to transcribe it because I know you've created this software. But in the olden days, we had to write everything down. And it was 12. I remember 12 pages, and there was paragraphs we had to write there was you know, yes, there were checkmarks. But you had to have documentation for everything that you were saying, right. So it had to be able to be proved, you can't just say someone uses cocaine three times a week, this person has used it, this is the history, this is the consequences to this. This is the surrounding triggers and kind of the environment that that person is in. So there was a lot more that you have to assess.

Steve Bisson: 43:07

Right. And I think that a couple of things that you want I want to come back to is doctors turning to us. And that's always been kind of like a weird one for me at the beginning. And then you get used to it. And it's almost at one point, you get so used to it. So if a doctor challenges your what your outcome is going to be or what you desire as an outcome and recommendation. It's almost like wait a minute, what the other guy was asking me whatever I wanted to do. Right? So I think that that helps to learn to be more critical about your clinical work and how you're going to make decisions. So I think that that's a good thing for me, even though it sometimes turns you off. Either way, it's something that you got to learn. One of the things that I think you're right, I think I read both of you saying this, but I'll say it in a different way, is that you learn to de escalate a situation significantly better in an emergency service than any other job you'll ever have. Because one of the things that I remember my first supervisor at the Job said, if someone has psychosis, and they tell you those, and again, we're not making fun of psychosis. But if they say there's little blue people coming to their room and telling them what to do, you can't challenge that you got to say, what are they saying? How many are there? And so you get to a point where the personal feels like almost acknowledge and validate this by possibly being in psychosis, and being able to make a better judgment. Is this hospital level of care? Is this outpatient? Is it partial hospitalization everywhere in between, obviously, but I think that that's one of the things that I've really also appreciate learning for you don't learn that in your internship, but you'll learn that on an emergency service.

Cara Tirrell: 44:39

Yeah, to that point, I think, and I think we talked about this in the first podcast that brings to mind if someone doesn't speak English as their first language. If someone is deaf, you know, asking, can you hear voices in your head and then I'm like, wait, I can't ask this question to a deaf person, because that doesn't make sense. You know, so then kind of adjusting it to what, what the client is presenting us, you know, and there's cultural differences. There's gender differences. There's the substance use issues, history of trauma. So there's so many aspects you really have to consider. I remember saying, doing an assessment where the client was, you know, Hispanic, and they were presenting this like saying psychosis, but when I did the evaluation with a, with a translator, or an interpreter, you know, coming to kind of assess that this was more about a face experience of seeing or hearing someone. So that was very different. You don't hospitalized someone for having a conversation with a grandmother who died three years ago, or whatever the that is, you have to assess it and figure out which is which. But that's an aspect of it, that you really have to be nuanced enough to, to assess.

Bill Dwinnells: 45:50

And I think, again, not to put too fine a point on it. But you know, I think what you're both say is in EMS, the primary job is to de escalate. However, we need to keep in mind that it's to de escalate the individual we're working with, but very possible, you need to de escalate the hospital staff, the residential staff, the insurance staff, we have to be able to build confidence in all of those people. So that we can get a really clear picture as to what's going on, and make sure that we're basing our decisions, our plans, you know, whatever, on actual clinical information versus someone, whether it's the client or one of their providers, emotional state. Right. Right. Yeah. Unfortunately, sometimes they have agendas to your right.

Cara Tirrell: 46:46

And that and that's another thing. And maybe that's the segue for, for Steve, having to have boundaries for as clinicians and how you develop that, because I don't I absolutely, and Steve, and Bill, you probably do it differently. But there was no training on that at all. I think my first day, nobody talked to me the whole day. And I didn't even know how to make copies. And I was in the ER right away already putting in those days, we had stickers, you know, we had to put a sticker on each page that we did those 12 pages of evaluations, the stickers with the clients information, then you had to have the medical issues. So I remember that and it was no, no. And there's also things that we talked about before about gender, me going into a room with a man who might have a predatory history, that's a different experience. And it's hard to be scared or uncomfortable and do a proper assessment. So that is really difficult. So you have to also be safe, you also have to be monitoring your own reactions and your projections and all those things to

Steve Bisson: 47:47

why you're saying stickers. I remember when we had to go to a machine and go

Unknown: 47:52

Clank clean.

