This is a standard question in therapy or psych assessment intakes, though the wording changes depending on the situation. We know that many mental health issues like anxiety, depression, bipolar disorder, and schizophrenia have a genetic component, and so do other neurodivergences like ADHD and autism. If we know our family history, we can better narrow down what diagnosis might explain difficulties someone is having now.

But our understanding of how our minds work has changed over time. Disruptive Mood Dysregulation Disorder, for example, wasn’t recognized in the Diagnostic and Statistical Manual of Mental Disorders until 2013. A child with these symptoms may have family history, but it would be impossible for the parents to be diagnosed in childhood because the diagnosis did not exist.

(The symptoms and the disorder existed, of course; we just called it other things, like childhood-onset bipolar disorder.)

The first American to ever be diagnosed as autistic is still alive, and our diagnostic understanding of autism is still very limited, causing many to be misdiagnosed or overlooked. So, if there is “no family history” of autism, does that mean it was not there, or does that mean no one was evaluated, or their behaviors were never conceptualized that specific way?

Or maybe a teacher or doctor recognized those traits, but their parents did not want them “labeled” (a valid concern in light of how terrible the stigma around these diagnoses still is!), did not think the issues were severe enough to warrant intervention, or thought, “That’s not a diagnosis! I do that too” (you know, because it’s genetic).

If you don’t have a known family history of a diagnosis, that does not invalidate your experience! Genetics are not everything – our interaction with the environment also informs how our brains develop. Besides, maybe you are just the first to label your experience this way.

When I was a kid, I got the game Set as a gift. I could never find anyone to play with me because I was too good at it, which sounds braggy but is true. Ask my parents.

Anyway, Set is a relatively simple card game that involves looking for “sets” of three cards. Each card has one, two, or three items on it, shaped like either an oval, diamond, or squiggle. Shapes are solid, shaded, or outlined, and purple, red, or green. You want to find three cards where each component is either the same for all three or different for all three.

See how the highlighted cards have the same number and shape, but different color and shading? They make a set. You and the other players are trying to see who can find the most sets the fastest.

Self-plug moment: I like that the version I created does not automatically keep score, so you could approach the activity as a cooperative puzzle, working together to find the most sets. It is also non-directive due to the PlayingCards.IO platform if that fits your therapeutic approach.

That being said, maybe you want to keep score but you don’t want to take your attention away from the session. Maybe you want your client to practice working within rules enforced by a platform. If this is you, Buddy Board Games has you covered. Simply create a room and have your client join with your private link. It also has a function to give you a hint if you get stuck!

If you and/or your clients like brain games and puzzles, this can help flex their focus and problem solving muscles. I even play it by myself sometimes when I need a break.

What other telehealth games do you want me to talk about?

Happy three-year anniversary to my second day working from home, when I proved that being a psychologist does not make you psychic:

Three years ago, I started working from home “temporarily,” which I guess is accurate if you consider that all of existence is a temporary state. In that time, I did eventually purchase a decent office chair for my home office (which is a business write-off, score!), HD camera, microphone, and green screen.

While I wish it did not take a pandemic, I am grateful for the current prevalence of telehealth. My town has had record-breaking snowfall multiple times this year, and I was able to continue supporting my clients through the storm without anyone risking their safety on the roads. Those with unreliable transportation could still come to my online office without leaving home. I have been able to get licensed and start practicing in other underserved states, increasing access to care in rural areas.

There has been a huge uptick in research verifying the efficacy of telehealth, and the American Psychological Association indicates that telehealth is considered a safe and effective method of service for almost everyone (it’s ok if you have a personal preference for or do better with in-person sessions, of course, but having options available is a good thing).

Personally, I love working from home. It’s not for everyone, but I enjoy not having to remember to pack a lunch, having no traffic on my commute from the living room, and getting to meet all my clients’ pets.

It has never been about “returning to normal.” It has been about making sure the changes we make lead to a better future. That’s what I am here for.

What have you gained in the last three years that you want to carry with you into the future?

I love boundaries. I love boundaries so much, I would marry them, except my husband and I are monogamous, and I respect that boundary. As much as I love boundaries, setting them can be exhausting. My friend and fantastic autism advocate, El, was talking to me about how they set and maintain their boundaries, and they shared with me how they create pre-recorded responses when they are having a hard time.

El gave me permission to share some of their boundary scripts, which they keep on hand and distribute as needed. This way, they can pull the script out as needed instead of having to articulate the boundary each time. They also put their scripts over some fun imagery. Since some people get angry and aggressive in response to boundaries, I like to think the soothing images could potentially help de-escalate.

Of course, if someone disrespects a boundary and is harmful to you after you set a boundary, that is their problem and not yours. But it is valid to worry about this and to take steps to avoid retaliation in response to your boundaries.

So here are El’s templates for setting boundaries!

The text for these images, from left to right, top row and then bottom row, read:

• We have complex disabilities that include Autism, Kinetism, and Trauma. You have made claims that are inconsistent with what we know to be true. Please direct us to explicit evidence that verifies your claim, withdraw your claim, or accept that we will be ending this exchange. Thank you (green heart)
• Hello, We have complex disabilities that include Autism, Kinetism, and Trauma. Our communication styles do not appear to be compatible. We will not continue to engage on this topic with you. Thank you (green heart)
• Hello, We have complex disabilities that include Autism, Kinetism, and Trauma. We are experiencing a double empathy problem with you, meaning that collectively we are failing to effectively communicate. At this time, we believe it is in everyone’s best interest that we go our separate ways. We wish you well (green heart)
• Hello, We apologize for any misunderstanding. Our comments are not mean tot indicate that anything is universal to every Autist. Comments about Autists are implied relative to a comparable Allistic peer. Thank you (green heart)

Remember, you cannot control how people respond to your boundaries, but you can set them and communicate them clearly. You can also choose who has access to you, and you have the right to limit or eliminate contact with someone who does not respect your boundaries. No one is entitled to access to you.

Recently, Facebook showed me a series of ads from a law firm encouraging me to sue my therapist. I read the article linked in the ad 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.