Recently, Facebook showed me a series of adds from a law firm encouraging me to sue my therapist. I read the article linked in the add and had some Thoughts that I decided to share with all of you. I want to preface this article by reminding everyone that I am not a lawyer or legal expert, and nothing I say is legal or medical advice. This is just my reaction to an article about suing your therapist.

I also want to acknowledge that many people have experienced harm at the hands of their therapist. Fairly recently, a therapist in a jurisdiction where I practice lost their license for inappropriate sexual conduct – and frankly, that’s just the easiest ethical violation to prove. You were either sexual with a client, or you weren’t. Emotional abuse and manipulation are much more difficult to conceptualize and prove, so “I couldn’t prove it” does not mean “It did not happen.”

Even if you get a gut feeling that is difficult to articulate, it is okay to switch therapists for any reason or for no reason. You deserve to feel comfortable and safe in your treatment.

Ethics are seldom all-or-nothing, so many things can be a “gray area” when it comes to “appropriate behavior.” Many things might be generally unacceptable with some rare exceptions. For example, in an ethics seminar in graduate school I was asked to role play how I would respond if a client invited me to their birthday party. The (fictional) client in question was a foster child who had never had a birthday party before and wanted Miss Amy to come to the party because “You helped me so much.”

After I tried to gently say no, the “child” began sobbing and promising to do better in therapy if I would just go to his birthday party, and my professor broke in to say, “In this case, it would not be unethical to attend the birthday party.”

So, according to some lawyer, here are things that indicate that your therapist is abusive, and my reaction as a therapist.

If they offer services for free or at a very low cost.

Therapists offer reduced cost services all the time. The organization I used to work for had an entire clinic to offer low-cost or free therapy for uninsured folks or those with really high insurance deductibles. In fact, Principle B of my ethics code states, “Psychologists strive to contribute a portion of their professional time for little or no compensation or personal advantage.” So actually I am supposed to offer free or low cost services to clients who need them.

If they schedule your appointment last in the day or after clinic business hours.

Based on my understanding of how schedules work, any therapist who sees any number of clients will have a last client of the day, so…we are choosing one client to abuse every day? As far as after hours sessions, that can be a boundaries issue if the therapist is not protecting their own balance and time off, but that is not automatically abusive to the client. The day I wrote this post, a friend actually mentioned a time that their therapist fitting them in “after hours” to accommodate a personal crisis, which they found really helpful and possibly prevented the crisis from getting worse.

Fictitious billing of insurance for non-existence treatments or sessions.

I wrote this word-for-word as it appeared in the article, but grammatical issues aside, this is correct. We should not bill for sessions that did not happen. That’s called fraud.

Therapy sessions run over time.

Again, this can be a boundary issue for the therapist, who may have another client waiting. However, it is not automatically abusive. This is a therapy Catch-22 – I have seen folks argue that therapists who insist on ending sessions on time are abusive, but so are therapists who are late for their next client. Apparently the only fully ethical therapists are Time Lords.

Practitioner seems aloof or not paying attention, or they check their phone in sessions.

Yes, your therapist should be attentive to you in sessions. Barring some type of emergency, they should not be checking their phone for things unrelated to the session.

Therapists invite clients to outside events such as a show or movie.

This is correct. Your therapist should not be inviting you to socialize. This would be a dual relationship, conflict of interest, and unethical. Some therapies involve going to a location for the treatment itself, like exposures for CBT, but your therapist should not be trying to be your friend outside of their role as your therapist.

Attending social events such as parties where the practitioner was.

I feel like I have to be misreading this. If a client goes to a social event where I happen to be, that makes me abusive? I am allowed to leave my house and have a life outside of my job. Again, I should not be inviting clients to social events, but if we happen to be in the same place, that’s just existing in a society. Imagine not being allowed to run into someone. Tell me you have never heard of a small town without telling me.

Offers rides home after sessions.

I have never given a client a ride home. When I took my ethics course, we were given an example of an extreme situation where there was a snowstorm, they had no cell phone, and they had an infant with them. I think this was meant to teach us there are no absolutes or something like that. I will say that an abusive person might use offering a ride home to test boundaries, so generally this may be an accurate statement.

