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.

Online Puppet Show

Dr. Karen Fried is truly the gift that keeps on giving. In addition to her online sand tray and virtual dollhouse, she has now created a website where you can do Online Puppet Shows!

Virtual Puppet Shows with Dr. Fried

Puppets help kids express emotions that they might not want to share directly. They can project that feeling onto the puppet and feel safer exploring uncomfortable feelings, or they can re-enact traumatic, stressful, or upsetting scenarios.

This website allows a variety of backdrops, diverse cast of puppets to choose from, and actions including “hugging,” “hitting,” and “jumping” to let your puppet show really come to life! Like with her other websites, you simply pull up the page and trade off with your client controlling the screen. Plus, you have none of the hassle of washing and sanitizing like you do with “real” puppets.

Although I have used real puppets in my session, holding them up to the camera and talking through them, this eliminates the issue of whether my client has their own puppets to bring to the appointment. It also makes my puppet interactions feel a lot more “real” because we are both on the same screen.

I highly recommend this as a telehealth intervention!

A Year of Resiliency: Now Available on Amazon!

After some back and forth figuring out a formatting issue, my guided journal is now live and available for purchase through Amazon!

A Year of Resiliency

I still plan to make a special edition of the journal with spiral binding, and once Lulu sends me the prototype, I will figure out distribution for that. In the meantime, the proof copy of the KDP version is actually very easy to write in!

So check it out, tell your friends, and have a fantastic day!

Psychological Evaluation 101: Health Insurance and Psych Assessments

Thank you for checking out my series on psychological assessments! My goal in writing this series was to help people who don’t have years of graduate training understand what an assessment is and what information they might seek from an evaluation. As of right now, this is my final planned post in this series, though I am in the process of finding a guest blogger to speak on neuropsychological assessments. This is a common referral that I do not have the training to do, and I would prefer to have someone with more expertise speak to it.

Do you have more questions about psych assessments? Contact me, and I will do my best to add it to this series!

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Insurance is meant to shield us from healthcare costs, like an umbrella shields us from rain. Most Americans will tell you this isn’t how it usually shakes out.

If you’re in the United States, you will most likely have to deal with health insurance at some point. Health insurance is confusing and annoying, so I am going to do my best to explain how coverage works for psychological evaluations.

Short answer: it depends.

Long answer: psychological evaluations consist of a number of different billing codes, and depending on your policy, these codes might be covered as a co-pay or toward your deductible. Most providers will call your insurance company to check coverage before doing the evaluation, but it can save a step (and some time) for you to call them yourself. There is a phone number on your insurance card, which will connect you with someone who can check your coverage.

Now, if you call your insurance company and ask, “Does my policy cover a psychological assessment?” they might get confused. Often times, the person taking that call is not trained in what a psych assessment is and can consist of, so I encourage people to call about specific billing codes. The codes that I use most frequently are:

  1. 90791: this is the diagnostic interview or intake, where I get the client’s history and information about their symptoms. Typically this is covered at the same rate as other office visits.
  2. 96136: this is the first 30 minutes of testing in-person, so if your evaluator needs to administer tests to you, this covers that time.
  3. 96137: this is additional in-person testing units, with each unit being 30 minutes. This also covers the time it takes your evaluator to score the tests administered, so if you spend an hour doing in-person testing, it is possible the evaluator will bill three units to include time spent scoring the assessments.
  4. 96130: this is the first hour spent interpreting the results and writing up your report. You will not be present when the evaluator writes your report and interprets your results, but they are still compensated for the time that it takes to put this together.
  5. 96131: this is each additional one-hour unit needed to interpret and write results. Most evaluations take me two to three hours to interpret and write up, though more complicated assessments might take longer.
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When you call the insurance company, you can ask if these codes are covered and whether they require preauthorization. Preauthorization means that the provider (me) has to call and request permission to do the evaluation before moving forward. The purpose of preauthorization is for the provider to demonstrate that testing is “medically necessary,” which is insurance-speak for “you can’t make us pay for that.” (What does “medically necessary” mean? Will you die if you don’t get an evaluation? Will your quality of life improve if you do? It’s vague on purpose. But the problems with health insurance could be a whole other series.) Occasionally when I call to ask about preauthorization, they specifically want to know if I will be testing for a learning disorder, so it’s good to know the answer to that question before you call.

