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.


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.

It’s About To Get Slightly Less Unprofessional

Everybody get excited! There’s a new coloring book in town (sort of). From the brilliant minds who brought you It’s About To Get Real Unprofessional comes It’s About To Get Slightly Less Unprofessional!

It’s About To Get Slightly Less Unprofessional

What is It’s About To Get Slightly Less Unprofessional, you ask? Well, it’s the exact same book as It’s About To Get Real Unprofessional, but the curse words have been edited out! It was brought to our attention that some might prefer their self-care minus the F-bombs, and we are nothing if not accommodating (read: willing to re-release the exact same product with small modifications in order to boost our sales).

It’s About To Get Slightly Less Unprofessional features 68 of the coloring pages you remember and love with profanity bleeped out. Now you can color in public or around your kids without showing anyone any profanity!

Buy the hard copy on Amazon and the printable, PDF version on Etsy!

Do you already have It’s About To Get Real Unprofessional? Are you intrigued by It’s About To Get Slightly Less Unprofessional but you don’t want to buy a book that’s 50% a book you already own? Order It’s About To Get [Redacted], with JUST the censored pages! Available on Etsy as a printable or in paperback via Amazon!

Interview with Katy Lees, Therapist & Author

I connected with Katy Lees through Twitter because the internet is a wonderful place that keeps introducing me to fantastic people. Katy is the author of The Trans Guide to Mental Health and Well-Being, a comprehensive resource for trans folks and the people who care about them. Information about purchasing their book is available at the link above.

Katy was kind enough to take questions from me about their book as well as their work as a therapist for LGBTQ+ folks.

Katy Lees with their book

1. First can you tell me a little bit about your background and professional interests?

I’m a person-centred psychotherapist, with a BSc in Psychology and an MSc in Person-Centred and Experiential Psychotherapy. I’ve been working in mental health for nearly fifteen years now, and I’ve been working in private practice as a therapist for three years. I’ve also written fiction and non-fiction for several publications since my early twenties, perhaps most notably for the now sadly defunct Dirge Magazine.

2. Do see therapy clients? Tell me about your practice?

I run a thriving private therapy practice online which centres LGBTQ+ experiences. I mostly see trans and/or non-binary clients, many of whom are otherwise queer, polyamorous, neurodivergent, and dealing with trauma. Working with trans clients as a niche happened mostly by accident – I’m open about being non-binary and using they/them pronouns, and I think this led to lots of trans and/or non-binary people finding me! It’s such an honour to work with my community, whether it’s to help clients who are questioning their gender, clients who need help to process their feelings as they transition, clients who need support as they face transphobia, or trans and/or non-binary clients with any other issues.

3. Tell me about your book?

The Trans Guide to Mental Health and Well-Being is a book about self-care and community care, designed for trans and/or non-binary people. It’s a practical guide for taking good care of yourself, and it covers a wide range of mental health issues that trans people commonly face, including anxiety, depression, body image issues, trauma, suicidal thoughts, and dissociation. I designed the book to be something like a warm, accessible, expert therapist who can sit on your book shelf, ready for when you need them!

4. How did The Trans Guide to Mental Health and Well-Being come to be?

I’d been thinking about writing something like this for a while, especially after looking for some trans-specific mental health help during my MSc and not really finding much. After writing and speaking about my work in mental health and my transness for a while, I started writing the book in 2020 after being approached by my publishers, Jessica Kingsley Publishers. I finished writing the book in 2021, and it was officially published in 2022. You can now buy a copy wherever sells good books!

Katy Lee head shot

5. What do you want your readers and potential readers to know about your book?

This book was made to be a resource for trans and/or non-binary people, by a trans and non-binary therapist. It’s there for you if you need a few self-care tips or a bit of a pick-me; if there’s a specific issue or two that you’d like some in-depth help with; or if you’re in crisis. The book can be read from front to back or dipped in to when you need it. – Even though the book was written by and for the trans community, I think it can also be used by therapists, mental health professionals, and allies of trans and/or non-binary people who want to take a look at what some people in the trans community might be going through.

