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An Open Letter to the North Dakota State Board of Psychologist Examiners

If you have been following my career antics, you know that I have been applying for licensure in North Dakota. The folks at ADHD Online had ONE psychologist serving the state, and that psychologist retired. Rather than telling the people of North Dakota, “Sorry, no accessible ADHD testing for you,” they offered to help me get licensed.

I am happy to say that I jumped through all the hoops, crossed all the Ts, dotted all the Is, and received approval to practice!

Photo by Matheus Bertelli on Pexels.com This is what comes up when you search “North Dakota” in free stock photos and it’s…not wrong.

As I was completing the qualifications for licensure, though, I stumbled upon a state law that unsettled me. North Dakota requires psychologists and other professionals to register any client that they diagnose as autistic in a state registry, including completing an extensive, two-page document with detailed personal information about each client. The North Dakota Department of Health has information about this law on their website.

Reporting your clients is mandatory, and failure to report a client results in a $1,000 fine plus a report to the board, which could cost your license to practice. What if an autistic client does not want to be registered with the state? Too bad! According to the FAQ page on the website, it’s legal because North Dakota says so.

When I first came across this law in my test prep materials for the state licensing exam, I thought they were testing me. I thought, “This cannot be legal. They want to see what I do when I find a law that directly conflicts with my ethics code.” It wasn’t a test. But here is what I do when confronted with an unethical law.

I will not be conducting autism evaluations in North Dakota while this law is in effect because I cannot do so in a way that is simultaneously legal and in accordance with my professional ethics code and personal moral values.

This does not affect my work with ADHD Online because, for some reason, the North Dakota government only feels that autistic people need to be put on a list.

However, I have written a letter to the North Dakota State Board of Psychologist Examiners and copied the Department of Health and Governor Doug Burgum detailing how this law violates the APA ethics code as well as international laws regarding human subjects in research. My letter to the board is attached to an email noting that I am happy to do whatever I can to help support the board in lobbying to change this law.

You can read my letter to the board here:

What can YOU do? You can report this unethical law to the Department of Justice. The Autism Support Society shared detailed instructions via this Twitter thread about how to do this, and if the DOJ gets enough complaints, they can pressure North Dakota to repeal the law.

If you live in North Dakota, especially if you fall under this mandatory reporting law, please join me in writing to your licensing board, the Department of Health, and the state government demanding that they repeal this law.

BE THE CHANGE, friends. For more information about how to support autistic folks, please check out the Autistic Self-Advocacy Network.

Featured

May You Live in Interesting Times

Gloriosa by Jitney58 is licensed through CC-BY-2.0

There is conflicting information about the origins of this expression, but it is generally agreed to be a curse. We are watching history be made as each day goes by, and frankly, I wish I lived during a more boring chapter of future history books. At the same time, though, it is through the difficult times that we grow.

As a psychologist, I’m used to walking with people through the difficult times. I usually can’t offer a quick or simple fix, but I can be there with tools, hope, and connection.

My goal in creating this site is to offer resources to a wide audience during these trying times. I want to reach those who share my drive to help children and provide them with the tools to do this effectively: teachers, social workers, counselors, and fellow psychologists. If there are specific resources that you would like to see, please let me know, and if I have the appropriate skills and knowledge, I will do my best to make it happen.

Thank you for joining me during these interesting times. Follow my site to stay up-to-date with resources.

Telehealth Activity: Magnet Poetry

I love creative therapy activities. Tapping into the client’s imagination is such an awesome tool. Kids, of course, have varying levels of comfort with different expressive therapies, and I never want them to feel pressured to engage in something that is not a good fit. That’s why I try to keep several options available.

white paper with black text
Photo by Suzy Hazelwood on Pexels.com

Poetry is a fantastic creative outlet and can help clients explore their experiences and emotions using words. Sometimes, a client seems like they could benefit from this type of intervention, but they aren’t sure where to start. They may be unfamiliar with creative writing or struggle to come up with their own words.

This is where magnet poetry comes in. You craft a poem from a complied list of words available. You and the client can work together to make a poem (either by choosing each word jointly or by taking turns deciding which word will go next), or they can create something independently.

