Jigsaw Puzzles for Telehealth

Many of my clients like doing puzzles, which is why I keep a few to choose from in my office, but pieces can get lost, and doing the same puzzles over and over gets boring. Enter telehealth. This website and lets you put together a jigsaw puzzle on your computer screen. Pieces never get lost, new options are posted every day, and you can even upload your own picture and create custom puzzles!

If you search for “online jigsaw puzzles,” hundreds of websites come up, but this is my favorite for telehealth for a few reasons:

  1. Custom pictures – a child and I did a puzzle of my cat yesterday, and it was amazing.
  2. You can choose how many pieces are in the puzzle! There’s a setting where you can make the puzzle more or less complicated, with options ranging from six to 1000 pieces.
  3. This site gives the option of making a custom link that you can share with your client, and you can work together on the puzzle in real time! This isn’t an option with custom images, so for those you would need to share the screen and take turns with remote control, but this is available for the hundreds of options pre-loaded onto the site.
Options are, in order: change the number of pieces, re-start, change the background color, and create a link to share the puzzle.

Plus, if that weren’t awesome enough, when you complete the puzzle a group of silhouettes jumps up and applauds you!

I did it!

Puzzles are great therapy activities for problem solving, asking for help, and executive functioning. I’m excited to have a way to use this in telehealth with so many great options!

EAPs and Mental Health

I’ve started a series answering questions on the cost of mental health. I firmly and passionately believe that every single person has a right to mental health care that fits their individual needs and is affordable, AND ALSO therapists and other mental health professionals deserve to be paid appropriately for their time. I spoke before about how health insurance works when you are seeing a therapist, and I’d like to explore some other options people can use to access mental health care. Today I am going to speak to Employee Assistant Programs.

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EAPs are programs through your employer that will cover a limited number of therapy sessions or other mental health services. If you have a high-deductible insurance plan, you might be able to get a few sessions at no cost to you through your employer’s EAP.

There are huge benefits to using your EAP:

  1. It’s free. Who doesn’t like free?
  2. Your sessions aren’t billed through insurance, so if you are given a diagnosis, your insurance will not see it.
  3. The EAP provider can help you connect with someone who has availability.
  4. You know going in how many sessions you get and do not have to worry about authorization or getting a surprise bill.

Of course, there are also drawbacks:

  1. Because you get a set number of sessions, EAPs can be useful for solution-focused work or working through adjustment issues or stress. But if you need more long-term care, they run out quickly.
  2. If you decide to continue sessions after your EAP runs out, your EAP-approved therapist might not be covered by your insurance, so you might have to switch therapists or pay out of pocket.
  3. EAPs offer notoriously low reimbursement rates, so many therapists will not accept them.

It is worth asking if your employer offers this service, as this can help people with high-deductible insurance plans get their foot in the door with mental health services.

What else do you wish you knew about the cost of mental health services? Ask me and I will try to find the answer!

Cyber Bullying

A version of this article was published in Hood Magazine in 2019.

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The rise of social media has allowed teenagers to keep in touch with friends and family more easily than in previous generations. In addition, youth can engage with communities that they did not have access to before, helping them feel less alone. However, this access has also given rise to cyber bullying.

The old adage, “Sticks and stones may break my bones, but words will never hurt me,” is unfortunately not true. In fact, verbal abuse is more harmful in the long term than physical assault. Social media messages are particularly harmful because the recipient can re-read hateful words several time, which prevents them from trying to move forward.

Not only can cyber bullying be more harmful to the recipient than in-person teasing, but the act of perpetrating cyber-bullying can be harmful to teenagers’ development. Adolescents are impulsive and say things they might not mean out of anger. When this happens in person, they see the emotional pain inflicted on the other person. Since most people experience some amount of empathy, they experience feelings of sadness or guilt, which helps them learn not to make this choice in the future. The mask of a computer screen can inhibit this empathy response.

If your teenager is the victim of cyber bullying, encourage them to delete hateful messages and block the sender. They might benefit from a social media vacation. Reach out to other parents so that they are aware and can monitor their teenager’s online activities. Since cyber bullying has led to low self-esteem, depression, self-harm, and even suicide behaviors, consider taking your adolescent to a therapist so that they have a space to process and cope with their emotions.

