I often mention executive functioning, usually in the context of how autistic people, ADHD-ers, and those with other forms of neurodivergence can struggle. On many occasions, I have said I’m having a day when my own executives are refusing to function.

But what exactly does this mean?

Executive functioning is a set of cognitive processes that our brains use to organize information, remember things, and make progress toward our goals. Executive functioning helps with attention, motivation, planning, and many other tasks. It also helps us manage our emotional responses, communicate, and juggle all the things we need to do in a day.

People with executive dysfunction struggle with these things. They may struggle in one area or several. Like other skills, executive functioning can fluctuate – you might have a good executive functioning day and have more trouble on other days. Energy levels, stress, mental health, and other factors can impact your executive functioning.

The components of executive functioning include:

1. Working Memory. Working memory is our ability to hold and manipulate information in our brains for a short period of time. If you’ve ever tried to remember a phone number long enough to write it down, you used your working memory.
2. Flexibility and Shifting. These refer to our ability to think about things in different ways or adjust our thinking in response to new informaiton.
3. Impulse Control. This is our ability to stop and think before we act or resist the temptation to do something we do not want to do.
4. Inhibition. Similarly, our ability to inhibit behaviors is part of executive functioning and emotional regulation. This includes our ability to stop ourselves from saying something inappropriate or harmful out of anger. I tell my clients, your feelings are valid and okay, but you can be held accountable for a behavior you do while you’re having a feeling.
5. Task Initiation. As the name suggests, task initiation is our ability to start a task without becoming overwhelmed or procrastinating.
6. Persistence. It is useless to be able to start tasks if they always go unfinished. Persisting towards the goal after starting a task is an important part of executive functioning.
7. Organizing. Keeping track of the tasks we need to do, remembering where our belongings are, and our ability to follow a system for keeping track of things are all part of organization.
8. Planning. The ability to break a task down into smaller action steps and act on each of these steps is planning.
9. Time Management. This includes knowing how long a task will take so that we can allot enough time to complete it, as well as our ability to use time wisely and efficiently.
10. Metacognition. Literally meaning “thinking about thinking,” metacognition is our ability to monitor ourselves, our thoughts, and our behaviors.

Everyone has trouble with things like disorganization or procrastination sometimes, but it interferes with your ability to do the things you want to in your life, you may have issues with executive dysfunction. The good news is, you can improve your executive functioning. Therapy, medication management, or support accommodations can all make it easier to function.

Psst…. Get more mental health tips and resources on my Patreon!

“Have you tried mindfulness?”

This has become a common, catch-all response when someone expresses a mental health issue. While mindfulness can help with some mental health issues, it is not a perfect fix-all. It is a tool, and like any tool, it can cause more damage than support if it is used incorrectly or applied to the wrong job. A hammer and a paint brush are both tools, and you wouldn’t want someone using a hammer to paint your walls.

Or maybe you would. It’s your house.

Anyway, one group for whom mindfulness activities can do more harm than good is those who experience chronic pain. (If you experience chronic pain and you love mindfulness, that is valid, and please keep doing what you find helpful! There are no absolutes. Except that one.) Because many mindfulness activities involve bringing your conscious awareness to your internal processes and body sensations, chronic pain patients often find their attention drawn to the pain itself. Suddenly, you are acutely aware of the constant, inescapable pain. That is hardly therapeutic.

Recently, I was asked if I know of any mindfulness activities that are helpful for folks with chronic pain issues. I did what I always do and asked social media for some tips to share here. As always, your mileage may vary, it’s okay if something is not a fit for you, consult your treatment team, et cetera. Take what works, and ignore what does not.

Externally-Focused Mindfulness

When we think about mindfulness, we often think about turning our focus inward, but this is not the only way to be mindful. Instead of tuning into your body sensations, you can be mindful by focusing on an object in your environment (like mindfully observing a rock or leaf) or listing every sound you can identify right now.

Even externally-focused mindfulness scripts often start with tuning into your body, so know that you can tweak any script or activity to meet your needs. For example, if deep breathing exercises that include a body check-in increase your pain level, you might prefer exercises that involve taking slow breaths without cuing you to the breath itself or your internal processes.