6. Do you have any other upcoming projects?

I’ve had a few conversations with my publisher about writing another book, so stay tuned!

CareDash Therapist “Directory”

Therapists, if you are not already aware, there is a website called CareDash that has created unauthorized profiles of thousands of mental health providers. The information posted is often inaccurate, and most colleagues I have spoken with were not aware that they were featured on the site before I told them.

My own profile lists me as an unlicensed, masters-level clinician in Massachusetts. I have not practiced in Massachusetts since 2013. It indicates that I specialize in anger management, eating disorders, and infidelity, none of which falls under my scope of practice. It also apparently lists me as a life coach.

Screen shot stating that my expertise includes Spirituality and Religion, Eating Disorder, and Life Coaching

Not only is the information about my practice inaccurate, but there is an option to request an appointment with me. This link does not lead to my practice – it leads to Better Help’s website. So, CareDash is pulling a bait-and-switch, using my name and reputation to funnel traffic to Better Help.

Let’s unpack everything that is wrong with this.

  1. A client seeking treatment is going to get inaccurate information about my practice. If they manage to get directed to me, they will waste valuable time and energy seeking services that I do not offer. This creates more steps and barriers in connecting them to the provider who can actually help them.
  2. This creates an administrative burden on me, since I have to then find an appropriate referral for the client, taking time and energy away from my other clients.
  3. A client seeking treatment who might actually benefit from my services could easily be routed to a different provider who is not a good fit for their needs. Clients seeking me out specifically are getting routed to Better Help instead of my practice.
  4. CareDash and Better Help are falsely marketing my services to get traffic and referrals for themselves.
  5. Since CareDash is misrepresenting my credentials, I am ethically “on the hook” for being falsely represented, per my ethics code.

CareDash’s website states that they will not take directory listings down because the information posted is through the NPI database and therefore “freely available.” Regarding complaints about misrepresentation, they state that you can “claim” your profile and update it. However, they will still use your name and accurate credentials to promote Better Help’s services.

I for one will not “claim” a directory listing on a website with unethical practices because doing so implies that I condone that directory.

I have reached out to CareDash demanding that they remove my profile but do not anticipate that they will comply. I have also reached out to my licensing boards to make them aware of the situation, let them know that I have taken steps to correct the ethical problem of misrepresenting my credentials, and to ask them to reach out to other psychologists to let them know that they might also be misrepresented on CareDash.

A PDF of my letter is below. I welcome any professional misrepresented on CareDash’s “directory” to use it as a template in contacting their own licensing board. I would hate for someone to have to waste time responding to a board complaint about misrepresentation they did not consent to or did not know was happening.

I also strongly encourage therapists to see if they are listed on CareDash. If you are, contact them demanding that your listing be taken down. My hope is that, with enough pressure, we can force their hand on ending this unethical and illegal “directory.”

Edit to Add

My friend and colleague, Stefani Goerlich, LMSW, put together a Google document for specific steps therapists can take when they find these fraudulent directory pages! This is not specific to CareDash and can be used with any website that surfaces with inaccurate information about your practice.

The document that Stefani put together is available here. Thank you, Stefani, for sharing!

Autism Databases: More Updates

If you’re new here or need an update, a rundown of the what this is, why it’s a problem, and what I am trying to do to solve it is available here. Please sign and share the petition to help escalate this.

As many of you are aware, I filed a complaint with the Civil Rights Office about the state of North Dakota registering autistic people in a government database without consent. Upon receiving my complaint, they contacted me and said that they would be pursuing it further.

Yesterday, I received an update, and it was not the update I hoped to receive. The letter they sent me is below, with my personal contact information redacted.