To request preauthorization, I have to complete the intake first in order to document why testing is appropriate, so typically that intake code does not require preauthorization.

Now, insurance companies also make a statement every time you call to ask about coverage: “Confirmation of coverage is not a guarantee of payment.” This, like the term “medically necessary,” basically means that insurance companies can do whatever they want – even if they tell you, “Yes, those billing codes are covered at 100% with your plan,” after testing is complete they can still refuse to pay.

As a human being with empathy, I hate this, but as a provider, I especially hate that I essentially have to then stick you with a bill for the cost of testing. The alternative is that I not only did the work for free, but the testing materials are quite expensive, so my practice loses quite a bit of money. I didn’t go into this field to become a billionaire, but if my employer can’t pay the electric bill, I can’t keep working. Not to mention, I also have needs like food and rent.

So, in addition to asking your insurance provider if these codes are covered, I suggest asking the provider who will be doing the testing for an estimate of what it could end up costing if insurance refuses to pay. (They might not have an exact number because the number of units is based on how long the evaluation takes, and sometimes things do take more time than expected, but they should be able to give you a rough estimate.) You can ask what kind of payment plan might be available if you are stuck with a large bill. At my practice, we are very flexible with payment plans and never charge interest as long as your account is current, so people with high deductibles can still be seen.

I hope this series has been helpful in giving people information about psychological assessments. Being referred for an evaluation can be intimidating, but this knowledge can make it easier to understand what to expect and de-mystify the process.

Psychological Evaluation 101: What Are Projective Tests?

(If you want me to write about more types of psychological evaluations, please let me know!)

Projective tests are a type of personality assessment that uses ambiguous stimuli to get information about things you might not be consciously aware of. They can involve having you respond to images, create drawings, or say the first response that comes to your mind in response to a prompt.

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Some, like the Rorschach, have a scoring system that gives the evaluator norm-referenced information about you, but others involve interpreting patterns in your responses. There are websites that try to coach people to get certain results, but these tests have measures to identify if you are doing this, so it’s best to just be honest.

I like using projective drawing tasks with kids because it can give me insight into a child’s feelings about their family and the world around them that the child might not have the skills to tell me another way. I might have a child do a projective drawing as a therapeutic activity, but typically if I am completing a psychological evaluation, I will not rely only on projective tests.

Because they are ambiguous, projective tests can seem intimidating, but if you give honest answers, you can get some interesting insight into your personality and your mental health.

Coming Soon: A Year of Resiliency

For several months, I’ve been working on creating a guided journal to help people with self-exploration. While no journal is a substitute for mental health services, guided journaling with specific prompts can help you get to know yourself better.

Enter: A Year of Resiliency: Growth Through Adversity. I’ve developed 365 prompts with the intent of spending a year exploring your identity with the goal of becoming a better version of yourself.

Isn’t it pretty?

Unlike with I Don’t Want To Be Bad, I will be publishing this journal in two formats. With everything I create, my main goal is accessibility. I want to reach as many people as possible, which I was able to use through Kindle Direct Publishing last time. I will be publishing A Year of Resiliency with Kindle for their worldwide distribution, and I’m very excited that this journal will be available around the world.

However, Kindle has only one binding option, and I feel like a journal is easier to use when it’s spiral bound. I found that Lulu will print spiral-bound books, but this was not a viable distribution option – with printing fees, distribution fees, and Lulu’s “cut,” I would have to charge $32 per book to break even. So at that price, my royalty would be $0.

