James Craig is Principal of Behavior Change Consulting, LLC where he advises ABA providers and payers on service quality and strategy. James was formerly the VP for autism services at Beacon Health Options, the largest US autism services managed care payer. Most recently, James has served as the director of payer relations at the Behavioral Health Center of Excellence. James, welcome to the pod dude.
James Craig: 0:56
Thank you, Jonathan. It’s always great to talk with you. I’ve always enjoyed our conversations and these podcasts and I’ve listened to a number of them, it just adds so much collective knowledge to the ABA provider community and it’s very welcome.
Thank you James. That means a ton to me, sir. I was remembering when we first officially met, you may not have any memory of this, but it was at an Open Minds conference in…
James Craig: 1:21
Philadelphia exactly. It was November of 2019, so just a little bit before covid, here was the funny part of that. It was about autism services and payer and provider relations and my business partner, Will and I, were like walking around as we were just entering in the morning looking for where we should sit and we saw a table with James Craig, the legendary James Craig and I think there were a couple other payers there too. We’re like, oh my gosh, we have to do anything we can to go sit with James. So I hope we didn’t come across as creepy, but I learned so much. And I still have the notebook from taking all of the different notes about what you were sharing. So, thank you for being willing to come on and talk about everything that you’ve learned over your career. And let’s start there, what inspired you to get involved in the autism services community?
James Craig: 2:10
Yeah. So I come from the behavioral health provider as well as payer worlds. I’m not a BCBA, although I was trained in behavioral therapy and also family therapy as a licensed clinical social worker. In private practice, what I found myself doing as a sideline was working with kids and families with developmental disabilities that weren’t being accounted for in the classroom. And so I found myself in a lot of IEP meetings. Also, I worked with a lot of families of gifted kids who had similar advocacy problems, believe it or not. So in addition to that and on a personal level, I became a parent of a brain-injured three-year-old boy. He was my nephew who had a failure to thrive, this was because of a sepsis infection he had when he was six months old, and it sealed off parts of his brain and also parts of his limbs. He had also been in a neglected environment, so what it resulted was a lot of meltdowns, as you can imagine, and behavioral difficulties. He’s now an adult. He has a bipolar one diagnosis and it’s very difficult for him to get appropriate placement and supervision when he goes off his meds. For that reason, I have empathy for families with autistic kids who are living with asd. When I was recruited by a former colleague, at Beacon Health, I jumped at the chance.
I honor you on your journey with your son, and, as you described, you get it, you get it what families go through. At Beacon Health you were a vice president who managed the autism benefit. Tell me more about that role, James. Including how did you and Beacon define success for the autism benefit.
James Craig: 4:02
Well, first it had to do with how we interacted with providers. Then how we developed relationships with them based on experience and much later, data. So Beacon used a consultative model using BCBAs that had at least five years of experience. Our goal was to spark better care for the cases that we were managing. We then acquired a new and larger company that, was treating autism. They were using a community standard and behavioral health professionals who were masters in counseling but really didn’t have training in ABA. And so a lot of what I did for the first couple of years was to bring all of those national teams into compliance with evidence-based practices. And this was also at a time when the CMS was rolling out the EPSDT benefit in July of 2014. It was like throwing all the balls up in the air at once. And so I also was able at that time to help craft the Medicaid program for New York, Maryland, Florida, and California, working with state officials and also Medicaid managed care organizations (MCOs). It was a crazy and exciting time. It was a seismic shift in funding that opened up treatment availability for kids, like never before. And then mental health parity happened too, which was responsible for limiting day-in dollar limits in all but a few cases and is now finally being enforced by the federal government. Initially, it was to ensure that there was consistency in the way that we managed cases and the way that we worked with providers. We got some huge contracts we had to learn how to manage. When you bring a Medicaid program on and you’re getting 8,000 cases on day one, that’s a little bit different than when you bring up a contract and you’re scaling up or ramping up in some sort of way. So, we developed a role called the provider quality manager. And these were field-based staff, some of them were BCBAs, some not, who are responsible for meeting with providers and addressing issues of mutual concern. And we also developed protocols for site visits and chart audits along with recommendations for how they could improve their responsiveness and also their services to children and families, as well as their documentation. Early on there weren’t really standards for documentation and some of the providers got in trouble, they really didn’t have the documentation that was gonna support the billing. And there was recovery that was in the thousands of dollars. That’s become increasingly rare now, and especially with the EMR platforms that the providers are using, it really helps to shape the documentation and that’s not such an issue anymore in terms of compliance.