For telehealth, I have two methods that I use for this intervention, depending on the options available to the client. If you are able to share links and have the client join you on a website, PlayingCards.IO has a magnet poetry game that is very easy to use. Simply create a room, share the link with your client, and the two of you can simultaneously manipulate the space.

If your client is unable to access a website from their device, you can use Magnet Poetry’s website, share your screen, and grant your client remote control. One great thing about Magnet Poetry is that they have several different “packages” that you can select, so you can get words that are developmentally appropriate or specific to your client’s interests. If your client cannot access remote control on their device, or your telehealth platform does not have this option, you can still screen share and create a poem with your client instructing you.

Of course, there are benefits and limitations to both approaches. By sharing the room on PlayingCards, you can both interact with the space at the same time. This can get complicated if you are trying to move the same piece simultaneously, though. On the other hand, Magnet Poetry requires taking turns and more communication between the client and therapist, which is of course beneficial for building these skills, but it could potentially interfere with the client’s process as they craft their poem.

Whichever platform works best for you, this is another great expressive therapy you can do via telehealth.

Show Your Therapist Your Spotify Wrapped

Music is a powerful therapeutic tool. It can reflect feelings we are struggling to express or change our mood. Music is emotion, connection, healing.

turned on black samsung smartphone between headphones
Photo by Vlad Bagacian on Pexels.com

For those who use Spotify, it’s that time of year when you get your rundown of what songs and artists you spent the most time listening to. If you use YouTube for music, they give a similar list – I am not sure about other platforms.

Anyway, many people find themselves feeling contemplative during this time of year. We look back on what we accomplished, how we spent our time, and what has changed. I’ve seen many commenting on how their yearly playlist reflects this.

If you have a therapist, you might consider sharing your year-end wrap with them. Together, you can explore how the music represents how the year has been for you, the good, the bad, the terrifying, the wonderful. Notice any themes that came up for you in the soundtrack of your life. Notice anything that surprises you, or anything you regret.

If you’re just starting therapy, your playlist could provide background and context for any life events that contributed to your decision to reach out. If you don’t have a therapist, you can still reflect on your end-of-year playlist as you prepare for the new year.

What do you want to bring with you into 2023? What will you leave behind?

That’s all for now.

4 Tips for Seniors Who Wish To Improve Their Physical and Mental Health

Julie Morris, regular guest blogger, shared today’s post. I appreciate her willingness to share with you all, especially as admin tasks related to my private practice have had to take precedence over blogging lately. I hope you all find this helpful!

White woman wearing a red hoodie and black leggings, running outside on a sunny day. Image via Pexels.

As you age, you may feel as though your quality of life stagnates or even gets worse when you don’t actively look for ways to improve your physical and mental health. While people of all ages find benefit in hobby activities, exercise, and lifestyle improvements, retirees and other seniors can greatly improve their lives by investing in one or more of the following tips, courtesy of Resiliency Mental Health.

1. Find A New Hobby

If you’ve just retired or you’ve spent most of your life engaging in work, you may feel restless, bored, and even useless. The reality is that you’re transitioning to a new phase of life in which you have the time to pursue your dreams, hobbies, and plans you may have put off in your youth. Start by making a list of hobbies that you can pursue without breaking the bank and pick one off your list. If it doesn’t work for you or inspire passion, move on to the next one until you find something to fill your time.

Perhaps work was truly your passion. If so, start a new business to stay fulfilled after retirement. Research what you’ll need to get started and run your business in the digital age including a website, social media, and a relevant marketing campaign. Don’t forget to register your business, perhaps as a limited liability company, to separate it as an entity and to gain important tax advantages. You’ll save money by filing online, but you can ask an attorney for help looking over your paperwork, too. Be sure to do some research into how to start an LLC in your specific area.

2. Take Control of Your Health

You may be struggling with arthritis, Parkinson’s disease, or blood pressure issues. According to the Mayo Clinic, even the normal aches and pains and cognitive issues that accompany aging can interfere greatly with your life. Review your medical plan with your physician and make it a point to adhere to any medication changes or supplement regimens to stay as healthy as possible.  

Even if you’ve never exercised regularly before, a new routine can greatly benefit you at 60, 70, or 80 years of age. Begin with exercises that aren’t too difficult and build up from there. Yoga, tai chi, swimming, and walking are great starting points that are gentle and won’t put a lot of pressure on your joints. 