Radical Permission

“Radical permission” is a strategy used in Dialectical Behavioral Therapy. It refers to a distress tolerance skill aimed at accepting what is happening without creating further discomfort or pain.

The mental health treatment facility HopeWay puts it very well:

Radical acceptance is NOT approval, but rather completely and totally accepting with our mind, body and spirit that we cannot currently change the present facts, even if we do not like them. By choosing to radically accept the things that are out of our control, we prevent ourselves from becoming stuck in unhappiness, bitterness, anger and sadness and we can stop suffering.

Fully and radically accepting the reality of pain without sitting with or becoming “stuck” in our emotional response to the pain is radical acceptance.

Comfort Items

I would like to extend a special thank you to @MichellePraiz on Twitter/X/whatever they’re calling it when this goes live for this tip. Michelle said that using soft blankets and pillows, candles with comforting scents, and cushions for her body can help bring attention to the things that feel good in her body.

Distractions

Several people I spoke with when writing this blog post recommended finding ways to distract yourself. Choose something engaging outside of yourself, like a show, movie, or other media that will pull your entire focus out of your body and onto something else. Find an activity, like stretching or another (non-painful) movement that takes your focus. Anything that requires your full attention can be a distraction from physical pain.

Leaning In To Familiarity

A great tip from @justmegg93 on That One Website is to recognize the familiarity and lean into the comfort that comes from knowing what to expect. Unfamiliar things are scary, and chronic pain can be predictable.

According to @justmegg93:

My chronic pain is known. I can process what I know. I craft a wall of pragmatism. When my pain flares up, it’s frustrating and I let myself feel that. However, I also firmly tell myself, “You know this pain. It is not new to you. Take comfort in the familiarity of it.”

Finding Community

Pain is so isolating, and it is hard to remember that you are not alone in your experience. Online communities in particular can connect you with others who understand your experience because they also live with pain. You can connect with people who “get” you, who will not downplay what you are going through or judge you for your disability, and exchange tips and advice for getting through your worst days.

Community support can open doors to better understanding your own experience and connect you with your people.

My course on developing a professional will has been updated to meet requirements for continuing education. Enroll today!

Cost: $25 for the course and continuing education certificate. There are no additional fees for this course. The fee offers you lifetime access to the self-guided home study course. Because you maintain lifetime access to the learning materials, no refunds are offered for this course.

Presenter: Dr. Amy Marschall, PsyD, Licensed Clinical Psychologist, certified in Trauma-Focused Cognitive Behavioral Therapy, trained in trauma-informed care.

Bio: Dr. Amy Marschall is a clinical psychologist licensed in South Dakota, North Dakota, Montana, Florida, Wisconsin, South Carolina, and New York. She is certified in TF-CBT and has extensive education in trauma-informed care, and she teaches Trauma-Informed Cognitive Behavioral Therapy with Children and Adolescents with PESI. Dr. Marschall is an author and speaker, and she has a full-time private clinical practice, Resiliency Mental Health. She also created a website to distribute mental health and therapy resources to the public.

Resiliency Mental Health is approved by the American Psychological Association to sponsor continuing education for psychologists. Resiliency Mental Health maintains responsibility for this program and its content.

Description: What would happen to your clients if you were unable to go to work tomorrow? All therapists have an ethical requirement to have plans in place in the event that we are unable to practice or be there for our clients. This webinar includes everything you need to know about creating a professional will as a therapist, including ethical requirements, what to include, choosing an executor, and disclosing to your clients.

This 60-minute presentation is one continuing education credit, which counts as an ethics credit. It is pre-recorded for home study, to be completed at your own pace.

Objectives:

1. Construct a professional will in compliance with applicable laws and ethics codes
2. Develop scripts for use with clients to explain the purpose of the professional will and address client concerns and questions
3. Determine appropriate safeguards to ensure client confidentiality and continuity of care are provided in the event a therapist becomes incapacitated

Target Audience: This is an introductory-level continuing education course for psychologists, counselors, clinical social workers, and marriage and family therapists.

Statement Regarding Conflict of Interest: Dr. Marschall and Resiliency Mental Health have no financial or non-financial conflicts of interest to disclose.