Yeah, just to explain, gut-check me here that I get this right. So the way that payers go out and get business is they’re bidding to states to manage an autism plan. So there will be any number of different insurance companies that are bidding on that, and then the state awards the plan. And in this case, in these different states, you described Beacon as managing that benefit.
James Craig: 7:16
Well sometimes. On the Medicaid side, either it’s administered centrally and you get a whole contract and you have a direct contract with the state or, it’s funneled through managed care organizations. Such as in California, you’re a behavioral health partner with them for autism or maybe for all behavioral health services, and that’s the way that you get the business.
Gotcha. You started to speak to some of the challenges, initially documentation, right? I know much of our field 10 years ago was still in pen and paper. What were some of the other biggest challenges you experienced working with providers in your role and setting up this benefit?
James Craig: 7:58
Yeah. So we dealt with providers of all shapes and sizes, from single providers to multi-state, multi-office, high-growth people, and size really didn’t matter. There was great variability in the quality of services. Sometimes it could be between provider groups, and a lot of times it’d be within a provider group. So you might have a look at the charts, for example, within a single office, and you can see there’s a lot of variability in terms of documentation and the administration of parent training or collaboration, and even supervision. And then you also had, with the high growth groups, at times, variability in terms of different offices, that they themselves were working on compliance and bringing things along. And then you add into all of that, the relative newness of the field. So with BCBAs, half of them being within four years of their training, if you think about a medical system where half of your doctors had four years of experience or less, you would expect to have some variability, right? But you also have to have mentoring and you have to have an infrastructure in these groups to provide onboarding to provide development, and so a lot of that isn’t billed. In terms of parent training, one of the Medicaid programs that we were collecting data on showed that 48% of families received one hour of parent training a month. Okay. Now, if I was living at home with a kid who was impacted with autism and I didn’t know how to respond to them in terms of a skill issue or a behavior issue, that would be a problem. You’ll hear me say several times throughout the discussion, parent engagement is so important and in a lot of cases it’s thought of as being kind of a secondary concern, it’s not as important. The other thing is collaboration with providers. If a doctor knows that your kid is in care and is improving or getting status updates, that’s a whole lot different than mom or dad coming in every six months or every year and not having any information beyond what was going on yesterday with that family. So all those things are really important. And then finally, medication. So 50%, according to some studies, 50% of kids, with asd are on one psychotropic, 15% are on two and 15% are on three or more. That has a lot of implications for behavior management and also for understanding side effects and so what are the side effects? A lot of these meds too are off label. And what we found is that kids with asd, when they’re administered medication, really need to have lower doses, almost subclinical by anybody else, but they’re very sensitive to medication and so it’s very important. There really needs to be, an understanding with ABA providers around, medication, its use, what to look for, and when to speak up if they see any concerns.
That almost seems like in the Maslow’s hierarchy of needs and just knowing everything that ABA providers end up doing or not yet doing, because we don’t fully recognize ourselves in the medical model, though we clearly are. That’s like getting up toward the pinnacle.
I remember in our conversation you had this beautiful framework and it was quite simple. Some of the metrics that you look at might be around just time to intake, Or you described just how much parent training is happening. And it feels like, for a lot of insurance companies or a lot of ABA providers, even those metrics aren’t necessarily getting reported back, or they’re not expected to be collected. And so is that how you, as an ABA provider, build a strong relationship with a payer? Is it share information and data, or what advice would you have for us as providers, to develop those strongest relationships with payers?