3. Adopt a Pet

There are countless benefits to adopting a pet, especially for seniors, ranging from reduced feelings of isolation to improved physical fitness. A pet can help you stay active and feel needed, and they aren’t necessarily that much work, either. One thing you might want to do, though, is invest in an escape-proof harness for your dog to take the stress out of walks.

4. Become Acquainted with Your Mental Health

A lot has changed in the mental health landscape over the past few decades, and it might be drastically different than what you grew up with. People speak more freely about mental health issues now, and it’s not as stigmatized. Perhaps you experienced postpartum depression as a new mother in the 1960s and you never got help for it, or maybe you just realized that you might be autistic after your grandchild was diagnosed with ASD.

Learning more about your mental health will only help you live a fuller life. Don’t be afraid to visit a mental health counselor or even speak with your regular doctor about these issues. They can point you in the right direction of resources and additional help.

Your “golden years” don’t have to be boring. Pursue what interests you, whether it’s starting a business, tackling a list of hobbies, or endeavoring to boost your health, and you’ll surely find fulfillment along the way.

Dr. Marschall created Resiliency Mental Health to provide resources for therapists and anyone who wants to learn more about mental health. Call 605-774-1754.

Black Friday/Small Business Saturday Sales

Photo by Max Fischer on Pexels.com

It’s that time of year again…. The time when we all plug our small business products! For Black Friday and Small Business Saturday, everything in my Teachers Pay Teachers store is 10% off November 26-November 28. Get your therapy resources and telehealth games at a discount, and help me buy Christmas presents for my loved ones.

And for the entire month of November 2022, use code november25 to get 25% off your order in the A Change For Better store.

Play classic board games and therapy-specific games in your telehealth sessions, and access activities to improve impulse control, emotion regulation, coping skills, communication skills, and so much more!

Do you need continuing education? All my PESI courses are discounted for Black Friday too! (A ton of other fantastic and brilliant presenters have discounts on their trainings as well. It’s a great time of year to finish up your CEs!)

I hope that you have a very relaxing Thanksgiving holiday, that your stress levels are low, and if you travel that those travels are safe and uneventful. Thank you for making this blog successful enough that therapists from all over have found ways to improve their telehealth practice.

I Joined Mastodon!

As I continue to diversity my social media presence, I was advised to check out Mastodon, a platform with several different servers that is volunteer-run and has a similar user feel to Twitter.

Screen shot of my Mastodon profile, @dramypsyd@ohai.social

I’m still feeling everything out, but I love that Mastodon reminds me to add alt text to photos to help those using screen readers engage with my content, and they make it really easy to add warnings or censor things that my followers might find triggering.

They also have an edit button and mods who actually respond if someone is engaging in harassment.

If you’re on Mastodon, you can follow me at this link!

Even if we aren’t on the same server, we can interact and share content. I’ve made some really fantastic connections with the neurodivergent community over there, and I look forward to learning more from the folks I’ve met.

Stutz Watch Along

Were you as excited as I was to learn that Jonah Hill was making a documentary about his therapist? I read an interview where Jonah Hill said the inspiration behind the project was that therapy helped him, and he wanted to pass that along to more people.

I hope I have made clients feel that way, but I also hope that none of them ever ask to make a movie about me. I like attention, but only in very specific doses.

The film is rated R. I curse a little bit in my commentary. You’ve been warned.

Anyway, I recorded my thoughts as I watched the documentary so that you can watch it with me! It’s like DVD bonus commentary. Below is the audio – when you hear me say “Here we go,” press play.

This was originally going to be a live tweet, but this way my readers who don’t use Twitter can participate. Certainly feel free to share your thoughts, though I’m on a social media break this month and probably won’t see them. (Oh also, I scheduled a bunch of tweets before I logged off for my break, so just disregard the “X time until the live tweet” or just do it without me. Twitter shut down dual authentication so I couldn’t log in even if I wanted to.)

I uploaded to SoundCloud. Click here to listen, or use the player below if I embedded correctly.

*Stutz movie poster is shared here under the Fair Use Act. Netflix retains all rights to the image.

A Change For Better: Free Mental Health Resources

Disclosure: this post features a mental health startup for which I serve as clinical director. This is not a paid post, but I have financial investment in this company.

