Tic Tac Toe for Telehealth

Tic Tac Toe is a pretty simple game that anyone can play, and even very young kids understand the rules. While it does not have some of the obvious therapeutic benefits of games like Chess or Battleship, it can be handy for rapport with kids who are nervous about meeting with a therapist.

You can play Tic Tac Toe in-person regardless of what games and supplies you have available as long as you have paper and a writing utensil. Over telehealth, a white board can allow for interactive Tic Tac Toe. In a pinch, a therapist could draw the grid on a piece of paper or physical white board, number each section, and hold it up to the camera, allowing the client to indicate their spaces.

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PaperGames.IO has an option to play Tic Tac Toe in a private room. Go to the site, choose “play with friend,” make your choices, and send a unique link to your client, and the game begins when they join your link.

You can choose a classic 3×3 design with the goal of getting three in a row or a 5×5 board with the goal of four in a row. Then, decide whether you want you or the client to go first, or if you want the first move assigned randomly.

You also get to decide whether or not to have time limits for each turn and for the game itself. When I am working on rapport, I prefer not to have a time limit, but with clients who are working on focus, executive functioning, et cetera, you could add a time limit to practice these skills.

There is an option to create a tournament, so you could play with groups, but this feature requires each participant to input an email address, which might not be an option. Remember, confidentiality is the first priority!

By the way…stay tuned for more continuing education on telehealth! In October I’ll be partnering with the Telehealth Certification Institute to do trainings on play interventions, psychological assessment, and trauma-informed treatment.

Guest Post: Are We In This For The Money?

Last week I was working on another Spring Health blog post about fostering healthy workplace culture and environment, and I ended up having Thoughts unrelated to this month’s specific topic. Naturally, I shared these thoughts on social media – to paraphrase Descartes, I tweet, therefore I am.

Therapists get told that we shouldn’t be “in this for the money,” but we have bills just like everyone else. We can want to help people and be passionate about our work, AND want to be comfortable, take vacations, etc. But supervisors, CEOs, organization presidents, like to ridicule us for advocating for higher wages. I’ve said before, I did not invent capitalism, I just live here.

(I’m also in favor of many other fields getting raises – I speak to mental health because that is my own experience. I will probably write more about this later.)

Jennifer Petersen, M.S., shared with me some thoughts she posted to LinkedIn inspired by my comments. She was kind enough to let me share them in the blog also. You can learn more about Jennifer’s work on her website.

I couldn’t agree with Amy Marschall, Psy.D. more. It may be a “bold” take to some, but here are some things I have been told by employers and supervisors when I talk about pay inequality:

-“You don’t know if the grass will be greener somewhere else. It could be worse.”
-“If you are in it for the pay then you shouldn’t have gotten into this field.”
-“I didn’t get paid that much as a clinical trainee either, you should just be happy with what you make.”
-“Pay inequality doesn’t get me activated because I focus on my why.”
-“I have to focus on my kids and spouse, I don’t have time to advocate for this.”
-“My spouse takes care of most financial things.”

I get it, most of these people are married, with kids, and have put up with the system for many years. So why change?

Do you know how embarrassing it is as a therapist to live pay check to pay check? To go out for coffee for case consult and worry your card might get declined in front of all your colleagues? To go to the grocery store to checkout and worry your card will decline? To have to cancel a needed hair appointment, one thing that makes me feel good about myself, because I have no money? To have to worry about which bill can wait to be paid so I can have more than $20 to my name?

All of these things I have experienced as a therapist. As someone who came from poverty, an abusive alcoholic family, first generation high-school graduate even, to continue to be in poverty…

I once told a therapist working in private practice my take home bi-weekly and she laughed and said, “You mean you make double that, right?” No, I don’t. In the three years I’ve been doing this, I haven’t even been close to making $50k a year. I get comments from clients and my family, “OH Jenny I bet you make the big bucks.” Talk about imposter syndrome at its highest.

On top of all of this, I am the only practicing certified sex therapist in all of southern MN and do you think I have ever gotten paid extra for that? Nope.

I made a post a while ago stating I know several therapists who are on section 8 housing and county assistance. There is nothing wrong with getting that help. It is the fact that someone with a masters degree and probably 80K+ student loans shouldn’t have to live like this.

Every single one of these statements from supervisors and employers is gaslighting. We are in a profession of advocacy. It is literally I the ACA code of ethics. If you are a supervisor and you say you “don’t have time” to advocate for your clinical trainees, then you should not be a supervisor. You are not following ethics. You are not speaking up for the ones that can’t. The ones you worked so hard to get the extra credentials to “help.” You are part of the systemic problem.

Stop asking why clinicians are leaving the field, why there is such a high turnover rate, and why you can’t hire anyone. It is you, you’re the problem. How are YOU going to help be the change?

Zoo Feeder: Telehealth Activity

I’ve been searching for years to find a telehealth version of Hungry Hungry Hippos that can be played for free via web browser. I feel like it has to be possible for someone who knows more about computers than I do – basically something like this game, where each player controls their hippo with one button. So far, my search has been unsuccessful.

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Photo by Derek Keats on Pexels.com

Recently, I mentioned my predicament during a presentation, and a participant recommended Zoo Feeder. It’s a game where you try to load as many watermelons into a hippo’s mouth as you can, so similar in concept to Hungry Hungry Hippos.