If I use Lulu’s printing and do my own distribution, I can sell the spiral-bound copy for $25 each (plus shipping) and include a special edition pen. This does limit me to shipping within the United States, but this gives my readers the option to buy the special spiral bound version.

So, once my proof copies arrive next week, I will do final edits, and A Year of Resiliency will be available for purchase! Thank you to everyone who has supported me on this journey.

Psychological Evaluation 101: Autism

Language note: although everyone has individual preferences, the overall consensus at the time that I am writing this post is that people in the Autism community prefer to be referred to as “Autistic people” rather than “people with Autism,” so that is the language I will use in this post.

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Last week I talked about what an evaluation for ADHD looks like, and today I will talk about Autism. I’ve spoken before about the similarities and overlap between these two diagnoses, so you can check out that webinar if you want more information on this.

Even though we know Autistic children grow into Autistic adults, and even though we know that many Autistic children (especially Autistic girls) go overlooked in childhood, the existing norm-referenced measures for Autism are mostly created for children and teenagers. This does not mean that you can’t get diagnosed as an adult! It just means that the assessment has some limitations. When I get a referral for Autism testing for an adult, I explain this and move forward because that seems better than saying, “Sorry you didn’t get tested as a child! I guess we’ll never know.”

The assessment itself consists of a detailed interview where I get as much information as I can about the client’s background and symptoms, and if they have any previous psychological records, I review that as well. Since personality measures look at symptoms that overlap with Autism, I often use one to get norm-referenced information about symptoms and presentation.

With children and adolescents, parent and teacher observation measures like the Autism Spectrum Rating Scale can be used to diagnose Autism. There is also the Autism Diagnostic Observation Schedule, 2nd Edition, which gives the psychologist observational data about the client’s symptoms. I am not trained in the ADOS-2, but my understanding is that it is a very popular tool for these kinds of assessments.

It can be difficult to determine whether someone should be referred for an evaluation for Autism because, although we have diagnostic criteria, there is a huge range of ways that Autistic people can present. If you’ve seen one Autistic person, you’ve seen one Autistic person. Even though assessment materials have not completely caught up, the good news is you’re never too old to get checked out!

Interview with Dr. Katie Gordon, Psychologist and Author

I connected with Dr. Katie Gordon on Twitter when she posted about her upcoming book about suicide prevention. Obviously, this is an important topic, and she graciously agreed to an interview with me.

Content warning: this post talks about suicidal ideation.

For more mental health resources, check out Dr. Gordon’s website.

1. Tell me a bit about your professional background.

I went to Florida State University for my Bachelors, Master’s, and Ph.D. in Clinical Psychology and was mentored in suicidal behavior and disordered eating research by Dr. Thomas Joiner. I completed a one-year predoctoral internship at the University of Chicago Medical Center with tracks in cognitive-behavioral therapy, dialectical behavior therapy, and eating disorder assessment and treatment. After graduating, I began my job as a professor at North Dakota State University (NDSU). I worked at NDSU for about 10 years before leaving in 2019 to begin working primarily as a therapist. I also continue to be involved in suicidal behavior and disordered eating research.

2. Your upcoming book focuses on suicide prevention, a very important mental health topic. What was the inspiration for this project?

I have been conducting research in the area of suicidal behavior and prevention since graduate school, and there have been some gains in the field since that time. However, it is difficult for too many people to access relevant therapy tools because of obstacles in the healthcare system related to cost, wait times, stigma, and availability of therapists with expertise in suicidal thought and behaviors. The goal was to create an accessible workbook that makes useful psychological tools available to people experiencing suicidal thoughts. There are few, if any, interactive workbooks specifically focused on suicidal thoughts instead of a broader focus on depression. My goal is to help close the gap between scientific, clinical knowledge and the people who most need it.