I’ve shared before about A Change For Better, a mental health startup out of New Zealand founded by my colleague and personal friend, Ashley Cairns. Ashley is one of the most dedicated people I have the pleasure of knowing. Despite road blocks and multiple web developers failing to deliver promises, she has successfully launched the website, provider directory, and resource database of free information about mental health.

The resource database is broken down by category so that you can learn about:

Providers can sign up for a membership, which unlocks a directory listing and resources to market your own practice. We are currently working on creating more content to help therapists, counselors, psychologists, and other mental health professionals improve their clinical skills and flourish in their practices.

If you’re looking for resources, ACFB also has a store with educational courses, therapeutic activities, and telehealth games. For the month of November 2022, use code november25 to get 25% off your order!

I’m so excited to keep following ACFB’s growth and share it with all of you.

Kokobot Review

With the possible impending demise of Twitter hanging on the horizon, I have been exploring other social media options for sharing my content and connecting with my communities.

I was on Tumblr for the first time in years and exploring some hashtags related to mental health when I got a new message. The last time a stranger messaged me on Tumblr turned out to be some kind of p*rn account, so I was wary. Instead, I was introduced to Kokobot, an AI that reaches out to people to offer them support with their mental health.

Screenshot: Kokobot. "Koko offers kind words of support from other Tumblr users just like you." Not following each other.
Tuesday
Kokobot: Hi! I'm Kokobot. I'm working with Tumblr to connect people who are interested in mental health topics. Type "hi" to get started...
Me: Hi
Kokobot: Hi (flower emojis) Koko connects you with real people who truly get you. Not therapists, not counselors, just people like you.

I am 100% in favor of making mental health support available and accessible, and I fully understand and appreciate the value of peer support. At the same time, this made me nervous. Who is it connecting? What is being shared? Is this supposed to be a substitute for mental health treatment?

Here is my experience chatting with Kokobot and my thoughts on it as a resource, from my perspective as a psychologist.

Kokobot: Great! Please note: we are a *nonprofit* and your data is anonymous. We will never sell it to anyone. (Links to privacy policy and terms of service) By selecting "Yes" below, you accept the terms of service and warrant that you are 13 years of age or older. Type the letter 'A' to continue... A. Yes

I want to point out, they say the information you share is anonymous. BUT there is a reason I tell clients not to use any social media platform to try and message me – they are not HIPAA compliant. Employees at Tumblr can view your direct messages, so it’s not fully confidential, and if any information connected to your account (such as your email address or IP) can be connected to your real identity, this is not fully secure.

That being said, I’m glad that Kokobot is transparent about a commitment to not selling your data. I hope this means they are also not giving it to anyone. My point is, just always be careful about claims of anonymity online. Computers always know.

Kokobot: Before we start, we just have one last question. How hopeful do you feel about your life right now? A. Extremely hopeful B. Somewhat hopeful C. Neutral D. Somewhat hopeless E. Extremely Hopeless

This is a pretty standard mood check in, similar to ones I have used with clients in the past. No red flags here.

Kokobot: Ok, let's get started! First - tell us what you're struggling with right now. Pick one category below. You can always change this later! A. Dating B. Friendships C. Work D. School E. Family F. Eating Disorders G. LGBTQ+ H. Discrimination I. Other...

Letting users choose from a list can make it less daunting to share what they are going through and makes it easier for the AI to determine how to proceed. I was concerned that there is a category for Eating Disorders, since this is clearly a peer support system and not a referral to clinical services. EDs are some of the most dangerous mental health issues with the highest mortality rates, and there is a huge online community around encouraging people with EDs to continue engaging in disordered and dangerous behavior. But when I said that was my issue, Kokobot did not connect me to a peer and instead offered educational information.

Kokobot: You are not alone. A lot of Koko users struggle with disordered eating. And, no matter your gender, about 10-40% of us experience body dissatisfaction. We have a short mini course that can help. It's free, anonymous, and it takes less than 10 minutes. Check it out here: (link). Note: This course is not currently designed for all disordered eating conditions. If you think it's missing something, it probably is. Please let us know. To see more resources, or to keep trying Koko, please continue:

If you select an issue that is appropriate for peer support, Kokobot asks for more details. I tried several different ones and got the same prompt in response.