Being invited to sleep over at the practitioner’s home.

Yes, this is not okay. Don’t invite your clients for sleepovers at your house.

Practitioner offers alcoholic drinks during or after sessions.

Unless there is a consideration I am missing, yes, this is also accurate. Your therapist should not drink with you or offer you alcohol.

Practitioner mentions that you have friends in the same circles.

Again, tell me you have never heard of a small town without telling me. No, I do not spend my clients’ sessions socializing or talking about friends we have in common. However, if the client mentions something that brings it to my attention that we may have a social connection, I disclose this to them. I don’t want them to be surprised if we happen to end up at a social event together, and depending on the nature of the connection, I might have to refer them out due to a dual relationship. They get to know if that is my reason for referring out.

Practitioner has offered to be friends when treatment is finished.

We are not friends with our clients, and there are rules about having social relationships after therapy has ended. So this is correct.

Have attended professional or social meetings together outside of sessions.

Do they mean attending together like going together on purpose? Again, professionally, this could be part of a CBT treatment protocol. If they mean you are not allowed to be at a meeting where a client might be, I will again say that therapists are allowed to exist as humans when we are off the clock. Therapists have our own therapists, and providers who work with other therapists might run into clients at conferences. They need their continuing education also. Therapists might participate in groups or organizations outside of work, which clients might also attend. Expecting me to never run into a client in another context is unrealistic.

If you are keeping score, a generous interpretation of these “red flags” was correct seven out of 13 times. That’s a failing grade. My conclusion here is that I will not dispense legal advice, and maybe this law firm shouldn’t be dispensing advice about therapists.

EVERYBODY SHUT UP FOR A SECOND

GUESS WHAT

My esteemed colleague and personal friend, Dr. Katelyn, and I have launched the long-awaited sequel to It’s About To Get Real Unprofessional. Are you excited? I’m excited. Get ready to color and curse.

Did you hear? Ignoring the mental health crisis somehow didn’t make it go away! So your favorite internet psychologists, Dr. Katelyn and Dr. Amy, are back with 69 more coloring pages and activities especially for therapists. We can’t make insurance companies pay you a living wage, but we can sort of draw. Help us pay off our student loans, and we’ll help you forget that mindfulness can’t fix systemic crises.

WARNING: This book contains language and imagery that some may find offensive. Not suitable for children, cowards, or buzzkills. As the cool young people say, Dead Dove Don’t Eat.

Get your copy on Amazon or a printable download on Etsy. Help us fulfill our dream of paying our bills!

I’ve written before about the role Roblox has played in my telehealth sessions, and I have shared before about how Let’s Play Therapy Institute has a free training in how to incorporate Roblox into your therapy treatment plans.

One hang up I have had with Roblox, though, is that in order to join your client in their Roblox world, you have to make an account. This is easy to do, and anonymous accounts can “friend” clients (with parental consent) without violating confidentiality, but I feel like this is not ideal when using outside platforms in therapy.

HiberWorld lets you join and create platforms without making an account, though there are more features available if you make a free account. You can make an account to access more features or save things you build, and your clients can join as a guest for confidentiality.

HiberWorld’s platform works on both desktop and virtual reality, so if you and/or your client has a VR headset, you can enter the world that way and become even more immersed in the platform.

While I did not do a deep dive, a quick search of virtual reality and telehealth shows that cognitive behavioral therapists have been effectively using VR platforms for exposure therapy for a while. I did not see peer-reviewed research for play therapy with VR, but the effectiveness of video-based therapy for play interventions has me optimistic.

Anyway, HiberWorld has space to create, so you and your client can use expressive therapies interventions within the platform. You can either start fully from scratch or choose a starting template that you can customize. There are also games with specific objectives you can join, including racing or mining challenges.

One thing to keep in mind is HiberWorld’s terms of service require that all users be at least 13 years old. As with all platforms, make sure you have parent or guardian’s consent for this intervention.

Note: Any references to clients indicate general themes I see over time or are fictionalized. This blog does not contain specific references to any of my clients.