3. What is the main takeaway you want readers to get from your book?

The main takeaway for readers is that suicidal thoughts are not something to feel ashamed of and that there are effective ways to soothe the pain that drives them. I want readers to feel valued, understood, and empowered with tools to improve their lives.

4. I’ve heard from clients that there is sometimes mistrust about disclosing suicidal ideation to a therapist because of anxiety about being hospitalized. How do we balance rapport and safety?

I think it’s essential that therapists become competent and comfortable discussing and addressing suicidal thoughts with patients. I recommend that clinicians read Helping The Suicidal Person by Dr. Stacey Freedenthal. It guides clinicians step-by-step through understanding what kind of suicidal ideation means someone is at immediate risk for killing themselves and the many other dimensions of suicidal thoughts and behaviors that do not mean that. The book is a guide for mental health professionals to respond compassionately, ethically, and effectively. If someone discloses suicidal ideation, and instead of panicking, the therapist uses the opportunity to understand how the client is feeling and what is driving them to feel that way, it can be a great opportunity to strengthen rapport and trust. Similarly, collaborative planning for safety and treatment between therapist and patient can truly strengthen rapport. For more about that approach, I recommend reading Managing Suicidal Risk: A Collaborative Approach by David Jobes.

5. I see from your website that you list “warmlines” in addition to crisis lines, for people who need support but aren’t necessarily in immediate crisis. How can people decide which resource is the best fit for them in the moment?

I recommend that people experiencing suicidal thoughts call hotlines. I recommend that people who need support, but that do not currently have suicidal thoughts, call warmlines. Well-trained hotline and warmline operators should help the caller reach out to the other type of resource if it would be more appropriate.

6. What can we do to reduce stigma around suicide and mental illness?

The strongest forces in reducing stigma are open discussions between people and in public spaces that counter misunderstandings about suicide and mental illness. This must be paired with policies in work places, schools, and communities that protect people from discrimination due to mental illness/suicidal thoughts and that prioritize well-being.

7. Do you have any other upcoming projects you’d like to talk about?

A project that I’m excited about is Psychodrama Podcast, which I co-host with my friend/clinical psychology professor Dr. Leonardo Bobadilla. Our goal is similar to my purpose for writing the book- to take psychological science out of academic journals and apply it to current issues that affect people. Our hope with the podcast is to share information through a scientific psychological lens, with a particular focus on societal controversies. We’ve been fortunate to have magnificent guests on our podcast to talk about topics ranging from #BlackLivesMatter to the sociology of cults. We have a lot of fun creating it and hope that people enjoy listening to it.

Dr. Gordon’s book, The Suicidal Thoughts Workbook, is available for pre-order.

Introducing: Parenting Consultations

Do you feel in over your head as a parent? Are your child’s behaviors or emotional needs overwhelming? Have you gone through a stressful life transition and are unsure how to manage your child’s response as well as your own stress? Do you simply need more options in your parent toolbox?

I’m here for you.

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Resiliency Mental Health now offers parenting consultations. Parenting consultations involve short-term, solution-focused guidance to help you build a strong, healthy relationship with your child. While a parenting consult is not therapy, I can put you in touch with therapy resources if needed. Check out the link above for more information about what parenting consults are and are not, as well as information about pricing.

I hope to soon offer parenting consultation support groups, where you can learn how to navigate the challenges of parenthood while receiving peer support from other parents who have been through similar experiences. These groups will begin as soon as there is enough interest to make them happen, so contact me today if you are interested.

Not local? No problem! I conduct these consultations over Zoom, so I can meet with you wherever you are. Reach out to set up a free 15 minute conversation to determine whether my services are a good fit for your needs.

Thank you to all the consultants and mental health professionals who answered questions and gave me the motivation to make this a reality!

Psychological Evaluation 101: ADHD

One of the most common referral questions I get for psychological evaluations is for ADHD, so I thought I would speak a bit about what an evaluation for ADHD looks like.