The text reads:

“Dear Dr. Marschall:

On March 3, 2023, the U.S. Department of Health and Human Services
(HHS), Office for Civil Rights (OCR), Rocky Mountain Region, received your
complaint alleging that the North Dakota Department of Health (NDDH) is
discriminating against against individuals on the autism spectrum when their
diagnosing psychologists are required to complete an extensive form
including individuals’ contact and personal information and provide this
information to the North Dakota Autism Spectrum Disorder database without
individuals’ consent.

In fulfilling our obligation to investigate complaints filed with this office, OCR
conducts a thorough and detailed review of all complaints (as well as any
other information provided to OCR (if applicable)), and requests and obtains
additional relevant documentation when necessary. After conducting such a
review, OCR determined that it will not further investigate your complaint
and is, therefore, closing it effective the date of this correspondence. OCR’s
determination as stated in this letter applies only to the allegations in this
complaint that OCR reviewed.

If you have any questions regarding OCR’s disposition of your complaint,
please contact Ms. Karel Hadacek, J.D., Equal Opportunity Specialist, at
(303) 844-7836 (Voice), (303) 844-3439 (TDD), or karel.hadacek@hhs.gov.
We regret we are unable to assist you further. Thank you.

Andrea Oliver
Regional Manager”

I emailed Ms. Hadeck asking why registering people with the government against their consent is legal, and she gave me a brief response: “Dr. Marschall: Disability-specific needs are frequently assessed for legitimate government functions, such as funding supportive services.”

I emailed back asking for more details about these “legitimate government functions,” specifically asking how the data is being used in a way that is not exploitative or a violation. She directed me to Code 23-01-41, which you can view here. From what I can tell, this seems to detail that they are keeping a registry, that it is mandatory, but not explaining why or what they will do with the data.

I feel disappointed. I hoped the Civil Rights Office would be of more help. Of course, I am not letting this go.

If you are autistic and live in a state with an autism registry, I encourage you to reach out to the provider who diagnosed you and ask if you were put on the registry (but only if you feel safe, comfortable, and able to do this). If you have been registered without your consent, please let me know. I am trying to explore options for taking this to the courts.

Thank you everyone who has followed this and shown their support. I hope we have good news soon.

Behavioral Scripting: Every Day Can Be Your Birthday

Today’s post is brought to you by Courtney, my friend who I met through the glory that is social media. Courtney is autistic, and like many autistic folks, sometimes she has a hard time making decisions or managing unstructured weekends.

Recently, Courtney shared that she was celebrating her birthday – but it wasn’t her actual birthday. It was a friend’s birthday, and the friend joked that it was Courtney’s birthday as well. She decided to go with it, and she shared that it helped her know what to do with herself.

Photo by George Dolgikh @ Giftpundits.com on Pexels.com

Courtney shared: “I never really thought about it this way. But I struggle a lot on weekends without my pre-pandemic beauty appointments. I don’t know what to do with my hands! Having a ‘birthday’ creates a structure I can visualize and is probably helpful for both my husband and me (autistic).”

Many autistic folks prefer to have a routine or structure to follow. The routine is soothing, and knowing what to expect can prevent overstimulation.

The term “scripting” refers to repeating specific language from media or other people. Some autistic people use scripting to manage anxiety, or to help decide what to say in an unfamiliar social situation. But we can think of “scripting” as more than just language! Certain events have a “script” or a series of expected, structured behaviors and activities.

Although it varies from person to person, when it is your birthday, you have an idea of what you are going to do. You know what you are going to wear, what food you will eat, and what you can expect from the day.

The same is true for other holidays: New Years, Thanksgiving, Christmas (if you celebrate), and many other days have predictable expectations for the day.

If you find that you have trouble with open-ended, unstructured days, you can make any day your birthday or another holiday. Let those scripts make your decisions for you, provide routine, and set up expectations for the day.

And if you are on Twitter, give Courtney a follow because she is wonderful.

Celebrating 10k

On Wednesday, I hit an arbitrary milestone with my following. I now have 10,000 followers on Twitter. Can you believe it? And only one of them is a bot I created of my cat!

