Psychiatry Boot Camp

In this episode of Psychiatry Boot Camp recorded live at Saint Louis University, Dr. Mark Mullen is joined by Dr. Kristin Mueller, an emergency medicine physician and physician-researcher at Washington University in St. Louis, for a discussion on firearm violence as a public health crisis. Dr. Mueller, who works closely with the Life Outside of Violence hospital-based violence intervention program, walks through the clinical fundamentals of lethal means counseling, including a live mock counseling session demonstrating how to approach a patient in mental health crisis with access to firearms. The conversation covers practical, evidence-informed strategies for secure storage counseling, verbal de-escalation, and navigating patient resistance without leading with statistics alone.

The discussion then turns to the epidemiology of firearm injury, including findings on non-fatal firearm injury rates, recurrent injury risk among adolescents and young adults, and the structural factors that shape risk beyond individual behavior. Dr. Mueller details the design and outcomes of the Life Outside of Violence program, a hospital-based intervention that pairs licensed clinical social workers with patients ages 8 to 30 following violent injury, and shares emerging data on goal-setting, goal achievement, and patient-reported outcomes. The episode closes with guidance for clinicians seeking to identify or refer patients to hospital-based violence intervention programs in their own communities.

To find your local hospital violence intervention program, visit www.HAVI.org.

Takeaways:

Clinicians in all specialties can and should ask patients about access to firearms and medications as part of routine safety counseling, not only during acute mental health crises.

Secure storage counseling is most effective when delivered with a calm, nonjudgmental approach that avoids leading with statistics alone.

Non-fatal firearm injuries vastly outnumber fatal ones, with 93% of firearm-injured patients at St. Louis's level one trauma centers surviving and returning home.

Patients treated for a firearm injury face a 7% risk of re-injury within one year and up to 17% within eight years, with adolescents and young adults at highest risk.

The Life Outside of Violence program pairs licensed clinical social workers with patients for up to a year after injury, addressing housing, transportation, and trauma counseling alongside medical recovery.

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Chapter:
00:00 Live Show Intro00:45 Meet Dr Mueller01:36 Asking About Firearms04:12 Mock Counseling Roleplay10:28 De Escalation Secrets12:50 Legal Options And EROs14:36 Psych Care Gaps In ED18:49 Clinical Pearls And Resources23:24 Ad Break26:01 Back From Break26:40 Firearm Violence Public Health27:00 Firearm Injury Public Health28:02 Beyond Politics and Blame29:48 Data Gaps and Hospital Sharing31:34 Nonfatal Injuries and Recurrence33:49 Funding and Program Origins34:45 How LOVE Works37:39 Meeting Patients Where They Are41:50 CVI Ecosystem Partnerships43:26 Measuring Impact and Outcomes51:54 Success Stories and LOV Meaning55:27 Call to Action and Resources57:14 Outro and Listener Review

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Dr. Mark Mullen welcomes Dr. Allison Hadley, a psychiatrist and medical director of the psychiatric emergency service at Oregon Health & Science University, for a discussion on motivational interviewing in high-acuity psychiatric settings. Dr. Hadley introduces a novel teaching framework that draws on Tina Fey's rules of improv from her memoir Bossy Pants, mapping core improv principles, including "yes, and," making statements rather than only asking questions, and treating perceived mistakes as opportunities, onto the foundational techniques of motivational interviewing. The conversation covers the OARS mnemonic (open-ended questions, affirmations, reflections, and summaries), the relationship between motivational interviewing and trauma-informed care, and practical strategies for identifying and reinforcing patient change talk.

The discussion also addresses the stages of change model and the ask-tell-ask method for delivering psychoeducation in a patient-centered way, along with harm reduction interventions used in the psychiatric emergency department, including methamphetamine safety kits. The episode concludes with an extended clinical role-play demonstrating how to apply these techniques with a patient presenting with anxiety and co-occurring cannabis use, illustrating how motivational interviewing can be used to build therapeutic alliance without alienating patients who are ambivalent about behavioral change.