While not a recognized “diagnosis” in the DSM, there has been more research and talk around Pathological Demand Avoidance (PDA), a behavior profile characterized by avoiding, resisting, or otherwise not complying with expectations or commands. Many autistic people identify with the PDA profile, though some research suggests that non-autistic people can display PDA traits as well (although with what I know of the rampant misdiagnosis around autism, I have questions about those studies).

Since it is important to be mindful of the language we use and how that language affects the communities we discuss, it is essential that we note how the name “Pathological Demand Avoidance” is inherently, well, pathologizing of the individuals who display these behaviors. It assumes that the demand avoidance is bad or wrong, and the individual should be complying or meeting these demands.

This is an issue in particular for the autistic community, many of whom are taught from an early age that their behavior is wrong and needs to be corrected, even though the behavior is meeting a need. Those pushing for affirming approaches to understanding the autistic (and other neurodivergent) experiences have called to change the name to Persistent Drive for Autonomy. Basically, instead of thinking of PDA as resistance or noncompliance, we see it as a desire to control our bodies and our experiences, a natural part of human experience.

As a side note, I also find “drive for autonomy” to be more accurate than “demand avoidance.” While I do not fit a full PDA profile, I have some of the traits. In high school, my math teacher told me she would not recommend me for AP Statistics because she felt I was not smart enough for the class. I went over her head, enrolled anyway, and got straight As purely out of spite. I would hardly call that “demand avoidance.”

Conceptualizing individuals as “avoiding” demands inherently strips away autonomy. It prioritizes getting someone to comply over identifying and meeting their needs, and it blames them for struggling when those needs are not met. We need to foster autonomy, not strip it away from those most victimized by the system.

Are there demands we need to meet? Of course! But when someone is unable to function, or is otherwise struggling, it is unhelpful to shame them and insist that they just do it anyway. Let’s shift the focus over to fostering healthy autonomy and connecting people to the supports they need.

Get more mental health tips and resources on my Patreon!

I recently wrote about the various revenue streams I have compiled for my business. As I have said many times, therapists deserve a living wage but often struggle to get there, and I have been able to expand my sliding scale and pro bono offerings by diversifying my income.

Of course, you do not need to pursue every possible revenue stream, and you probably should not. Work-life balance, people! If you want to find other revenue streams for your business, choose streams that fit your business goals and that you actually enjoy working on.

Use these tips to figure out which revenue streams are right for your business.

What Fills You Up?

There is a myth that we are supposed to hate our jobs, and I would like to dispel that right now. I spend more time doing work for my business than probably any other area of my life, and I would like to enjoy that time.

Think about the various projects you have been a part of, as well as the tasks you do day to day. Which tasks bring you a sense of joy or fulfillment? Personally, I get a huge sense of satisfaction knowing that I have shared useful knowledge. That is why I spend so much time writing about mental health. I know that an unlimited number of people can read what I share, and it can potentially make them more knowledgeable or improve their lives. Because of that, I lean into revenue opportunities that involve sharing knowledge with the public.

Maybe you enjoy creating resources people can use in their sessions. Digital downloads and other resources might be a fit for you. Or maybe you feel fulfilled from consultation work. Lean into what you enjoy.

What Does Your Ideal Day Look Like?

If you could plan out your ideal work day (yes, I know, we do not dream of labor, but for the purpose of this activity), what would it look like? What would you spend your time doing? Personally, while I understand that some meetings are essential, I do not spend my time in meetings I am not paid to attend.

I enjoy working from my home office so I can spend time with my cats, so I’ve structured my business to only require me to be in an office one day a week. I like having breaks in my day, so I space my sessions out. I love writing, so I find opportunities where I can spend my time doing that.

Make a list of revenue streams that involve your ideal day.

What Do You Wish You Could Do More Of?

I love my clinical work but found reimbursement rates unsustainable, so I partnered with EAP programs that pay a living wage so that I could open up my availability to more clients. What do you wish took up more of your time? Is it possible to turn that into a revenue stream for your business?

I don’t mean to suggest that you have to monetize everything you do – it’s okay to have hobbies and to just enjoy things without profiting. But this blog post is about revenue streams, which is why I mention it here.

What Do You Wish You Did Less Of?

On the other side, which parts of your day do you dread the most? What do you wish you could cut out completely, or at least reduce? It’s important to know this and avoid potential revenue streams that lean into these non-preferred tasks.