Kokobot: OK, pplease tell us more about your situation. Write a few sentences below and we'll send it out anonymously. A. See examples

If you’re not sure what to say, Kokobot will provide you with responses that others have provided. Also, if you write something profane or graphic, the AI will indicate that it isn’t appropriate to send out. I did not screen shot that message, but it basically said it understood if I did not mean to be inappropriate but asked me to re-word my message. This showed me there are protections in place for people using the bot, though of course I cannot speak to how effective they are.

Kokobot: Ok, just one more thing... Let's tag your situation with your most negative thought. What's the darkest thought you have about this? What goes through your mind? Select an option below. Even if you think they all apply to you, just choose one. A. This sucks B. This won't get better C. I'm a loser D. No one cares E. People suck F. Other..

Identifying negative thoughts is a cognitive behavioral technique that I do in many sessions. It can be included in a thought record as a way for clients to explore their thought processes on their own as well. Pretty standard.

Kokobot: Ok, now do the opposite. Tag your situation with something positive (even if you don't really believe it): A. It's not so bad B. This could get better C. I'm actually ok D. People can be good E. Unicorns exist F. Other..

This is basically an overly simplified version of cognitive restructuring. Again, not a substitute for therapy, but it could have benefits for users.

Kokobot: OK, thanks for sharing all that. Sending this off to the Koko community... You should start getting replies in a few minutes. While you wait, let's try helping others. The vast majority of Koko users say that helping others helps them feel better. A. Let's do it

If you say that you want to help others, it walks you through a very brief and simplified training about how to express empathy for another person. It is incredibly basic though, so I’m not sure the quality of responses that users are getting.

If you choose to talk to other users, it gives you the option to skip any responses you don’t feel comfortable answering, or you can flag them as inappropriate. I do not know what Kokobot does with posts that are flagged, unfortunately.

Overall, my feeling towards Kokobot is cautious optimism. I can see this being a valuable resource that connects people to supportive peers when they are having a hard time, but I worry about its potential for abuse. I would like to know more about how it handles this and what steps it takes to prevent misuse. I would also like to see more resources being offered to connect users to professionals when appropriate – I didn’t see anything about that when I tried it.

We definitely need more resources that meet people where they are, and you can’t get more “meeting people where they are” than sliding into their DMs on social media.

Did you talk to Kokobot? Tell me about your experience!

Every New Beginning… (Tips for Therapists Considering Private Practice)

This morning I turned in my keys, ID, and laptop, and I signed the form cancelling my benefits. I am fully, 100%, officially self-employed. Want to talk to my boss? Sure, she’s me!

For anyone considering starting their own practice, I thought I would share a few insights from my transition. By the way, let me know if more private practice content would be helpful because I’m happy to write more about it.

Anyway, here are some things I wish I had known before I got started, since they would have made the leap less anxiety-provoking for me.

Your Referral Sources Will Follow You

I personally think it is unethical for an organization to ask therapists to sign non-competes. Clients have the right to make decisions about their care, so if they want to follow their therapist if the therapist changes jobs, they have the right to. Usually a non-compete for a therapist won’t hold up in court, but “I didn’t think they’d enforce it” is not an argument you want to make to the judge, so I recommend refusing to sign one.

That being said, even if your clients do not all come with you, mental health is all about relationships and people. Referral sources keep lists of organizations, sure, but the physicians, teachers, pastors, and agencies that I’ve worked with over the past six years send people to me. And they will keep doing that regardless of the business I’m working for.

Billing Is Hard But Also It’s Actually Not That Hard

This is a quick, unpaid shout out to my electronic health record, Therapy Notes, and their one-click billing system. All I have to do is input each client’s insurance information when I create their chart. After that, I just hit “submit” after each session.

Credentialing is a hassle, but once it is up and running it’s pretty streamlined. I have to chase some payments and follow up on rejections (which is why I would never fault someone for choosing not to take insurance), but honestly it’s nowhere near as complicated as I thought it would be.

You Don’t Have To Do It All At Once

Especially since insurance credentialing can make it take a while for the payments to start. I transitioned over the course of several months – for reference, I turned my keys in November 4, but I told my boss I was leaving in April. Not every organization would give me the kind of support I got in transitioning, but you can start off doing just a little at a time if you need to.