Sometimes when clients talk about depression, one thing that frustrates them is that they see their mood issues as fundamentally at odds with who they are as a person. I have heard many people express confusion about their depressive symptoms because “I’m a happy person.”

The thing is, “happy” is an emotion, not a permanent state of being. When I took Spanish in high school, we learned two different words for “to be.” “Ser” referred to permanent states, who you are fundamentally, and “Estar” is a temporary condition. Since no one feels one emotion continuously forever, happiness is always a temporary condition, just like sadness, anger, fear, and all other emotions.

Feelings are communication from our brains. Anger, for example, can be a cue that someone is mistreating you. Sadness after losing a loved one can be an expression of how much that person meant to you.

Toxic positivity refers to when we insist on optimism, hopefulness, and positive outlook in all situations, with no space for nuance or the broad spectrum of human emotion. Sometimes things just suck, and denying that only serves to invalidate real feelings rather than addressing them.

If you struggle to let yourself have these less pleasant feelings, it can help to explore what being a “happy person” means to you. Do you get overwhelmed by the discomfort of holding those emotions? Is there a judgement you make about yourself if you can’t live up to the expectation of being a “happy person”? Have you been punished in the past for expressing other feelings?

Unfortunately, denying feelings will not make them go away. They demand to be felt.

If you are struggling with your emotions, it can help to work through it with a therapist. Even though you can’t be happy 24/7, you can develop skills to handle upsetting emotions in a healthy way and address underlying issues. Remember that your feelings do not impact your worth, and you deserve support.

I have talked before about how every conversation is really three conversations: what was said, what was meant, and what was heard. Recently I stumbled on another way to explain this phenomena to young children.

Note: Any references to clients, as always, are fictionalized.

One of Zoom’s many cool features is live closed captioning. While not perfect, the automatically generated captions can help Deaf or HOH folks understand what is being said in a video meeting, and they can help those with auditory processing issues follow along. They do not turn on automatically, and some might find them distracting, so they are certainly not mandatory if no one requires them.

Sometimes, kids will request closed captioning in a Zoom meeting, often not realizing what the function is. They then notice that the subtitles do not always accurately hear what we are trying to say and shows incorrect words.

Some kids get frustrated when the captions are wrong, though usually their response is amusement. “That’s not what you said! That makes no sense!”

Ask: When is a time you heard something that didn’t make sense? Did you find out later that you misunderstood? Or conversely, when is a time someone thought you were not making sense because they misunderstood you?

Even though the automatically generated captions exist to help people, they still get things wrong sometimes. Misunderstandings happen, and that’s okay! We can work through them.

You thought I was finished talking about license reciprocity for telehealth therapists? You absolute fool! I am never done talking. Ask my husband.

I want to preface my thoughts by saying that I really appreciate the work that organizations like PsyPact are doing to make license reciprocity a reality. I am so happy (and not at all jealous) of the 36 states that have enacted legislation allowing licensed psychologists to practice across state lines.

You have to be a resident of a PsyPact state and licensed there to join, so if you live in South Dakota (not PsyPact) but are licensed in Wisconsin (PsyPact), you still cannot join.

But you might notice something looking at that map: North Dakota, South Dakota, Montana, and Alaska, some very rural states, have not opted in. That is because state lines laws around mental health care require licensure at the client’s location at the time of service – that means that, by opting in, every state agrees to honor the credentials of every PsyPact psychologist, most of whom their board has not vetted and who do not pay licensure fees that allow the board to investigate unethical practice.

This means that small boards (like those in states with fewer providers) with fewer resources may have to investigate providers who might not have met their criteria to become licensed in the first place.

So basically, the states who need reciprocity due to provider shortages have the biggest barrier to joining the compact.

Other states have said that they do not want to join PsyPact because it means out-of-state providers will get revenue from the state without paying income tax there. (This is the same reason why I’m not allowed to accept Medicaid in other states where I am licensed but don’t reside, by the way. I’ll blog about that another day.)

In both cases, it comes down to money – small boards cannot afford to oversee out-of-state providers, and some larger states do not want the lost tax revenue if other providers practice in their state.

And the provider shortage continues.

In conclusion: Call your reps.