When I was a graduate student, I offered editing services, reading texts for factual accuracy, typos, and quality of writing. I hate editing – it is why I work with publications and publishers that do that part of the writing process for me. What an awful idea.

Focus your energy on the revenue streams you enjoy.

What Are Your Income Goals?

You love your clients and you are passionate about your work, and also you live in a capitalistic system where things cost money. Consider your income goals when choosing revenue streams. Do you want to be able to supplement your therapy practice, or develop a fully sustainable business not reliant on your clinical practice? Do you want to create streams of income that continue paying over time, like through royalties or other passive income?

Choose projects and activities that fit with your goals for your business and income.

I know, I know, we aren’t in this for the money. But until my bill collectors start accepting the warm feeling I get from helping my clients in lieu of payment, I need to generate income. (Did I ever tell you about the supervisor who told me I should be grateful to get paid at all because if I really believed in the “mission” I would work for free? And then told me I had too many Medicaid clients on my caseload and wasn’t generating enough revenue?)

Insurance companies reimburse at unsustainable rates, and the hoops we have to jump through with billing are an administrative nightmare. Coverage changes constantly too, and it feels impossible to keep up. On the other hand, so many of the clients who need our services simply cannot afford to pay out-of-pocket. (By the way, the ACFB Fund is working on bridging the gap between affordable mental health care and living wages for therapists in New Zealand, with plans to launch in other countries soon!)

So, by popular demand, here is the big list of revenue streams I rely on as a therapist. As always, your mileage may vary, try at your own risk, vet any companies you work with to make sure they meet your ethical and moral criteria, et cetera.

In creating this list, I stuck to ideas that fit under my expertise as a psychologist and therapist. I took out those student loans, and I am getting my money’s worth, darn it!

Here are my top 8 revenue streams for therapists!

Employee Assistance Programs (EAPs)

An EAP is a program where your employer covers the cost of a certain number of therapy sessions so that your out-of-pocket cost is $0. I used to refuse to accept EAPs because the reimbursement was awful (sometimes as low as $30 for a session billed at $160), took forever (I once got a payment 18 months after the session date), and unreasonably time limited (some programs made the client stop seeing me after three sessions).

In recent years, many companies have contracted with EAP providers like Spring Health and Lyra, offering a sustainable reimbursement rate, more reasonable number of sessions, and much simpler billing. I’ve also had opportunities to facilitate wellness conversations and develop mental health educational materials through these companies.

Although EAPs simplify the billing process and tend to pay better than many insurances, you are still providing therapy services, so if you’re looking to develop income streams without increasing your caseload, this might not be the best fit.

Adjuncting (And Other University Work)

In the spring semester of 2021, my graduate university held classes online, so I had the opportunity to teach Family Therapy over Zoom. I must have done an okay job because they have had me back in 2022 and 2023 even though the rest of the courses were in-person. In addition to adjuncting this course, I have helped out with the admissions process, reviewing applications for prospective students and answering questions about my experience in the program.

The reimbursement is not fantastic compared to my other revenue streams, but teaching can be rewarding and enjoyable, and I like knowing that I am helping the next generation of psychologists be good at their job.

Digital Downloads

Have I mentioned my Teachers Pay Teachers store lately? How about the A Change for Better store? Basically, when I need a worksheet, educational tool, or other resource that I can’t find in my existing library, I put one together. Then, I list it in an online store so that other therapists can access it for a few dollars.

I do not make a huge amount of revenue from these downloads, but what I make is passive income, so that’s nice.

Writing Articles

I love writing (can you tell?). I submit articles to many different online publications on various mental health topics, which helps the general public better understand my line of work and their own mental health. Plus, I can use time when clients cancel at the last minute or miss their appointment to write, so I can be more flexible with my cancelation policy without sacrificing my income.

Plus, I get quite a few referrals for both clinical work and consultations from people who read my articles and found them helpful.

Writing Books

Taking writing a step further, if you have an idea for a book, this can be another great way to get information out there and make income through royalties. We live at a time when self-publishing is incredibly accessible, or you can pitch your idea to a traditional publisher for help with editing and marketing your book. (Just beware of vanity publishers – a reputable publisher will never charge authors. Their job is to pay you, not take your money.)