Steve Bisson: 47:55

Like, that'd be my first thing to do. You got the

Cara Tirrell: 47:58

stamp. Right?

Bill Dwinnells: 48:00

And then the stickers. Alucard card.

Cara Tirrell: 48:03

Yeah. Oh, yes. Yes. Yes. That was that was always a paper clip. On the front, my memory.

Steve Bisson: 48:10

But no, I think that it's a good segue to talk about self care. Because for me, self care wasn't something that really occurred at the beginning of emergency service work for me. The first thing was, oh, take a few phone calls. Alright, you're good. So no overnights a Friday night. You're good. When you mean, you're good. You're good. You answered three phone calls. You did great. That's awesome. That's was your training. Steve. The one lesson that I remembered that I truly, also respect from one of my supervisors. It said, like, if you have personal issues, when you get to work, take the backpack of personal issues, you leave it at the door. Once you get into this office, you pick up the work office back back, put back on your shoulder, you go in and deal with that. And when you're done with your day of work, you take your backpack, put it down, pick up your personal stuff, and you put it over your shoulder again. And it was a good way to kind of set it wasn't called boundaries, obviously now we use better language. But for me, it was a good way to think about boundaries in regards to like when you're in your personal life, you know, carry your work stuff with you. But I don't know if we give enough. We call it self care whether it's teaching people how to do self care, but more importantly, having agency support self care. And I don't know about what happens today, Bill, and what your points of views are, but I would love to hear more about how do we encourage people to do EMS, which is hard work. But we also joke about because we liked it. We certainly would go back for it for a significant amount more money. Just before you ask Bill again. At the end of the day, though, it's what can we do about self care so that people can get this work and actually last for like us like, what? 61 years combined?

Cara Tirrell: 49:53

And we're only 20 years old.

Bill Dwinnells: 49:56

I wish what can we do? for self care? Well, I mean, a lot of it, I think is kind of what you said I having some good boundaries. I think we used to call it compartmentalizing. You know, I can compartmentalize what I do at work versus what I do at home. Unfortunately, because of the work we do, sometimes it spills over. And when that's happening, you need to know, when you need a break, and everybody has different self care, things that they do. I know, I work with one clinician, she she likes to go get a massage. Personally, I've always used meditation, I've done a lot of meditation for my own self care. But other people will go for hikes, they'll go canoeing, they'll go camping, they'll do something to get themselves out of their mindset. One of the things that recently occurred to me is we do a lot of talk about self care. And I don't want to be misunderstood. self care is very important. But you don't have to do self care alone. And I think that's the part that gets missed is, you know, especially if you're going to do this kind of work, talk to your colleagues, do things with your colleagues, that's not related to emergency services, that's going to help you develop healthy coping mechanisms. It's also going to, you know, lead us to some pretty good friendships, kind of like what we have here on screen. But because the people who do emergency services, especially if we do it for any significant length of time, we actually become our own community. Because unless you've done the work, you're never going to truly understand the work. I do make this comparison between the emergency service workers, the first responders, military, it's not exact parallels, but there are some aspects of it that are very, very similar, that unless you've been us, you don't know us, though, I encourage everybody to try it. Because the benefits, I think certainly outweigh some of the struggles that you may have, you know, but I think that's an important aspect of the self care too, is that self care doesn't mean you have to do it on your own. You know, you should be working with your colleagues and having them support you and you supporting them when necessary.

Cara Tirrell: 52:19

It does make a difference if someone is role modeling a supervisor as role modeling their own self care or community self care, like you're talking about and the environment and the culture of the department that you're in, because there's no way that people would not have a problem with some of the things that you have to see maybe processing them or seeing people in their maybe their worst day, that's a really tough thing to have to do. And then to go home and not be able to really talk to anybody about it. Not only to confidentiality, but like you said, you you can't really explain to someone who's an engineer, what you saw at the ER, and they'd be harmed by by some of the things you're like, well, that's not what I'm horrified by this is the other aspect that I'm kinda is more upsetting, you know, because you see it differently, you

Bill Dwinnells: 53:06

definitely see it differently. Like you said, you know, you can tell them the story and exactly, you know, the like, oh my god, that must have been hard. It's like no, the hard part was dealing with the insurance company.