If your teenager perpetuates cyber bullying, talk to them about the effect of their behavior on their peers. Remember that social media use is a privilege, not a right, and it can be taken away. If their victim is receptive, have your teenager make amends for their behavior in person to build their empathy response. Since many adolescents act out from a place of their own pain, your teenager might benefit from counseling. Remember that internet posts can never truly be deleted, and a future college or employer could potentially find posts or messages that bully.

 Although there are many benefits to social media, this access has given rise to cyber bullying among teenagers. Whether your teen is a victim or perpetrator of cyber bullying, this is an opportunity to teach boundaries, consequences, and empathy.

Thinking Outside the Box for Therapy

Karen Caldwell is a Certified Rehabilitation Counselor, Licensed Professional Counselor, and International Psychometric Evaluator who provides mental health services as well as resources on her website, mentalbliss.org. She was kind enough to offer to share her writing with me. KC is raising money to provide free therapy sessions, and you can donate here!

This post is from her mental health blog and was originally shared in November 2020.

Blue 3d illustration. Light bulb. Idea and think outside of the box concept.

Cost is a barrier for millions of people who are seeking therapy.  The national average of a typical therapy session in the United States is about $75.00 – $200.00 per hour.  This average does not account for major cities like San Francisco, CA and New York City, NY, which averages up to $250.00 per hour for psychotherapy sessions.  To assist you with researching alternative therapy options, I identified 6 different strategies you can implement to think outside the box for therapy and secure free and/or low-cost mental health services.  Let’s start with #1.

1.     Double Check Your Health Insurance Benefits: Some employers offer Employee Assistance Programs (EAP), which are short-term benefits for things like behavioral healthcare, legal counsel and financial assistance.  Contact your HR department at your job and ask about EAP.  If your job does not offer EAP, they may have a community referral for you. 

2.     Community Mental Health Agencies in Your County: Community mental health agencies are housed in many counties throughout the nation.  They are usually not-for-profit organizations, and they offer low cost and/or sliding scale mental health services.  Community mental health agencies also provide case management services for food, housing, transportation, employment, legal and food needs. 

3.     Support Groups: Support groups alleviate the cost for individual therapy sessions that we discussed earlier.  When you receive support within a group, you are allowing yourself to heal out loud.  Support groups further allow us to process our trauma with people who have similar experiences. People tend to overlook support groups, but they are very beneficial for those who need social support.  Add the low cost of entry for support groups and this strategy is ideal for just about anyone.  Many private therapists and community agencies offer support groups. 

4.     Local Colleges and Teaching Institutions: Seeking mental health services from local colleges and teaching institutions is definitely thinking outside the box! Essentially, you are killing two birds with one stone because mental health services from these areas will be the best service at a reduced rate.  Why? Because students are eager to gain hands on experience and clients are happier paying for behavioral health services at a reduced rate.  I’m sure you have a local college and/or teaching institution nearby.  Tap into their resources and report back with updates.

5.     Pro Bono Slots: There are therapists who reserve 1 or 2 slots per month for pro bono clients.  I am one of those therapists. Yes, there are other therapists who provide pro bono services as well, but you would never know unless you asked.  With that being said, have the courage to ask potential therapists if they provide pro bono services.  The worst thing they can say is no.  Even if the answer is no, the therapist may provide you with a referral.

6.     Vent – Express Your Feelings: Vent – Express Your Feelings is a mental health app that encourages individuals to express how they really feel. The app includes a community that provides support. Groups are offered to connect with other people that share similar interests.  Vent offers 24/7 support and the premium subscription includes a 7-day free trial.

Like any other expense, therapy can get costly if we are not intentional about budgeting for it.  The good news is that there are options available for free and/or low cost mental health services.  All it takes is for you to think outside the box for therapy.

Work From Home, Day 365

One year ago today, I received news that the county I lived in had its first confirmed community transmission. (I think we had community transmission well before then, but the governor only authorized testing for people who had travelled.) Because some of my clients or their family members might fall into the high-risk category, and because I was at increased risk of exposure due to my husband working in a hospital setting, I went to my boss and told him that I was requesting to work from home. He’s great, so it wasn’t an issue.

I vividly remember calling clients to give them their Zoom IDs and telling them, “I’ll probably be back to in person by the end of May at the latest.”