Therapists can write books to help other therapists be better at our jobs, or write books for the general public about mental health.

If you are considering pitching a book to a traditional publisher, by the way, my post today on Patreon shares a sample proposal with tips for writing your own.

Consultations

When the State of Emergency ended and I knew some of my clients might lose their Medicaid or Medicare coverage, I increased my professional consultation rate. That allowed me to offer more pro bono and sliding scale spots in my practice without sacrificing my passion for eating and paying bills on time.

Just make sure you are clear about your rate and get in writing that they understand that they have to pay you. No free interviews. T-Mobile offered me a “consultation role” but said I had to interview first, and the interview was a consultation. They used the information I gave them to make their company more profitable but weaseled out of compensating me for my time.

Now, I make them sign a contract up front before I will provide my expertise, and it has become a solid source of income.

Continuing Education

Every licensed mental health professional is required to take continuing education every year to make sure we are up-to-date on the treatments we offer our clients and are doing our jobs to the best of our ability. Those courses need to be taught by someone qualified. Why not you?

I have taught continuing education with a few different companies. Some pay a higher speaking rate up front just for the course, and others record the course, sell it, and pay me a royalty. Hooray for passive income!

If you have the resources, you can apply to be a sponsor and create your own continuing education content that you fully own and can distribute independently. However, this comes with startup costs and takes a lot of unpaid time and labor to get it going. Figure out what is realistic for your business.

Other Speaking Opportunities

Conferences, organizations, and groups are often looking for experts to share our knowledge. As with consultations, make sure you are up front about your speaking fee, and get a commitment in writing. Some organizations will want you to speak for free, but your time and labor has value.

I recently hosted an Ask Me Anything about neurodivergent parenting that helped a lot of people and allowed me to talk about a topic I care deeply about.

So there you have it – my eight favorite supplemental income streams. Another day, I will speak to how you can decide which stream is a good fit for your interests and business goals.

What other revenue streams have you developed in your practice?

I have spoken before about how feelings are not good or bad – they simply are. A feeling might be unpleasant, but you are not wrong for feeling it. A feeling might not be logical, or in proportion to the precipitating trigger, or fully in touch with the facts of reality, but it does not need to be justified.

Sometimes we act out in response to our emotions, and we can be held accountable for our behavior regardless of our emotional state at the time. In particular, some people struggle to make appropriate choices when they are experiencing anger. I constantly tell the kids I work with, “It’s ok for you to feel angry. I feel angry sometimes, too! It’s not ok to (hit, break things, hurt people, hurt yourself) while you feel angry.”

One way to process emotions in a healthy way is to identify what the emotion is trying to tell you. I have seen many people (both professionals and non-professionals) say that anger is a “secondary” emotion, meaning that we feel angry in response to a different emotion, like sadness or fear. While this may be true some of the time, sometimes anger is the primary emotion. Insisting that anger is always secondary invalidates when anger is primary.

When you feel angry, ask yourself, what message does my anger have for me?

My anger might be cuing me to injustice. Something is happening that is not okay, and I feel angry and motivated to fight back.

My anger might indicate that someone is mistreating me. It is telling me that I deserve better and have the right to stand up for myself.

My anger might tell me that something I am doing is not working, and I need to take concrete steps to make a change.

If you feel angry constantly, the emotion can wear you down and be unhealthy. At the same time, denying your anger is unhelpful and can be self-invalidating. If you struggle to find your balance, a therapist can help.

Psst…. Get more mental health tips and resources on my Patreon!

Friends, get excited. Enemies, get jealous. Slipper the Penguin eBook is available for pre-order on Kindle NOW! The eBook will be available on October 1, 2023. Unfortunately I cannot do pre-orders for paperback or hardcover copies as a self-publisher, so you will have to order those when they go live.

The plan is for both to go live on approximately October 1, keeping in mind that KDP does not let you instantly publish and can take a couple of days to activate. Keep following along, and thank you for all your support in this journey!

Slipper is a bird who lives in the jungle with her bird friends. She wonders why some things that come so easily to her friends are so difficult for her. “Why am I so bad at being a bird?” When the weather changes, Slipper meets other birds like her, called penguins. Slipper’s new penguin friends teach her that she is a perfectly wonderful bird, just a different type of bird than she thought before!