Takeaways:

Motivational interviewing is considered a cornerstone, evidence-based treatment approach for substance use disorders in psychiatric practice.

The improv principle of "yes, and" can be applied clinically by affirming an emotionally salient part of a patient's statement before introducing a new therapeutic direction.

The OARS framework, open-ended questions, affirmations, reflections, and summaries, provides a structured method for conducting motivational interviewing conversations.

The ask-tell-ask method allows clinicians to deliver psychoeducation only when a patient has explicitly consented to receive it, preserving patient autonomy.

Harm reduction tools, such as methamphetamine safety kits distributed in emergency settings, reflect an evidence-based, non-judgmental approach to meeting patients where they are in their stage of change.

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Chapters:

00:00 Why Motivational Interviewing

01:09 Meet Dr Allison Hadley

02:33 Who MI Is For

04:37 How MI Works

07:27 Tina Fey Improv Lens

09:06 Improv Rules In Practice

19:19 OARS Core Skills

23:13 Reflections That Land

24:25 Summaries And Change Talk

25:01 Sponsor Break

27:38 Spotting Change Talk Cues

32:08 Stages Of Change Basics

34:23 Ask Tell Ask In Practice

39:30 Roleplay And Final Takeaways

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Dr. Mark Mullen welcomes Dr. Christine Crawford, Chief Medical Officer at the National Alliance on Mental Illness (NAMI) and author of You Are Not Alone: For Parents and Caregivers, alongside Steve Hoffmann, Senior Vice President and Chief Preclinical Officer at the Foundation for the National Institutes of Health (FNIH). Dr. Crawford discusses NAMI's mission and its 650 chapters nationwide, the concept of the "distress radius" as a framework for identifying when a child's behavioral changes warrant professional evaluation, and practical strategies for engaging skeptical patients and families through primary care. She also highlights dialectical behavioral therapy (DBT) as a broadly applicable clinical tool and underscores the importance of evidence-based education for patients and caregivers navigating the mental health system. The conversation then shifts to Steve Hoffmann's work at the FNIH, including the newly launching Multimodal Assessment and Phenotyping in Depression (MAPD) study, a longitudinal, multi-site initiative designed to identify biological, clinical, and digital biomarkers associated with depression subtypes. Hoffmann outlines the study's design, including neuroimaging, genetic testing, digital wearables, and patient-reported outcomes, with the goal of moving depression treatment away from a trial-and-error model toward a precision medicine approach. Dr. Crawford and Hoffmann both emphasize the importance of including patient voices in research design, drawing parallels to the foundational impact of the Alzheimer's Disease Neuroimaging Initiative (ADNI) on that field.

Takeaways:

The "distress radius" framework encourages parents to evaluate whether a child's behavioral changes extend beyond the home into school, social, and extracurricular settings as a signal for further evaluation.

NAMI operates 650 chapters nationwide and offers peer-led support groups and educational workshops that clinicians can use as a clinical resource for patients and families.

Dialectical behavioral therapy (DBT) skills, including emotional regulation and mindfulness techniques, have broad applicability beyond borderline personality disorder and may benefit general populations.

The MAPD study aims to identify multimodal biomarkers, including neuroimaging, genetic, sleep, and digital data, to enable more precise, individualized depression treatment selection.

Engaging primary care providers early in the mental health conversation can reduce reliance on long specialist wait lists and help identify safety concerns sooner.

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Chapters:
00:00 Meet the Guests
00:58 What NAMI Does
02:31 Why NAMI Matters
04:24 Why Write You Are Not Alone
05:38 Building a Parent Roadmap
09:08 Distress Radius Warning Signs
12:46 NAMI as a Clinical Resource
18:37 Skeptical Patients and Primary Care
23:29 DBT Skills Everyone Needs
26:56 Sponsor Break
29:26 What Is the FNIH
33:32 MAPD Mapping Depression
46:40 Hopes and Takeaways

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Dr. Mark Mullen welcomes Dr. Megan Schott, a child and adolescent psychiatrist specializing in pediatric emergency psychiatry, for a discussion on the escalating boarding crisis affecting youth in psychiatric emergencies.