James Craig: 12:12
Looking out at the horizon, almost all payers or providers rather, are considered to be pretty much at the same level. There really isn’t a lot to distinguish them, other than volume of cases and volume of claims. That’s all that payers have. So there is a lot that you can extrapolate from that. And we did, at Beacon, we put together a dashboard. It was almost totally based on claims data, and it was very revealing. It measured things like dosage, access, how long does it take to have an assessment appointment after referral? How long does it take after that to have your first treatment appointment? And then, what is the dosage, that the provider, recommends or is the average across the board? How do you risk adjust for that in an organization? And this is part of, I think, profiling. Some providers have a very narrow band of kids that they admit to their programs. So one provider, for example, will tout the fact that they have a high percentage of kids that after 14 months are mainstreamed into schools, but they highly curate the kids that are coming in. So when you think about things like length of stay, when you think about number of hours a week, all of that you have to take into account what’s the range of the level of impairment that a provider is willing to work with? What are the ages that they’re willing to work with? Is it mostly preschool kids or are you also working with school-aged? Are you working with adolescents, which by the way, is a very underserved population. If you think about young adults, people moving into adulthood, that’s like a whole other universe, practically. Okay. And that’s a problem of funding as well as, of, provider inclination or provider training or anything like that. So, what you wanna develop is a relationship with a payer and the way to do that is to provide them with data. Now, right now, the only data that they have is case specific data. That’s pretty easy to get because that’s what your EMRs are set up to do, right? And so you can get a return on, here’s the number of goals that were accomplished, here’s the parent goals and here’s what’s going on with them. But really for a provider to understand, or a payer to understand you as a provider, the more information that you’re passing on the better. And so, really we’re talking about is transparency. And that for some providers, and in some cases, that feels risky. You’re also talking about responsiveness. So if I have a question about a case, does the provider talk to me? Do they answer my calls? And is there a need on my part to reach out to this provider frequently? So what’s going on now for the most part, is case specific types of interaction. And what I think we want to move to is, when you’re talking about things like value-based care, is really understanding your population as that; a population. So what does that look like? Who do you work with? How engaged are parents? What is their role in treatment? What are your outcomes? We’re starting to really get a feel for this, and it comes down to measurements. I’ve sat in conferences and you have too where for the last five years people have been talking about measuring ABA, right? Part of it is that when you think about measurements such as HEDIS measures or other measures, that would lead you into a value-based care relationship. Part of that is that autism kind of lacks a lot of those things. You’re not measuring responses to medications such as ADHD meds or, you’re not measuring antidepressants, you’re not measuring the percentage of admissions into inpatient or readmissions to inpatient because they’re pretty rare. They do happen, but they don’t happen all that much. And so usually when you have a value-based type of relationship, what you’re trying to do is you’re trying to have cost avoidance for high impact and high-cost events. Potentially any case in ABA can be a high-cost event. When this all started, payers were scared to death because they thought that every autism case was gonna be a million dollar case. That didn’t happen for a couple of reasons. One is that the supply of providers was so low and was such a poor match to the demand and so that didn’t happen. So all we saw was under utilization, I think, in many, if not most cases. Well then what’s happened is the supply has greatly increased over the years, in some cases it’s doubled. I think over the last five or six years it’s doubled in the number of BCBAs. And so what’s happened is we’ve seen an increase in enrollment. We’ve seen an increase in utilization, and it doesn’t really show signs of plateauing. So payers are worried, providers at the same time are worried, because the worst outcome, and this is the thing I’m most afraid of for the field, is that payers will say, you know, we’re just gonna drop the rates. And that’s happened in a couple of cases where the rates have been slashed by maybe 20%. The problem with that is that a lot of the services that ABA providers do are not billable. The enrichment, the onboarding, the development, the CEUs, the benefits, all those things that are part of a quality organization, whether it’s an ABA organization or any other. That’s one of the reasons I really like your podcasts, Jonathan, because it really brings to light these problems. If you have an ABA organization, you have the same issues as any other organization that’s providing services. You have to figure out a way to bring people in. You have to figure out a way to engage them. You have to figure out a way to keep them. You have to build a culture. You have to build an infrastructure of learning. You know, all of those things. Well, those aren’t paid for in a lot of cases because you can’t bill for those. An alternative to slashing rates is to begin to have a database relationship.