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To be fair, I didn’t specify which May.

Today I am actually in the office to finish up some paperwork before I take next week off, but I am still about 90% telehealth with no end in sight. The APA formally recommends continuing telehealth as much as possible, with exceptions if both the therapist and client are fully vaccinated, but with my caseload almost entirely comprised of people under the age of 16, this doesn’t apply to me. Fortunately, I really enjoy working from home.

In the last year, I started this blog, self-published two books, and started doing speaking engagements with PESI. I am so excited about all the friendships and professional connections I have been able to make through Twitter, and I’ve loved being able to share information about mental health to countless people.

Thank you to everyone who has followed me on this journey. Stay tuned for my next project, a coloring book for therapists promoting humor and self-care.

Insurance and Mental Health

This post will probably end up being Part 1 in a series, since it is definitely information that people need to know. As my followers are aware, I’ve been writing about various mental health topics to help people who aren’t professionals understand psychology, therapy, evaluations, and other topics related to mental health.

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I would like to talk today about insurance and therapy. These issues will be specific to the United States, as that is where I practice. Fortunately, most health insurance plans now cover mental health, but the specifics of that coverage varies based on your plan. Typically, therapy sessions are covered in the same way as an office visit with your primary medical doctor, so if you pay a co-pay at that office, you will probably owe the same co-pay for your therapy appointments. If you have a deductible plan, your therapy sessions will apply to that deductible until it is met. At the end of the calendar year, your deductible starts over.

Therapist rates vary, and in Sioux Falls, South Dakota, where I practice, sessions typically bill between $125 to $160 per session. However, if the provider is paneled with your insurance (basically, the insurance company has decided that the provider is “in network” and can bill to your plan), they have a negotiated rate, which can vary significantly. Some insurances I’m paneled with have a negotiated rate of $80, and some have a negotiated rate of $130. So if you are paying for sessions out of your deductible but you change providers, it might look like my rate changed because the negotiated rate with your new insurance company is different than the previous company. It might also look like the rate went up if you switch from a co-pay plan to a deductible plan – if your copay was $40 but the negotiated rate is $100, suddenly what you pay per session more than doubles!

When signing up for therapy services, ask the provider what their per-session rate is, and if they are in-network, you can ask your insurance provider what the negotiated rate is to get an idea of what sessions will cost you.

Most therapists use one of the following billing codes and have unique rates for each:

  1. 90837: This refers to a one-hour therapy appointment and is billable for a session lasting 53 minutes or longer. Some insurances will not accept 90837, so make sure that what your therapist bills is covered in your plan.
  2. 90834: This is for a traditional 45 minute session and can be billed for sessions lasting 38 minutes to 52 minutes.
  3. 90832: This refers to a 30 minute session and is billable for an appointment lasting between 16 and 37 minutes. I use this code sometimes with young kids who can’t engage for a full 45 minutes or if someone arrives late but still wants to meet during the time remaining.
  4. 90847: This code indicates family therapy, so I sometimes use it when meeting with the parent and child together to work on their relationship. Some therapists will use this for couple’s therapy, but some insurers specify that family therapy does not include couple’s work, so you will want to ask your insurance carrier if this applies to you.

I also recommend asking your insurance provider if there are any diagnoses that they do not cover. For example, some insurance will not cover therapy if the primary diagnosis is an “adjustment disorder” because that is not considered “severe enough” for treatment to be “medically necessary.” I am not going to say more about that because it makes me too angry to be coherent, but it is information you need to know.

Please know that your therapist has no control over what your insurance carrier covers or does not cover. Insurance companies have a standard line that they say whenever you call them: “Confirmation of coverage is not a guarantee of payment.” This is a fancy way of saying that your insurance can tell your therapist, “Yes, that code is covered!” and then refuse to pay, and there is nothing your therapist can do about it. And once something is billed to your deductible, your therapist has to bill you the remaining balance determined by the insurance company. We can offer flexible payment plans, but we are legally bound by our contract with the insurance company.

If you gain nothing else from reading this post, know that the headache that comes with paying for therapy is at least 95% because insurance is annoying.

What do you wish you knew about the cost of therapy services? Contact me and I will try to explain it!

Psychological Evaluation 101: What Is A Neuropsychological Assessment?