10,000 people want to hear what I have to say!

If you have followed this blog for a while, you know I am on social media trying to help people get accurate information about mental health, advocate for important issues, and try to make the world a tiny bit better with my reach.

When I reached 5,000 followers, Armani hosted a drawing, so we are doing that again! Enter below to win an autographed copy of Armani Doesn’t Feel Well. Unfortunately, we can only ship in the united states. Fill out the form below to enter!

Armani will draw a name on Saturday, May 20, at 12pm Central time.

By entering, you consent to me reading your name off at the LIVE drawing.

Let’s Talk About The Phrase “Medically Necessary”

Often when someone contacts me for a psychological evaluation, their health insurance requires me to request authorization before starting testing. The reason the insurance companies give is that they want to make sure that the evaluation is “medically necessary” before agreeing to pay for it.

Photo by Olya Kobruseva on Pexels.com

But what exactly does it mean for testing to be “medically necessary”? Will you drop dead if you don’t get an evaluation? Probably not, but an accurate diagnosis informs an effective treatment plan. Here are some reasons (with small details changed to ensure privacy) that insurance companies have tried to deny testing:

  1. “You already know they have anxiety, so why do you need to test for ADHD?” Um, because many people have both? And because anxiety treatment will not be effective if the anxiety is compensating for ADHD? Imagine telling someone they don’t need to be tested for a medical disease because they already have another medical disease.
  2. “We don’t think it’s necessary to know if they have a learning disorder.” Why not? It’s impacting their functioning, and they want to know.
  3. “Autism isn’t curable so we don’t cover testing for it.” I hope I don’t need to explain why this is an awful statement. By the way, check out the Autism Self-Advocacy Network to see how you can support your autistic loved ones!
  4. “PTSD is not a biological condition, so we don’t cover it.” This is basically the opposite of refusing to cover a pre-existing condition: refusing to cover a condition that you were not born with. Essentially, your insurance company uses this double-talk to just not cover anything ever.

“Medically necessary” means “We won’t cover things we don’t want to pay for.” It is just vague enough for insurance companies to pad their pockets with your premium without actually having to cover your expenses.

Whether or not testing is necessary is a decision for the client (or client’s legal guardian(s) when applicable). It is a decision for them to make with the guidance and advice of the licensed, qualified professionals on their treatment team. Insurance execs who profit from denying claims and who do not have the training to understand these evaluations have no place deciding who needs testing.

My point is, call your reps. Demand healthcare reform. And if you feel like more clarity about your mental health would help you, see what your options are for an evaluation. You deserve the best care, based on your needs and not arbitrary insurance denials.

Any Piece of Media Can Be a CBT Intervention

I have talked before about what “makes” an activity have therapeutic value and how this description grows and changes over time. As I have said many times, in therapy sessions, I am not there to make a certain intervention happen; rather, my job is to take whatever happens and make that thing therapeutic.

Photo by Pixabay on Pexels.com

This is especially true when you work with kids. A six-year-old is not going to sit down and tell you in detail what is stressing them out right now. Even many pre-teens and teenagers would rather talk about their interests and things they enjoy rather than “doing therapy.” This leaves the therapist with two options: try to force and direct the session to go another way, or lean into what the client wants to share with you. Guess which option I prefer to go with.

In my clinical practice, I often pull from Cognitive Behavioral Therapy (CBT) as I conceptualize and treat my clients. In essence, CBT involves identifying how thoughts, feelings, and behaviors interact with each other. Sometimes we have thoughts without even realizing it, and those thoughts can trigger unpleasant feelings or problem behaviors. Sometimes the thoughts are not even based on reality. CBT helps clients identify these patterns and respond to them in a healthy way. You can learn more about CBT here.