Cara Tirrell: 53:17

Right, right. That part was our parts that frustrated

Bill Dwinnells: 53:20

me because the the damn person just wouldn't listen, or the doctor disagreed with me or whatever it's like it. It's funny that those are the things that ended up bothering you, when you would think it would be the story that person told it's like, no, that I can handle that. All right. But it is interesting. It's interesting, what, what may bother one person doesn't bother the other.

Cara Tirrell: 53:44

And that's a good point, too, is is knowing your strengths. Because if you are the best one able to deal with younger kids versus you know, I was called in a lot of times for working with the elderly, which I feel like that was a passion of mine. But also, I felt very knowledgeable about working with elders and seniors and some of those aspects. I felt like that was kind of a niche that I had a strength in. So you know, when you say like, Bill, or Cara, do you want to take this case, I would say well, if it's an older person, I'll take that one or bill you would say, you know, a teenager or younger child.

Steve Bisson: 54:18

And I think it's all important stuff to remember. I mean, to me with the self care is that I remember at one point when I was working for the team, I got a call on a Sunday and like they like Steve, I know you're not on call. But we have a firefighter in the emergency room. We need someone who will get it. So it wasn't about saying anything bad about our colleagues. But that was kind of my my strength. My forte and I think sometimes it's good to think about that. We have someone who is elderly who may have started early onset dementia, or any dementia for that matter. I may not be the right person for that and might be more Kara. And you know, Bill really finds a way to relate to a whole lot of people that a lot of people find very hard to relate A two bill is really good at that. It's finding those strengths and knowing your team enough, but also knowing that if it's just you, you do it and then go, Hey, Bill, when you have a chance to just this is what I was going to try to like this. One of the things I've learned in the last year, is that when you're having a hard time, don't sit there and say, I'm having a hard time. No, call care call bit, but maybe not you, that's I'm talking for me. But call of someone you trust that will listen to you. And if you're saying like, you know, I was thinking this, but this happened. And it really bothered me that the nurse did this. And you'll all of you will not like exactly what I'm talking about, oh, yeah, you talk to someone who's not working our field, they're going to be replaced by the nurse. Ah, you're missing the point here, right. Reaching out to people who get it is also very important.

Cara Tirrell: 55:51

Yeah. It is a unique experience. And there are a lot of positives, and we all kind of have, you can see us light up. But when we talk about it still, that there was some excitement that we loved about it. We loved you know, showing our skills and always having something that might test us and we kind of looked forward to that was fun, it was exciting. You have to do have have a certain type of personality like crisis, because it is very unique.

Bill Dwinnells: 56:20

Let's face it, it feeds our egos to a little bit. Because think about it. When you're working in emergency services, what do you get, you get the cases that nobody else knows how to figure out. Nobody else knows how to handle or help this person. And you don't have anyone to refer them to. It's you, you figure out how to best help this person. And again, the solutions you come up with may not necessarily be the long term solution, because we usually think in terms of 24 hours, what can I do to help this person within the next 24 hours? Which going back to our quirks, probably is one of the reasons why I'm a very impatient person. I don't wait Well, right. I want things done immediately. But I do think it's one of the things that can give us confidence. As a therapist, think about it. The two of you have done emergency services for a long time. I know you have your specialties when it comes to doing the private practice therapy. But in all seriousness, is there anyone who's going to sit across from you that you won't be able to find some way to help? It may be that you know, you need to refer them out to somebody else. But you're at least going to be able to address their immediate need. Right?

Cara Tirrell: 57:35

I agree with that bill, because I remember when I first was thinking about the practice, and you know, Tanisha, not to niche and your specialties are and I always everything I looked at, I said, Well, I could do that. I know I could do that. Do I want to or you know, is that kind of part of my business plan? What do I want to do? But I knew in every situation, I couldn't do that. Because I've seen that. And I've worked with all different types of populations. And I have that experience and that knowledge that again, you don't get from a book. Right.