Slipper the Penguin is illustrated by Abby Lastowski of Actually Owltistic.

A body scan is a mindfulness activity that can help you check in with the physical sensations and emotions happening inside your body at a given time. It can help you become more in tune with your body’s needs in the moment, and it can help with relaxation.

Like all therapy activities, it is not the right fit for everyone. In particular, people who experience chronic pain sometimes report that a body scan can cause an increase in distress because it draws their attention more deliberately to feelings of physical pain.

On the other hand, some populations that experience executive dysfunction, like autistic folks and those with ADHD, sometimes find that the body scan can help them remember that they need to take a break to attend to their needs. Of course, many autistic and/or ADHD people also have chronic pain, and some simply do not like this activity.

All that is to say, use this if it is helpful for you, and if not, don’t. No tool is right for every possible job.

First, find a comfortable position for your body, standing in a relaxed posture, sitting comfortably, or lying on a soft surface. Rest your arms at your sides. Use cushions or pillows if you need them.

If you feel comfortable, close your eyes, or allow your gaze to focus softly on a point in the distance. Bring your attention to your breath, and slow your breathing with longer inhales and exhales. Feel your muscles relax with each breath. If you’d like, pause for a moment between each inhale and exhale, allowing yourself to feel still in this moment.

Bring your attention to the bottoms of your feet. What sensations do you experience here? Temperature, tingling, tension? If you’re wearing socks or shoes, are you aware of those textures? Slowly draw your awareness up your toes and the tops of your feet, noticing any internal or external sensations.

Slowly, slowly, at your own pace, bring your attention up your ankles. Calves. Pausing on each area and noticing what you feel. Knees. Thighs. No judgment, just awareness. Hips. Stomach. Back. What does your body need right now in this moment? Ribs. Chest.

What physical and emotional sensations come up for you in this activity? Remember there are no right or wrong answers. Draw your awareness to your shoulders, then slowly down your arms, to your hands, palms, fingers, all the way to your fingertips. Keep letting your breaths come slowly and deeply.

Now draw your attention slowly up your neck, into your head, the muscles in your jaw and face, all the way to the top of your scalp.

Wiggle your fingers and toes, and if you closed your eyes, open them when you are ready. If you were sitting or laying down, get up and take a big, full-body stretch. If there were any areas where you noticed a lot of tension, breathe into these areas to help them relax and let go.

The more you practice the body scan activity, the more you will become aware of what your body needs in the moment.

I know what you are thinking. What do you mean it’s release day again? Didn’t you just release a book a few months ago? You would be correct! Hyperfocus is my superpower.

Clinical Documentation with Children and Adolescents is LIVE as of today. Thank you everyone who pre-ordered – we didn’t quite make it to the #1 new releases list on Amazon this time, but that is okay. I am just glad that lots of people are going to learn more about documentation considerations when working with minors. It is an important part of the ethics in our work and one that is often overlooked.

If you didn’t pre-order, that’s okay! You can get your hardcover, paperback, or ebook copy through Routledge (my publisher) or on Amazon.

In case you forgot, here is what this book is about:

This book addresses the unique challenges therapists face when documenting their clinical work with children, providing insight into what ethical, appropriate, and culturally competent practice looks like.

Clinical documentation is vital for ethical and legal practice, and good documentation helps clinicians leave room for client-centered and age-appropriate interventions, such as play therapy. Beginning with an overview of the important considerations unique to providers working with children, Amy Marschall offers guidance on all aspects of clinical documentation, such as intakes, treatment plans, mental status examinations, progress notes, safety plans, and more.

Each chapter includes specific examples of clinical situations with guidance on how to document these situations effectively. With chapters on client confidentiality and telehealth, as well as special attention being paid to cultural awareness, including race, ethnicity, gender, sexual orientation, and socioeconomic status, this book includes blank templates of treatment plans, progress notes, and risk assessments for therapists to use in their practice.

This book is essential for any mental health professional who works with children in both individual and family work, including psychologists, licensed clinical social workers, licensed professional counselors, mental health counselors, marriage and family therapists, play therapists, school counselors, and therapist interns.