I would like to give a HUGE shout out and thank you to Dr. Renee Madathil and Dr. Jessica Serbel for talking to me about neuropsych. Dr. Madathil is an assistant professor at the University of Rochester in New York who does this type of assessment, and Dr. Serbel is a licensed psychologist who completes psychological and neuropsychological evaluations in Pennsylvania.

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So, what exactly is a neuropsychological assessment? According to Dr. Madathil, “Neuropsychologists are clinical psychologists who specialize in the relationship between the brain as an anatomical structure, and brain functioning. We use principles from both psychology and neurology to assess perceived changes in cognition, emotion, and behavior.” Neuropsychological assessments are indicated when someone exhibits a change in thinking or executive functioning and to assess for personal strengths and weaknesses. Dr. Serbel noted, “Some of the most common reasons for this type of testing are to determine if there is a presence of a learning disorder, to aid in vocational planning, or to test for memory impairments.

Neuropsychological evaluations are intensive assessments to determine what is causing the underlying problem, such as a memory issue. It tends to be much more comprehensive than a typical psychological evaluation and can look at personality functioning, cognition, achievement, memory, and higher-level problem solving.

There are not specific tests included in a neuropsychological evaluation. Dr. Madathil shared that these evaluations consist of “a customized battery of validated tests in order to help answer the referral question,” which often includes a diagnostic interview, additional information from other records, and a wide variety of other assessments. Measures she uses include the California Verbal Learning Test, Trail Making Test, Delis-Kaplan Executive Functioning System, the Wechsler Adult Intelligence Scales, PHQ9, and PAI. Dr. Serbel said that she uses a clinical interview, a test of intelligence, achievement scores, neurological testing, and tests of memory and personality.

If you are referred for a neuropsychological assessment, a psychologist who specializes in these types of evaluations can help answer your questions.

Thank you Dr. Madathil!
Thank you Dr. Serbel!

Virtual Fidgets

Fidget spinners and cubes exploded in popularity a few years ago. Initially, this was fantastic because it meant that neuro-divergent children (and adults) could incorporate fidgeting and stimming into their lives in a way that was not ridiculed or mocked by those around them. Of course, like with most fads that kids get into, eventually schools began banning fidgets as “distractions.” This backfired because there are kids who focus better when they are permitted to fidget. At this point, many teachers have come to an appropriate balance between minimizing distractions in the classroom but allowing kids with ADHD, Autism, anxiety, or other conditions to move in ways that help them learn.

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I have over a dozen different fidget spinners in my office, not to mention fidget cubes, stress balls, and other sensory items. Since these items are less popular than they were in about 2017, I can give parents recommendations to buy these items for their kids at a fairly low price too.

I’ve talked before about Antistress, an app with several different virtual fidget options. This is one of my favorite therapeutic apps, but like most apps, there is not a version that can be used on a laptop or desktop computer. Kids can use physical fidgets during telehealth sessions, but some kids engage better in a telehealth session if I can keep their focus on the screen rather than on a physical item in their home.

Virtual fidget spinners are available here and here. A virtual fidget cube is available here. And this website has a variety of virtual fireworks games, which are great both for fidgets and for a visual sensory intervention.

What virtual fidgets have you used in your telehealth sessions?

Flower Breathing

This is an activity I use with kids to help them take big breaths. It’s good to have a lot of breathing activities to choose from in your arsenal as a therapist, since everyone responds differently to the different techniques.

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This activity will help you practice taking big breaths to calm your body. You can use the flower on this page, trace an imaginary flower in the air, or picture the flower in your mind.

Slowly trace each of the flower petals, trying to take as much time as you can. On the petal with an arrow pointing up, inhale as your finger goes around the petal. When you get to the petal with the circle, hold that big breath while your finger goes around. Then, blow slowly out of your mouth like you are making a bubble.

You can repeat this activity as many times as you need to until your body feels calm!

Pictured: a daisy with arrows and circles to guide this breathing activity

Let’s Talk About Risk Assessments

CW: This post discusses suicide in general terms.

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I wrote this piece to help therapists do a better job with risk assessment and talking to clients about suicide. Recently, I have seen evidence that many mental health professionals are not as comfortable talking about suicide with clients as we need to be. Of course, this statement does not apply to every therapist out there, and if this isn’t you, then great! Please also know this is a very brief overview of the topic and not meant to substitute ongoing education.