I have written previously about laws regarding state lines, licensure, and telehealth services. The way laws are currently written, a therapist must be licensed at the client’s physical location at the time of service in order to provide care. Some states have enacted exceptions to this law; for example, some providers can continue seeing an existing client for continuity of care even if the therapist does not get licensed in an additional state. However, for the most part, the expectation continues to be that providers obtain licensure in any jurisdiction where their clients will be.

In my deep dives into these laws as a telehealth expert (that’s what PESI calls me based on my experience and knowledge, isn’t that cool?), there are some rationales behind this rule, but honestly none of them seem to hold up:

1. What If The Client Experiences A Crisis? Providers are most well-versed in the crisis resources in their geographic area, so if a client is in a different state, how will I know where to refer them to? Well, there is this awesome new thing called a search engine that allows anyone to find resources in any geographic area in seconds! Since I am currently licensed in six states, I keep a spreadsheet of local resources in all jurisdictions. I would simply have to make sure that I maintained these resources for any other locations where I have clients – which would not be difficult. We all managed these crises when states offered reciprocity in early COVID days.
2. What If A Client Needs To Report An Unethical Provider? If I am inappropriate with a client, they have the right to report me to the licensing board that oversees the jurisdiction responsible for me. If I see clients outside of where I am licensed, clients still have the right to report me to my licensing board. But thanks to the internet, anyone anywhere in the world can get the email and phone contact information for all my boards, again within seconds. So the oversight is still there.
3. What If The Client Needs To Be Seen In Person? I will acknowledge that, if a client might need to be seen in person, they might have trouble with a telehealth provider who is not in their geographic area. However, this already exists within jurisdictions. You can drive more than five hours to the West of my office without leaving South Dakota, so plenty of clients I’m licensed to treat already not in a position to come in person. As with crisis resources, I keep information about in-person options so that I can make appropriate referrals as needed.

Some clients might even prefer to choose a therapist who is not in their immediate geographic area for a variety of reasons:

1. Privacy. I have a colleague who specializes in mental health for pastors. Before telehealth became an option, their clients expressed concern about parishioners seeing them in a therapist’s waiting room or encountering their therapist in the context of their work. If you have the option to choose a therapist who is located more than 1,000 miles away, you can have added privacy in your treatment.
2. Dual Relationships. As a therapist who has done my own therapy, I can tell you it is impossible to find a provider licensed in my location with whom I do not have a pre-existing professional relationship. Changing jurisdiction laws opens up my options.
3. Specialization. When I first got TF-CBT certified, I was the only provider in South Dakota with that training. What if someone wants or needs that treatment protocol, but I don’t have openings? You should have the right to choose a provider based on who meets your needs even if they don’t happen to live in your state.
4. Continuity Of Care. As a provider who works with kids, let me present you with a scenario. (The same scenario can of course apply to adults as well.) Your family is moving to another state. You will live in a different house, have a different bedroom, go to a different school, and you do not know when you’ll see any of your friends again. On top of all that, your therapist says they can’t keep seeing you out of state even though you have video sessions, and you could join a Zoom meeting from anywhere. How is that fair?

In conclusion – let people choose their providers! PsyPact and other compacts are working towards making reciprocity a reality, but they have not fully solved the problem (I’ll speak to this in another post). We need national standards and protections.

Do you like board games? Do you like geese? Are you desperate for a new board game you can play over telehealth? Well, today I’m filling an very, very specific niche in the marketplace.

I found Goose Game by accident because apparently this blog is mentioned somewhere on their website, and Coko Games came up as a referral in my stats. I couldn’t find where I am linked over there (I hope they said something nice!), but I did find a treasure trove of more telehealth-friendly games.

Goose Game is a standard board game where players take turns rolling dice and trying to get from the start to the finish line. As with many of these telehealth board games, share your screen with your client, grant remote control, and play!

The game works with two to four players, so it can be used for small groups. You can make some of the players automated, so you could add a computer player if you wanted to.

Some squares on the board give you boosts, like rolling again, and some make you go backwards. If you land on the same square as an opponent, they have to go back to start. In order to win, you have to roll the exact number of spaces. This makes for interesting gameplay, as someone can be really close to the end but get stuck trying to roll the exact final count while someone else catches up and passes them.