Steve Bisson: 58:07

I think that bill called us egomaniacs. But that's just my opinion. And I agree with you wholeheartedly by, by the way, because there is something about the work that we've done that just feels right. For us. And one of the things that I would just coming back a little bit about those who want to do ies and why they should do it. There's not a day, I don't walk into my private practice outpatient service that I sit on my butt and deal with people's past issues or what have you. And go, this is so much easier than sending in an ER and figuring out what's going on how to create this. Also, how are we going to get the right outcome for this particular like that that's a lot. And like we did it went in three hours. Now I'm sitting across from someone for 45 minutes to an hour, and I don't even have to figure out the outcome. The outcome is I'll see you in two weeks or right or whatever. Yeah, about that. Grateful I created a lot of great, yes,

Cara Tirrell: 59:00

I totally, that's a good really good point, Steve is when you're thinking and then that's something I've struggled with, in the private practice of every session trying to to think that I have to do something, or fix something or make sure I provide them with a resource that will be something that they can leave with. And that was like, like simmer down power. Like it doesn't have to be this is part of when my husband said, Am I supposed to just listen or give you ideas. I'm like, just listen, you know, and just that learning to just sit with that feeling and just saying, you know, I can have that shared empathy, you know, that that compassion teach you different strategies, but I can't fix it. You know, and that's okay. And that's part of what why therapy is different from crisis work.

Bill Dwinnells: 59:45

Absolutely. I know when I first started in private practice, I was like, Oh, you came back. Was Was Was I unclear what you should do last time. You should be fixed. What's going on? Why are you back? I don't understand it.

Steve Bisson: 1:00:00

I remember a conversation with you start private practice, we had a conversation about that, because someone had come in with a specific acute issue. I'm going to talk generally here. And you're like, Well, I took care of the acute issues, the what do I do for the next few weeks? Talk to them, you think that's the only issue they have? What do you mean, like took care of the issue, Bill? That didn't just show up with an issue. There was probably a history.

Bill Dwinnells: 1:00:25

I told them what to do what's

Steve Bisson: 1:00:28

I don't know if you remember that conversation? I

Cara Tirrell: 1:00:30

do. Yeah, and to try to sit with that feeling that some of the rapport building, especially with the teen clients, that I see is just as important as giving a solution is that so that building that rapport building that relationship so that when they do have something to say you're there for them, because they know, next week, and then and then they'll come out of the blue from these teams, and you're like, wait, they're telling me something so intimate or so, so important. I'm the only adult they've ever talked to about this, you know, that that playing Jenga, or, you know, uno, or beating them at all those games was was important because I don't let them win. But But I think that was like it still was important in validating them and all of us, see, we're on the cusp, but Bill and I are, you know, veterans of having teens at this point. And they're a hard nut to crack. You know, my kids don't talk to me. But these these kids I see in private practice, I'm a different, you know, a parent is different from a therapist. So those were you have that advantage.

Steve Bisson: 1:01:37

I'll be consulting with you guys for that one. But you know, the problem is, is you guys had boys? I have girls.

Cara Tirrell: 1:01:44

Yeah, it is. It's tough. Either way. It's tough. No,

Bill Dwinnells: 1:01:48

I have a I have one right now. Like, well, you, I can't talk to you don't understand me. I'm like, I talked to 10.

Cara Tirrell: 1:01:57

I'm literally went to school for this. Okay. You don't know anything?

Bill Dwinnells: 1:02:01

I have an advanced degree in interpersonal communication. It's no practices, all 18 to 22 year olds, I, you know, right.