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Attention-Deficit/Hyperactivity Disorder is a neurodevelopmental disorder, meaning that the brain of a person with ADHD has structural differences compared to a brain that does not have ADHD. It is listed in the DSM-5 as a disorder, though there is evidence that ADHD brains evolved to meet specific needs that just don’t exist anymore. This makes sense when you consider that countries with child-centered approaches to learning have lower rates of diagnosed ADHD despite a review of research sources showing that rates are pretty consistent worldwide. Basically, if you play to a child’s strengths and support them, they might not exhibit “bad” behavior leading to a diagnosis.

I have a theory that this is why the “rate” of ADHD is lower in adults than children despite our knowledge that it is a lifelong condition. As adults, we are able to choose our job and a lot of our environmental factors that kids have no control over, so we self-select environments where we thrive. That being said, adults can absolutely get testing and benefit from additional support.

ADHD can be diagnosed as young as age four, though many clinicians are hesitant to diagnose at that age because there is a pretty big range of “appropriate” behavior for a four-year-old!

In my own clinical work, there are two ways that I do evaluations for ADHD. First, at my full-time practice, I complete a real-time test of an individual’s ability to focus and compare their performance to people with ADHD and people without ADHD. I give an assessment with a form for the client to complete and a second form for someone close to them to complete, which gives me data on their experience of symptoms compared to how they look to other people. (For kids, there is a form for the parent and teacher so I can track behavior across settings.) Then, if the client is willing and old enough, I give a personality measure that looks at a broad range of symptoms. I like to include this measure because most people with ADHD have a secondary diagnosis, and this information gives me a bigger picture of the client rather than a simple yes or no answer to the question, “Do I have ADHD?”

Although what I described above is a very thorough approach to an ADHD evaluation, not everyone is interested in completing testing in this depth. Some might also not have the finances for a full evaluation. ADHD Online offers a more affordable option that can be completed anywhere in the United States, which both makes getting tested affordable and makes this service accessible to people living in rural areas who can’t travel to complete testing. This assessment specifically answers the yes/no question of ADHD, but this is a great starting point to someone who needs services.

You get to decide what treatment route is the best fit for you. My goal is just to give you the information you need to make that decision.

App Review: ProviderResilience

I found my new favorite app. It’s called ProviderResilience, and it’s free. When I saw the name, I knew it would fit right in with my brand! ProviderResilience helps mental health practitioners track levels of burnout and encourages choices that increase our resilience.

ProviderResilience has daily affirmations that it encourages you to focus on throughout your day, and it counts down to your next vacation. There’s a daily “Builders & Breakers” assessment that tracks choices you make each day that contribute to burnout, which includes questions like, “Did you go for a short walk today?”, “Did you go to work sick today?”, and “Did you eat lunch at your desk?” (And if you, like me, smugly indicate that you did not eat lunch at your desk, it then asks if you skipped lunch).

Daily intention: Do not let what you cannot do interfere with what you can do. – John Wooden

Once a week, you are prompted to complete a self-assessment of your level of exhaustion and your level of disengagement so that you can see your current level of burnout and make appropriate choices to mitigate that. Over time, you see a graph of how your burnout level has changed over time and analyze patterns that contribute to your mental health.

Shockingly, the week I took off work had the lowest burnout level. I’d better repeat the experiment to see if it holds up.

On a monthly basis, the app assesses your professional quality of life, including “compassion satisfaction,” burnout, and secondary traumatic stress. This is so important for mental health professionals because our jobs are incredibly high-stress, and we need to be mindful of these things in order to be our best for our clients.

I have been using this app every work day for a few weeks now, and I’ve found it really helpful. We will see if my burnout levels go down over time, but I have noticed a shift in my thinking. For example, last week I considered doing notes during lunch and remembered I would have to tell the app that I had lunch at my desk, so I took a more deliberate break. Accountability works!

ProviderResilience is available on the Apple Store and the Google Play Store.