Goose Game is another spin on games kids are already familiar with, so there is novelty along with familiarity, and the rules are easy to learn and follow.

Enjoy!

Quick Disclaimer: This post includes some speculation on my part. Anything prefaced with “My guess,” “I predict,” “I think,” or similar statements are my own projection based on what I have observed. I previously predicted that I would only work from home for “two weeks, maybe a month tops,” in April 2020 so take my input with the appropriate amount of salt.

Good morning internet! I apologize that this blog has been quieter than usual lately. I just submitted final edits for the two manuscripts I’ve been working on over the past year, and I have been exhausted on the writing front. I have also been working on my application to be an APA-approved CE sponsor, which has taken up a significant amount of my time. Don’t worry, I am still here dolling out important information, just at a slower rate.

On May 11, 2023, the federal state of emergency is set to end. We are still learning exactly what this means on many different fronts, but we know that it removes many protections that have been in place over the past three years.

First, the state of emergency maintained Medicaid coverage for many who might have otherwise stopped qualifying during that time. I cannot stress this enough: if you have Medicaid, please check your coverage to see what your options or next steps are.

According to the webinar I viewed to learn more about this, you should receive communication if you might lose coverage, but if you aren’t sure, please check.

As a South Dakota Medicaid provider, I’m increasing my consultation rate. If any of my clients see an interruption in their coverage, charging more for consultations will allow me to open up more pro-bono spots in my therapy caseload so that my clients’ care isn’t interrupted and I can still pay my bills. Not everyone has the option to just add pro bono slots, though – look into it now to make any upcoming transitions as smooth as possible.

Second, this might mean that private insurance companies will try to push back on telehealth coverage. I hope the huge burst of research showing how safe, effective, and helpful telehealth is for people’s access to care means that we will not see any big changes here, but of course this is not within my control. However, since certain big telehealth companies have been accepting insurance over the past few years, I predict that those companies will push back on any changes in coverage. Insurance companies versus telehealth giants battling it out in court would be like Godzilla Versus Kong. I hope they destroy each other.

Medicare and Medicaid have different requirements in place that look like they will keep allowing telehealth coverage at least through 2024. I will of course keep my ear to the ground on this and watch closely for any changes.

Third, there will be some changes to telemedicine as far as medical visits and prescriptions. Ask your doctor about how these changes might impact you.

Finally, the state of emergency ending likely means that student loan deferrals will also end. Recently many saw changes in their loan service provider, and I have heard from colleagues that the transition has been rocky at best. Many were told they lost their qualifying payments towards forgiveness and have to start over, and now payments and interest might come back on top of that.

A lot of this depends on how the Supreme Court handles the cancellation plan. Keep an eye out, stay informed, and know your options.

Personally, I’m ready to live through a boring chapter of history. I’ve had enough interesting times.

I was recently browsing the various therapist groups on Facebook, looking (as I often am) for resources about neurodiversity-affirming care for my clients. Several colleagues were talking about I Will Die On This Hill, a book created to help parents of autistic children best support and raise their kids. Since autism has a genetic component, many parents of autistic children are also autistic (whether they are aware of it or not). Both autistic and non-autistic parents struggle to best parent their children, whose brains were not built for the way society is structured.

Seeing a resource created to help parents navigate their children’s diagnosis in an affirming way is amazing! I reached out to Jules and Meghan and honestly was surprised when they responded that they wanted to talk to me (yay imposter syndrome!). I so appreciate both of them taking time out of their day for this discussion. I am still working on getting my copy of I Will Die On This Hill (yay record-breaking snowfall screwing up our mail!), but they shared their experience of creating this awesome resource.

Our conversation covered a lot of ground, partially because these two are fascinating people I could listen to forever and partially because we put three ADHD people in a room together, and that is what tends to happen. This post ended up being just a snapshot of everything we dug into, and I hope we can all chat again soon.