Hmm. There’s so much to double-click on, in what you just described, but let’s look at what would prompt a payer to just unilaterally slash rates. I mean, is it entirely a budget thing? Is it a quality of the network thing? Is it other reasons? Help me understand what’s going on as that happens.
James Craig: 19:28
Well, first of all, there aren’t a lot of levers to manage ABA benefits really. So, at the outset there were dollar limits. There were day limits. There were benefit limits that payers could apply to keep things within a certain limit, that went away with mental health parity. Secondly, you could have two similar cases and wildly different recommendations for dosage. Where does that come from and how do you make a determination between a kid needing 17 versus 20 versus 25 versus 30 hours a week? Okay. There are criteria, that have been developed for that, InterQual for example, I think is one that some of the managed care companies use. Some of them use their own criteria, but it’s subjective and so really what you want to understand is on any particular case, and this is time consuming. I mean, again, when we think about a case by case model, and understanding a provider from an individual case perspective it can take 45 minutes to go through a case. You’ve got a lot of information there. You have goals, you have charts and graphs and all kinds of detail about how a child is progressing and I would say there’s white noise too. So there’s a lot of information in there. Where is the signal? Where is the signal that shows you what is actually happening? One of the ways to get to that in a more concise way is to utilize assessment tools. And so some of the newer things that have happened, the ICHOM has developed a program where they’re looking at core symptoms and they’ve settled on the Vineland and the Child and Family Quality of Life questionnaire. The Lancet published an article last year where it talked about addressing autism in rich countries and addressing it in poor countries. It looks at countries that can spend a lot of money on assessments, and countries that can’t. And so there are two sets of recommendations. If you look at some of the managed care companies they are utilizing assessment based tools. And so, one of them utilizes any norm based tool, another one utilizes a Vineland in every single case, TRICARE has their own record of tools that need to be used. Well, you know, from a simplistic point of view, you can look at a profile, it’s color coded. You can see where some of the changes are happening. You can look at that profile and if you have a question about one of them, you can refer back to the notes or refer back to the report. But that’s a quick and easy way to say, okay, I actually can see the progress that this child is making.
Hmm. You know, something really powerful that you mentioned earlier. actually, you subtly sneaked it in, but it’s really true, as a payer, most ABA providers look the same. There is no way to differentiate, who the good and who the bad ones are, but there’s a bell curve, right? And there’s a probability of distributions, of, quality of providers. And I think it’s easy as an ABA provider to forget this. To know “Hey, I’m special and here’s why I think I’m special and why we’re great for families” and yet if as an ABA provider, we are not helping our payer partners understand why we’re special, then the fight is lost right then that you can’t even start a relationship. So I think this is a really powerful reminder to make sure data, outcomes, satisfaction scores, whatever it is, be communicating these back to your payer That’s part of what underpins a strong relationship.
I wanna start talking about value-based care. Before we do though, you, used the term risk-adjusted. Can you just talk a little bit more about what that means in the context of a payer and how you think about population and individual member management?