You Get To Have The Best Boss

I used to say I didn’t want to ever work for myself because I didn’t want to work for an asshole, but honestly, calling all the shots about my work and my business is amazing. I am in charge of how my practice is marketed, which insurances I want to drop because the reimbursement is too low, and my entire clinical focus.

I was lucky to have a good amount of freedom at my last job, but now I am fully in control. And no more staff meetings! (No offense if anyone from my old work is reading this.)

Plus, my new boss is so intelligent and good looking.

Private practice is certainly not the right route for everyone. But if you are considering it, know that a lot of my hold ups and reasons I waited so long turned out to be so much less than I imagined!

Tips for a Compelling Letter for an Insurance Raise

Today’s post comes from my colleague who, like many private practice therapists, found herself struggling to accept insurance rates and still pay her bills.

Well, did you know therapists can request a raise from the insurance company? my colleague did, and she shared the letter template so that other therapists can request pay increases. With recent inflation, we deserve to pay our bills too!

Photo by Leeloo Thefirst on Pexels.com

If you have been in an insurance network for over a year, you have the right to inquire about a raise in the rates for your contracted service. Given inflation, you can (and should!) hold them accountable for raising your rates to account for increases in overhead. While I cannot claim expert status in this area, I did extensive research before drafting my letter, and had success with my most recent raise request. 

Here are the major points to include:

  1. Highlight how long you have served their customers and your enjoyment in working with them. 
  2. Make note of any referral sources you have in your community (even if it’s a general statement such as local physicians, psychiatrists, or other health care providers). This demonstrates your active involvement in coordination of care and connection with other in-network providers.
  3. Identify changes in overhead costs or general inflation trends (if applicable). I referenced the average inflation rate within the past two years since I started in their network. I noted how this has increased my operating costs (if your experience is anything like mine, crucial things like rent, your records system, and other platforms are all likely more expensive).
  4. Emphasize how irreplaceable you are to their network. Identify relevant trainings/continuing education you have pursued. Note any niche areas you specialize in. Identify populations you work with (children, teens, families, or older adults are particularly in-demand). Share if you offer evening hours or weekend times to accommodate the schedules of working/in school clients. This is your opportunity to demonstrate why they should invest in keeping you in their network.
  5. Create a table that notes your present rates for the billing codes you used and a column for your requested rates. This makes it easy to read and clear about what you’re asking for. There isn’t a clear guideline regarding how much you should/shouldn’t ask for. In most cases, the insurance company will negotiate with you, so do not be afraid ask high. I factored in the inflation rate with some additional wiggle room to account for my time on their panel and my additional training. 
  6. Share your interest in continuing to serve their customers for a long time. While this isn’t a necessity, I consider this a courtesy that demonstrates good faith and offers a kind conclusion to your letter.

Below is a template I created:

Name of Insurance Network Coordinator
Address
Number 
Fax

Re: Rate Increase 

Date of Letter

Dear ____________,

I am kindly requesting your review and consideration for an adjustment in my contracted rates for service. 

I am a (your credentials/licensure) and have been serving clients through (insurance company) since (date). The demand for mental health services in the past two years have been unprecedented. The referrals I receive for my practice significantly out-pace the availability I have. I receive referrals regularly from various primary care and pediatric practices in the greater (your city) area. With that demand has also come an increase in overhead costs to match current inflation trends. Inflation has increased overhead costs by, on average, 8.26% over the past two years. I wish to continue to be able to make the important services I offer available to your customers, which is why I am requesting an adjustment in rates to match inflation and demand for services.

Here are my current rates and my requested rates: 

CPT CodeCurrent RatesRequested Rates
90791$$
90837$$
90834$$
90832$$
Fill in the table with your rate information

I am one of the only providers in my area to offer several unique specialized psychotherapy services that have required additional training. These include:

  • Bullet points of niche services your offer

I also work with these specialized populations:

  • List populations you work with

I also offer evening appointment hours to meet the academic and work needs of my clients.

In conclusion, I appreciate your consideration of my request for adjustment in rates to reflect the high demand for my services in addition to the level of specialized services I offer. I have greatly enjoyed working with (insurance company) customers and wish to continue serving them for many years. 

Sincerely,

Your name and contact information