Jules Edwards is an autistic parent of an autistic child and writer. They are also on the board for the Autistic Women and Nonbinary Network. They shared that they are working on creating a more accurate and affirming self-report measure for assessing for autism, which I am very excited to use in my practice once it becomes available.

Meghan Ashburn is a parent of autistic kids with a background in education. She has a reading list for parents whose child was recently diagnosed as autistic, does educational consulting, and works to connect parents of autistic kids to appropriate resources.

Meghan and Jules’s kids were diagnosed autistic around the same time, and Jules began following Meghan’s blog for resources. They ended up connecting when Jules gave Meghan feedback about writing about her children, and they realized that they were given different resources: Jules received resources for someone diagnosed as autistic, and Meghan was given parenting resources. Meghan didn’t realize that she was also following Jules’s blog at the same time. (Side note—I love the idea of connecting with one of my Pocket Friends about a shared interest and writing an entire book from that! Maybe someday….)

Meghan shared, “Parents want to help their kids, and all they’re given is ABA or the 100 Day Kit. … They’re not given first-person resources; do you know what I mean? They’re not being ushered to the autistic community.” She runs into the same issue with teachers, who are not given resources or tools to support students, determine unmet needs, or meet students where they are.

When her child was diagnosed, Meghan had a “diagnose and dump” experience where she was not given resources, and she found herself digging into the research herself. Jules noted that medical doctors are tasked with identifying “red flags” (and they asked me to make sure I put that in quotations) and make referrals for evaluations, without receiving adequate tools or training to provide support and resources to families.

Jules and Meghan are both parents of BIPOC children and found the additional struggle of navigating resources written by and for white individuals and families. Their book is a step in the direction of filling a major cultural competency gap in the existing resources.

I Will Die On This Hill is “so many things to so many people,” aimed at helping not only parents of autistic kids, but also providers, professionals, educators, or anyone who wants to learn more about autism and the history of diagnosing and supporting autistic people. While they are the two authors, they consulted many contributors in writing their books, including nonspeaking autistic people, AAC users, Black autistic people, and trans autistic people.

One thing we discussed in our conversation is autistic burnout, which only recently began being recognized and addressed. Even when it is addressed, though, Jules pointed out that the emphasis is on getting the individual to “bounce back” and become productive again as soon as possible. They shared, “Being autistic is being expected to repeat my best day every day. … You’re a machine, and they treat us like we’re expected to be machines.” Meghan noted that, because her children were born prematurely, she believes they were in burnout as soon as they came home from the hospital.

The book is not intended as advice, but rather to share stories of autistic experiences. Meghan said, “It’s not really an advice book.” Jules noted that, from her Native culture, she shares “advice” by sharing a story and letting people take what they need from that story. She wants people to take the information and apply it to what is best for their own family.

We discussed the importance of having a plan if a child has periods of dysregulation or aggression, though the plan needs to ensure the child’s safety. Unfortunately, law enforcement is often unhelpful or even dangerous in the event of a mental health crisis. Many autistic people have died as a result of law enforcement escalating the issue rather than assessing and bringing the situation down. Autistic people who are overstimulated or experiencing a meltdown struggle to follow instructions and self-regulate. Police violence is particularly a risk for Black, Indigenous, and Brown autistic people.

This risk is not mitigated with police training: Jules shared, “Pre-assault indicators are basically autistic traits, and there’s no actual science behind it, but they use that to decide.” Keeping a “registry” of autistic people in the community for the police to be aware can actually cause further escalation because of bias and stigma around the diagnosis.

Meghan pointed out that certain autism “awareness” groups focus on “behavior management” and reducing the “danger” posed by autistic people, which again further perpetuates stigma and puts these individuals at risk for violence. For Black autistic people, the already increased risk for police violence is exacerbated even more.

With limited non-police resources, especially in rural areas, this leaves many hanging with nowhere to turn for support safely. We need funding reallocated from law enforcement to affirming, disability justice-oriented resources. The issues surrounding disability justice are twofold: parents do not receive adequate resources, and the systems in place perpetuate oppression. When ableism intersects with racism, transphobia, and homophobia, these dangers increase. I will leave you with Jules’s thought: “When we meet the needs of the people who are most oppressed, everybody benefits.”