Steve Bisson: 1:02:14

I think it's already been an hour. So we got to kind of wrap up here. And if there's anything I know, we started off with the plugs. But is there anything you wanted to add that you know, for people who reach you? For me, I think about people who might want to know more about es work, particularly Bill, what you're doing now and carry your work with? For me, the stuff that really fascinates me is your work with the elderly, but also pandas, which is something that's not well known. So if you guys want to speak to any of those things, or none of that is fine with me too. But,

Cara Tirrell: 1:02:43

sure. And again, Tanisha, not to Naish, I thought about, you know, I said to Steve, when I was first I said, Well, I can't do this. I don't know enough about one thing. And he's like, Are you kidding me? Remember all this experience? Remember, the work you've done in the school system with for Tourette's or pandas? And I started to be like, Okay, wait a second, I do have some, some strengths. And you know, maybe some things I'd prefer, I've been ran a caregiver support group. I've worked with domestic patients, I have an Alzheimer's training, I worked at several nursing homes, senior centers, elder protective services. So I do have that strength, along with the pandas that you mentioned, which is pediatric autoimmune, neurological disorder. So it's, it's it's very interesting, like you said, because it's not always accepted in all the medical field. So if you have some knowledge about Tourette, which is a neurological disorder, there is a connection there with that. And sometimes kids who have strep throat or some sort of an infection and ends up escalating some of their response. There's, there's a lot more information. It's neurological, but basically, some of the responses end up being maybe some obsessive OCD, obsessive compulsive type of behaviors, some self harm type of behaviors, or some behavioral issues. And it's really a hard, difficult and complex disorder to understand, especially in the school systems, which expect kids to just sit down and not move or talk during instruction or curriculum. So it's really a place where, where knowledge is needed education as needed, and that support in the medical field, but also the psychiatric field. So again, that's something I'm drawn to, I have a personal relationship with that and a professional relationship. So I have some compassion and empathy for parents trying to parent children who are experiencing that, but especially a kid trying to manage that as well.

Steve Bisson: 1:04:40

Thank you, Karen. And definitely hopefully you'll get those referrals and more. So thank you for that

Bill Dwinnells: 1:04:46

bill. I'm still doing emergency services. So if anybody wants any information on that, feel free to contact me through my website. You know, anybody who has any questions about that, feel free to reach out to me that's that's fine. Private Press. Practice. As Steve taught me a long time ago, apparently I'm very good at solution focused therapy, and brief therapy and been working a lot with older teens. And you know, those who are kind of transitioning out of college into the adult world, as well as anxiety, and so forth. You know, I'm really drawn to like mindfulness practices, and the use of meditation, as I had commented before. So if you're into stuff like that, hit me up, happy to talk to you about it.

Cara Tirrell: 1:05:31

That's great bill. Because I love the mindfulness, I really started to work with that. I really love that. And that's so important, and really starting to talk about self compassion. I tried to practice it myself, but as an Irish Catholic woman, it is very hard thinking about, you know, having compassion for yourself, because I always think about, would you talk this way to a friend, No, you wouldn't be such a hard as, basically, you'd be really compassionate and, and mindful and giving them a pass. And, you know, saying that's okay. All those things that you would do for friend trying to turn that in

Bill Dwinnells: 1:06:05

on yourself? Yep, absolutely. It's very, very difficult and very needed. Yes.

Steve Bisson: 1:06:12

It might be something that we could discuss off air or even in the next podcast, if you want to come back. But how that mindfulness and meditation and other process practices like that helps you ground yourself, especially in the ies work, but also in general, and how that could help individuals to do that good self care during yes work, but

Bill Dwinnells: 1:06:32

just the thought. Sounds good.

Steve Bisson: 1:06:35

I thank you very much, guys, and I'll see you I'm sure soon. See you later. Thank you. Thank you. Well, that concludes episode 55 with Kara Terrell and build windmills. Thank you so much again for the great conversation. Really enjoyed it. I hope that you enjoyed it too. Next episode will be with Lisa Dennis, who will be talking about spirituality also. So I'm looking forward to having a conversation. I know we talked about wrestling a few seasons ago, but looking forward to our conversation in the next episode. Please like, subscribe or follow this podcast on your favorite platform. A glowing review is always helpful. And as a reminder, this podcast is for information, educational, and entertainment purposes. If you're struggling with a mental health or substance abuse issue, please reach out to a professional counselor or therapist for consultation.