Photo by Andrea Piacquadio on Pexels.com

Sometimes when we feel uncomfortable talking about our own thoughts and feelings, it can be easier to talk about someone else’s. Fictional characters can feel particularly safe to talk about because they are not real, and so their feelings are not real either. But noticing connections between thoughts, emotions, and behaviors is helpful even if the child is not sharing a situation from their real life.

Ask your client to share a story from a movie or show that they enjoy watching. Explore with them what is happening for a particular character in the story. How does the character feel (and how can you tell that they are feeling that way)? What thoughts do you think they are having? What choices are they making, and how do their thoughts and feelings impact those behaviors?

Help your client identify cognitive distortions that the character is experiencing. (There is a great, FREE worksheet on cognitive distortions available here, or you can make your own based on the client’s developmental level.)

This gets the client thinking about situations from their own life and the thought patterns that contribute to difficulties they are having, without making them acknowledge or talk about “bad behavior” in their session. Media I have discussed in sessions using a CBT lens includes but is not limited to:

  • Clarence
  • We Bear Bears
  • Encanto
  • SpongeBob SquarePants
  • Animaniacs
  • Teen Titans
  • Cruella
  • Luca
  • Adventure Time

Introduce this activity by asking what they have been watching lately, and go from there. Let clients explore feelings in a way that is safe and interesting to them, and make therapy fun!

Telehealth Activity: Rush Hour

The first draft of my second telehealth book is submitted, and I am excitedly waiting for my editor’s comments. Of course, days after I submitted the manuscript, I found an online version of yet another game I have used in my in-person office. But that is why I started this blog, right? To offer resources.

Photo by Levent Simsek on Pexels.com

Rush Hour is a logic-based game with levels of varying difficulty. Your client must move the cars around to release the red car from the parking lot. The physical game comes with a book of levels, which allows the client to choose a difficulty level but requires you to set up each level before you play. The setup takes time, and it is possible to accidentally put a car in the wrong place, making the level unsolvable.

The online version of this game has the same rules and goal as the physical one. Share your screen, and grant the client remote control. You can take turns on different levels, work together to solve a level, or narrate your client’s emotions and problem solving process as they work through the game. The levels auto-populate, eliminating the need to set them up and ensuring that each level is accurate and solvable. It is also much easier to watch your client’s problem solving approach and process since you are both viewing the game from the same angle with the screen share. Levels are also timed, which is a great way to work through anxiety about timed tasks or help redirect the client to practice their focus skills.

One drawback to the telehealth Rush Hour game is that you cannot choose levels. When the game loads, you start at Level One each time. You also cannot turn off the timer feature, so if a client wants to focus on the task without the pressure of being timed, this is not an option. I have used this game in situations where time anxiety was a factor, and the length of time allowed for each level was sufficient to reduce anxiety while still having the timer there.

Overall, I think this is a great addition to my telehealth arsenal. It works for problem solving, executive functioning, focus, and anxiety related to timed tasks, and if you and the client work together on a level, you can incorporate communication skills and teamwork.

Happy therapy-ing!

Against HB 454: Impact on Licensed Counselors in the State of Ohio

CW: This post discusses proposed anti-trans laws in the United States.

Photo by Oriel Frankie Ashcroft on Pexels.com

I connected with Lily Cunningham, M.Ed., LPCC-S, on Twitter. As you may have noticed, I take my ethical commitments seriously, especially when laws try to force me to contradict my ethics code. And you may have noticed that many states have been pushing for laws that would harm the trans community.

Lily practices in Ohio, where HB 454 aims to ban gender-affirming care. She is testifying about why this law is harmful and asking her state government not to pass it. (More information on gender-affirming care and the science behind it is available here. The short version is, gender affirming care improves mental health outcomes and significantly reduces suicide. As with many things, early intervention has the greatest impact on outcomes. Check out these studies to learn more.)

You can view Lily’s presentation here. If your state is pushing for this kind of law, use this as a template for speaking against it.

In the meantime, keep up with the news in your area. Call your reps. Tell them to stop making it illegal for us to do our jobs ethically.