James Craig: 23:52
So, if a provider is talking to me about their average dosage, their average length of stay, how can I be sure that I’m dealing with apples to apples versus apples to something else? Risk adjustment is as simplistic as looking at initially some sort of measure of severity. And you can get that, you can get that from the ADOS, you can get that from the SRS2, you can get that from the CARS2. And sure it’s not perfect, and it might be somewhat rough, but it’s a start. So a way to think about this is okay if I’m thinking about like a range,on the low end, what are the low end scores that I would obtain from people that I’m working with and on the high end, what would that look like and where is the median or the mean? That gives a lot of information about the kind of practice I am. For some it’s gonna be very, very narrow, and then if they come to me and they say, well, you know, I have this result and we have a graduation rate of this, I can adjust that based on the fact that maybe they’re on the lower end of impairment and maybe they have a smaller corridor, if you will, a smaller range. That means a lot more to me than someone saying to me, I have this great response that they have to treatment against a provider who maybe takes all comers, who work with people who are very impacted and people who are less impacted. That helps me understand why those llength of stays or graduation rates or dosages might be different. Also if you can break out age groups and stuff like that you can even get further, but the idea is to adjust it based on the population that you’re serving, and not every provider serves the same population.
Mm, I gotcha. And, that adjustment that you referenced is based on the risk adjustment. That’s ultimately important so you could compare providers’ clinical outcomes or so you can predict and budget what you might have to pay for services for certain providers versus others, or how does an insurance company use that information?
James Craig: 26:18
Well, they’re not using it now cuz they’re not getting it.
James Craig: 26:22
I think again, with transparency, the risk is that you’re gonna be opening up all this information and the payer is really going to be able to see what goes on, that does feel risky I think in some instances. So it’s about the relationship. If you have that and you’re furnishing this data, you know that will evolve. Here’s what I’ve learned, when you provide data to someone, it always provokes questions and more data, but that’s in the context of a relationship. I’ll give you an example of maybe how this worked. When I was at Aetna, we worked with inpatient facilities for behavioral health. My group was responsible for the Eastern United States, and most of our concern actually was in the northeast. So what we decided to do was instead of reviewing every single case on an inpatient basis, what we would do is generate data based on the care managers who are reviewing it and based on data that we collected, not that they collected. I think with autism it’s gonna be hard for payers to actually take up that, but anyway, we developed a dashboard. Every quarter we shared the dashboard with the providers. We had their performance in that time period, and we had their peers’ performance in that time period, which was very effective. One thing we noticed within a very short period of time was the utilization went down more than what we had been able to do when we were managing these cases every three days or so. And it was a more satisfying relationship. Autism is not all that different from the rest of behavioral health. In behavioral health for inpatient, you’re dealing with a nurse who’s reading a chart. And so if you have a question that nurse says, okay, well I’ll go back and I’ll ask the doctor that. Is that a satisfying relationship? No, it’s not. So what we did was we had quarterly meetings with the facility. And that included the CEO, the CMO, the director of nursing, the director of social work, all these people pouring over these documents, whether it was in person or whether it was over a conference. My hope was that we could bring that same thing to life with autism. Where we would develop a dashboard that we’d roll out. We’d have discussions, we’d notice trends. You know, look, we noticed your enrollment went up this much. You know what’s going on? We noticed that you’ve had more discharges, what’s going on? We did for a part of Beacon’s business, we did develop a dashboard that was largely based on claims, but included other things too. And we brought them out to the providers and, contractually, I think we had to meet with providers once a year, but in reality we met with many of them every quarter and we shared this information. But that means that the payer has to develop analytics and a lot of them are not gonna do that. So what it means then is that the providers have to do that. Whether that’s fair or not, I don’t know, but you have to represent the work that you do somehow. Whatever it is that you can provide in terms of engaging in a relationship. Nobody’s gonna do value-based care off the bat, okay? You’re gonna have to have some period of experience together where you’re sharing information. There are some rare instances now where, um, there’s some bonusing that’s happening. One of the measures is the number of hours that were authorized versus the number of hours that were actually used, and those are rated. And then depending on how providers do they get bonused on that. So that’s one. The first step I think, in value-based care is that you set up a goal and if it’s met or exceeded it’s rewarded. And then the next is taking on more risk. So if I say that I can do cases for a certain amount of money per month, that, we can settle on, that’s predictable for the payer and that’s predictable for the provider and works for them, then that would be the next step. Then all the way on to subcapitation but I don’t see that happening because that means you’re totally responsible for somebody’s healthcare. And that’s not gonna happen, I think, in ABA. So, I think the more information, the outcomes data, parental satisfaction is a big, marker there. I think if you’re talking about assessment results using some of the tools that were already mentioned, graduation rates, discharges, um, and so on. Those are outcomes.