In my graduate training, I remember risk assessment being focused less on client need and more on clinician liability. Absolutely, as a therapist I need to think about my liability! If I lose my license, I can’t help any of my clients (or pay my student loans). But if I am not putting my client’s needs first, I am not doing my job. So what does that mean regarding talking to clients about suicide?

Quick disclaimer before I continue: I am speaking here to my own clinical judgement and style. Although we all need to be comfortable talking about suicide with clients, and we all need training in risk assessments, the specifics of how I handle this are unique to my practice, and each clinician has to decide what is best for their practice.

When do I ask clients about suicide?

I have a standard set of safety questions that I ask at intake. When working with young kids, I ask parents about safety concerns separately from the child, since sometimes children feel uncomfortable giving me an honest answer. I make a point of asking about self-harm behavior separately from suicide, since these are not the same thing.

If a client reports passive suicidal ideation (thoughts of suicide without plan, means, or intent to act on those thoughts), I regularly check back in about this. If a client denies suicidal ideation, I screen less frequently, since it can damage rapport to keep asking if the client said they are not suicidal. If at any time a client’s symptoms increase or they say something that makes me think they might be having suicidal thoughts, I ask again.

We know that asking about suicide does not cause someone to have suicidal thoughts, but as a new therapist, it was difficult for me to get this irrational belief out of my head. But it is absolutely essential that we address our own anxieties, get past them, and ask.

How do I ask about suicide?

I work with a pretty broad developmental range in my practice, so this varies. I always ask parents about “safety concerns” and whether their child has “tried to hurt themselves on purpose” at all ages. I also ask if the child has made statements about “wanting to die” regardless of age. However, I am not about to sit down with a three year old and ask if they have suicidal thoughts. I spent a lot of money and time learning about clinical judgment, so I use that in each situation.

One choice I often make around the language I use is that, depending on the client, I do not always use the word “suicide.” This is because I have had experiences with middle and high schoolers who will say that no, they do not have thoughts of suicide, but when asked if they think about dying or ending their life, they say yes. (My theory is that it is like how some people will say no, they have not been assaulted but will go on to describe things that absolutely meet the definition of assault – they just don’t relate to the technical term.) As soon as a client uses the term “suicide,” I mirror their language preference, but this is something that has made a lot of clients more comfortable talking about these thoughts. Again, this is not necessarily the right choice for every clinician, just something I have found helpful.

When do I recommend hospitalization?

I have seen some unsettling comments that clinicians have been taught to hospitalize any client who expresses suicidal thoughts. This goes back to the liability concerns I mentioned at the beginning of this post. This policy is going to absolutely cause harm to clients and is why we need better training in risk assessment.

The fact is, many people who have suicidal thoughts are not going to act on them. Of course, we have to continue to monitor passive thoughts and prioritize client safety, but this means that someone saying that they have suicidal thoughts does not automatically mean they need to be hospitalized. Hospitalization is an important resource for someone who cannot safely be out of the hospital, but if it is not the needed resource, it can do more harm than good. In fact, many suicide behaviors occur immediately after a hospitalization.

So if a client shares that they are having suicidal thoughts but do not intend to act on them, I ask questions about plan, means, and intent, and I encourage them to talk to me about the thoughts. What triggers them? What specifically do the thoughts look like? How does the client feel about having these thoughts?

Many clients have these thoughts but are not appropriate for hospitalization, and having the opportunity to talk about these thoughts in an outpatient setting can be highly beneficial. Now, if they share that they have a plan and means to act on that plan, we discuss hospitalization. Or if they share that they do not necessarily want to form a plan to end their life but are engaging in high-risk behavior, I might suggest hospitalization to keep them safe.

Risk assessment is a terrifying part of our job as therapists! We want our clients to be safe, and losing a client to suicide is horrifying. But when we lead with that fear, we end up putting our anxiety ahead of what is best for the client.

Therapist Aid has a free suicide risk assessment that can guide you when talking to clients about suicide, and PESI offers continuing education about risk assessment. I encourage any mental health professionals reading this to take steps to be competent in risk assessment so that we can do the best we can for our clients based on their needs.