Dr. Schott, who has built pediatric emergency psychiatry programs from the ground up across multiple academic health systems, details how the presence of a trained child psychiatrist in the emergency department can reduce unnecessary admissions by more than half. The conversation examines the definition of boarding, the systemic and financial pressures that limit psychiatric bed availability for children, and the often-overlooked risks of inpatient hospitalization, including social, academic, and long-term consequences for young patients.

The episode also features a supervision-style case discussion on managing a challenging conduct disorder presentation, along with a series of rapid-fire "hot takes" covering healthcare parity legislation, the risks social media platforms pose to adolescent safety, and practical guidance for emergency staff without access to a child psychiatrist.

Takeaways:

Having a trained child and adolescent psychiatrist in the pediatric ED can drastically reduce psychiatric admission rates

Boarding is technically defined as remaining in the ED or on a medical floor for eight or more hours after a disposition decision has been made.

Inpatient psychiatric admission carries real risks for children, including social stigma, academic disruption, and potential long-term consequences.

Mobile crisis teams and psychiatric urgent care models offer promising alternatives to traditional ED-based psychiatric evaluation for lower-acuity cases.

Clinicians should openly acknowledge systemic limitations to patients and families rather than overpromising solutions that the current system cannot deliver.

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Chapters
00:00 Meet Dr Megan Schott
01:44 Why CAPs in the ED
03:23 What Boarding Means
04:31 Why Beds Are Scarce
07:23 When Not to Admit
13:59 System Fixes and Crisis Teams
17:28 Tough Case Supervision
23:34 Cut Admin Burden
24:47 Medlines Podcast Plug
26:02 CPS Boarding Clash
32:33 Advocacy Beyond Psychiatry
34:02 Parity Law Hot Take
36:01 Social Media Dangers
38:31 ER Tips And Wrap Up

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In this Season 5 premiere of Psychiatry Boot Camp, Dr. Mark Mullen welcomes Dr. Lia Thomas, Associate Program Director at UT Southwestern, co-lead psychiatry specialty advisor for medical students at UTSW, and co-chair of the Psychiatry Residency Application Advisor Group for ADMSEP , for a comprehensive, practical review of the psychiatry residency match process.

Speaking from both the program director's and specialty advisor's perspectives, Dr. Thomas addresses the questions medical students and their advisors most frequently encounter: how many programs to apply to, how to strategically deploy the 10 available program signals, what program directors actually weigh when screening applications, and what can silently sink a candidacy even after a strong application earns an interview.

The conversation proceeds systematically through each major component of the ERAS application, including clerkship grades, board scores, the personal statement, meaningful experiences, research, away rotations, letters of recommendation, and academic "red flags," before turning to interview strategy for the virtual recruitment environment, post-interview communication, letters of intent, and the distinct considerations for couples matching, DO students, and international medical graduates.

Throughout, Dr. Thomas emphasizes that the match is a job application process governed by holistic review, and that the highest-yield investment an applicant can make is to know their application, know their competitiveness, and work closely with an advisor who can help them tell a coherent narrative about who they are.

Takeaways:

Psychiatry is meaningfully more competitive than a decade ago but remains well below the most competitive specialties like dermatology; applicants should consider targeting around 50 program applications, with 30–40 being appropriate for most students, as exceeding 50 produces diminishing returns on interview yield relative to cost.

Program signals should be deployed strategically rather than on prestige alone. Stacking geographic preference with program signals communicates a compellingly specific intent to train in a region, while burning signals on top-ranked programs the applicant is unlikely to competitively match at represents poor return on investment.

When screening ERAS applications for interview invitations, most program directors weigh clerkship grades and meaningful experiences above board scores, and letters of recommendation are nearly last, as they are largely homogeneous documents that speak more to the letter writer than the applicant.

Academic and professional leaves or red flags must be addressed head-on in the application with a clear account of what happened, what was learned, and how the applicant will be a better physician because of it. Defensiveness or excessive detail are both contraindicated, and applicants should review this language with a trusted advisor or dean before submitting.

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