You used the word predictability that one thing payers crave is predictability of knowing, “Hey, this kiddo is gonna be with this provider for a certain amount of time.” It’s not just sort of an endless thing, but there’s, there’s predictability, which then leads to a payer being able to accurately predict what they’re gonna have to spend on that case. Is that a fair characterization?
James Craig: 32:10
Well, usually the way it would work, and again, this has to do with using tables to figure out what happens. So year one might be a certain amount, year two might be a lesser amount, year three and so on. it really comes down to having a sense of your own practice about that way that works with your cases that’s going to equip you to be able to have discussions with payers that are informed and that are gonna serve you well. If you don’t have that information then it’s gonna be very difficult to go into that with eyes wide open.
Hmm. That’s part of the challenge of our field not having moved yet toward a value-based relationship. What are a couple of the other things in addition to outcomes that need to be true in order for ABA to move toward more value-based care models?
James Craig: 33:01
Well, so we talked about access already. You can talk about the tenure and years of experience of your staff. You can talk about service locations, you can talk about place of service. Do you do home-based, center-based, hybrid, telehealth, language and cultural competencies, and turnover rates of staff? We have benchmarks for that stuff now, and it’s a proxy for continuity of care. In terms of performance, you can talk about length of stay, dosage, weekly ABA hours by age group, and, caregiver engagement. Evidence of collaboration with other professionals. One managed care company that I know of insists that you do screenings for depression at age 12. Everybody age 12 has to get a screening. So when I’ve suggested this to ABA providers, what they come back with is, we’re not able to do that because we’re BCBAs – nonsense. Office staff and pediatric practices do this all the time, and they’re not trained, they’re not masters level people. What we know is that children with asd have a higher incidence of anxiety disorder, they have a higher incidence of depression, especially when they get into the, teen years. They have a higher incidence of substance use as well. They also have a higher risk of suicide. And so, if you’re doing these screenings and you have a way to refer them out that is important. Some practices are even hiring behavioral health people, mental health counselors or social workers, so those points are addressed at intake. Not to mention there’s also the family. Again, this is partly outta my lived experience, but partly because I was a family therapist. Having a child with autism within your family is a major, major stressor, and it produces all kinds of role changes for everybody in the family. For the parents there’s an impact on jobs, I think 14% of the time one of the parents has to stop working. That’s terrible. There is a higher divorce rate among parents. Siblings, very underutilized. There are some groups that do sib groups, those kids either are invisible in a family or they become part of the parent group, kind of. And so all of those people need help. They all need support, and they all need possibly treatment. So if you can assess for those things, even if you’re not yourself a BCBA, that is important. I’ll just give you an example. I’m reading a chart, and mom and dad are divorced. it was a case where the child’s behavior had spiked considerably and what had happened over the weekend is that dad and mom had separated. That wasn’t anywhere in the notes, it just said, well, the behavior increased dramatically. Again, you have to be thinking about this in the context of what’s going on with the family as well.
So well said because no child exists independent of that family context and that environment.
James, what’s one thing ABA practice owners should start doing and one thing they should stop doing?
James Craig: 36:36
I’m gonna repeat myself here, and that is increasing meaningful family engagement. This was a real hot topic when we were doing training with providers in Massachusetts. This is a real hot topic because it’s not part of the standard ABA curriculum. So you have parents that are sometimes intrusive, you have parents that are sometimes the opposite and hard to get involved. One example that comes to mind is, the parents have to be home when there’s a in-home session, What happens? Mom goes to the grocery store, dad goes out and mows the lawn, right? Are they getting anything? Are they observing what’s going on? Are they getting anything out of that? And when that happens, what is the BCBA’s reaction and how do they address or manage that with a particular family? And it’s understandable. It really is. Families need respite and they need time to do other things. Then in center-based cases, a lot of times it’s difficult for families to make it in. If you can get in between, eight o’clock in the morning and six o’clock in the afternoon, then that’s fine. And if you can’t, then you know, you’re out of luck. Or maybe all that you get is, every six weeks you get an update on how they’re doing. That’s not the same thing as equipping parents to be able to be a part of the treatment process. So I would say meaningful family engagement.
And how about for stopping?
James Craig: 38:07
I would say believing that providing individual case data is gonna be sufficient. Now, we’ve already mentioned that, part of the problem there, Jonathan, is that that’s the way that data is collected with the existing EMRs. They really weren’t designed to aggregate data. And so what we find is that providers have to do that on the side. They have to have staff that sets up databases, that tracks the stuff that when an assessment tool comes across their desk, they log that score on and so on. There has to be a conscious effort to set up these measures and then populate them, and at least the way this currently happens it has to be done on a manual basis, so it is difficult.
And would it be fair to say that a provider who’s able to share that kind of data and start to invest in that infrastructure which then leads to a meaningful dialogue with a payer, that’s when a payer might consider differential reimbursement rates or other payment arrangements because providers are investing in that? Is that right?
James Craig: 39:15
Or even as a start developing a stronger relationship. This provider really stands out because I have this information about them. Otherwise, it’s anecdotes that you get from the care managers and its claims data, and that’s really not representative of what’s actually happening.
Well James, where can people find you online?
You could reach me at firstname.lastname@example.org.
I will drop a link to that in the show notes.
James, are you ready for the hot take questions?
Sure, yeah. Let me have it.
You’re on your deathbed. What’s the one thing you want to be remembered for?
I want to be remembered fro my curiosity and that I never stopped learning.
That is so important, never stop learning.
What is your most important self care practice?
Running, I started running in my late thirties, and I’ve run in three Boston marathons and it just keeps me sane. It allows me to clear my head and really come up with a lot of ideas.
What is your favorite song?
Okay. Well, it’s Cracker Box Palace. it’s a George Harrison song, and it’s a very sweet song about the universality of growing up and growing on. I just love it and it’s got all his musical touches that he does as well. But it’s just such a sweet way of talking about what it’s like to grow up. And everybody goes through that same process.
If you could give your 18-year-old self one piece of advice, what would it be?
No matter what, whatever happens, you’re gonna be. I mean you go through so many things in life that are first time experiences and they all feel like it’s the end of the world, but when you work through them, you understand that’s not the case. You’re gonna be okay.
You can only wear one style of footwear which would it be?
Sneakers so versatile. Anything else to share?
Yeah, I’d also like to make a plug here for just a couple of programs that I’ve seen recently that I think are wonderful and maybe your audience knows about them, but one of them is Extraordinary Attorney Woo. it’s a Korean, TV series and it’s about a 27 year old attorney with Asbergers and an eidetic memory, who has all kinds of really severe problems. She has a fixation on whales as well, which comes through. And it’s just such a wonderful representation of being in that world, living in that world, and all of ts distractability and all of the difficulties with being involved in the legal system of all things. But also interpersonally. And the other is Temple Grandon. I saw this film just recently, it is from 2010. It starred Claire Danes. It’s on HBO Max now. What a wonderful representation of Temple Grandon and the gifts that she had, despite all of the limitations that she has as well, and, both of those things were just dramatized to me, so beautifully. With the proper support and with the opportunity people really can maximize what they can do and their contributions to themselves and to other people and society at large. We have a ways to go to make that happen.
Thank you for those recommendations, I will put them in the show notes. I can’t wait to watch them.
Thank you for sharing your wisdom with us today James.
Thank you, Jonathan.