This is a one-player game, but if you and your client play simultaneously on your devices, you can compete to see who collects the most watermelons! You have to gather a minimum number on each level to progress, and the levels get more challenging over time. Sometimes you have to gather the watermelons while avoiding garbage.

It’s not quite the same as Hungry Hungry Hippos, but while I wait for whoever makes internet games to drop whatever other projects they have and just do whatever I want all the time, it will work.

Like Hungry Hungry Hippos, Zoo Feeder involves focus and quick thinking. It can be frustrating, requiring you to regulate your emotions in real time. And if you and your client play simultaneously, there is a competitive component to it that kids enjoy.

Also, if you know of a free, desktop Hungry Hungry Hippos game, LET ME KNOW!

Free Resource: Mindful Co-Parenting Guide

Recently, the folks at Custody Xchange reached out to me about some parenting articles I’ve written. Custody Xchange is a company that helps divorced parents manage schedules and communication.

Note: Custody Xchange has paid services, including a subscription plan. I am not financially involved with this company, I do not get any referral bonus if you sign up, and I cannot speak to their paid service because I have not used it.

father teaching his son how to ride a bike

In addition to their scheduling and communication resources, Custody Xchange has a free Mindful Co-Parenting Guide on their website. This guide takes you through telling your kids about an upcoming divorce, making and maintaining appropriate and stable rules and discipline in multiple households, cooperating with the other parent, and managing kids’ emotional and behavioral responses. It also talks about blending families, the court system, and gives you concrete tools for making a parenting plan.

Something I often point out to divorced parents is that if they got along perfectly, they probably would not be divorced. This means there is history, conflict, hurt feelings, and disagreements that can get in the way of effective co-parenting.

Your feelings about your ex are valid, and also you have a responsibility to your children to create and maintain a parenting plan. Even though divorce is sometimes the healthiest and safest choice for a family, children need consistency and stability, and it is the parents’ responsibility to provide this.

Of course, you cannot control what the other party does, only what you do. Fortunately, this guide includes practical tips for managing conflict with your ex and coping when they are unwilling to work with you.

Get additional support if you need to, including having your own therapist. Fortunately, tools like Custody Xchange’s Mindful Co-Parenting Guide can help you with the many aspects of raising a child post-divorce.

A Note About Online Games with Telehealth

You might have noticed that I talk a lot about different activities and interventions that therapists can do via telehealth, including games that you can play online with your clients. There are, of course, privacy concerns that we must keep in mind in order to provide legal and ethical telehealth services. This is something I speak about at length in the telehealth trainings I have done but have not yet addressed in the blog.

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When I conduct a telehealth session, I use either Zoom or my electronic health record, TherapyNotes. I have the HIPAA-compliant version of Zoom created for healthcare providers, and TherapyNotes is a fully HIPAA-compliant system. Sessions have end-to-end encryption that ensures privacy and confidentiality of all information exchanged during the session.

The various websites with online games that can be played in telehealth sessions do not use encryption. The private game rooms themselves are not encrypted. Because of this, I do not use any communication features in those game rooms. If a client wants to use text chat to talk to me, I let them know that they must use Zoom’s encrypted chat feature and not one on the website. If the website asks for names, we use first name only or false names.

Nothing in the game room indicates that the game is part of a therapy session. If someone were to access a private room, they would simply see that someone was playing the game. Most sites that use private game rooms have an option to play with a random stranger, so if someone viewed the room they would not even know for sure whether or not the players have any connection other than being randomly assigned to each other.

If you use these activities, make sure your clients understand that they are only to use the game room for playing the game and not to use any chat features.

Always, always, always maintain confidentiality and uphold HIPAA standards!

Announcing: Subscriber Giveaway!

Friends, I have both bad and good news today. The bad news is that Armani’s diabetes is acting up, and he needs some more tests and treatment to make sure he keeps living his best possible life. The good news is, in order to help offset the cost, he is doing a giveaway of his book!

All you need to do to enter is subscribe to my Patreon or Twitter Subscription (if they ever actually figured out how to make that feature work). Telehealth Bonus level subscribers get two entries, double the chance to win! You also, of course, get all the other benefits of being a subscriber.

Learn more about this promotion and giveaway on Patreon. See you there!

Interview with Amy Baglietto, Counsellor and Author

Amy Baglietto reached out to me recently to see if I would be on her podcast, and of course I said yes! You should go listen to it if you have not already. While recording, I learned that she wrote a book about her experience as a therapist with ADHD, which you may recall is a topic I have some knowledge of. She was kind enough to answer questions about her book!

First can you tell us about your background and training?

I trained at Roehmapton university in London, UK. I trained as an integrative psychotherapist and started my own private practice 2013

    Tell us about It’s Not Me It’s ADHD.

    In the book I cover:

    • Understanding what ADHD is
    • Common Types of ADHD in woman
    • Tools that might help with ADHD
    • Some of the positives about ADHD
    • Tips to manage your ADHD

    You can download the book from www.yourspacecounselling.com.

    What led to you writing a book about the ADHD experience?

    Since being diagnosed with ADHD as an adult, I’ve realized that a lot of my struggles in life were a direct result of my condition. I’ve also realized that I’m not alone – far from it, in fact.

    Many people suffer from ADHD, and many of them go undiagnosed for years, just like I did, I wanted to give people a better understanding of ADHD.

    What do you wish the general public knew about ADHD?

    I feel at times that people with ADHD are often judged unfairly. There is a lot of misinformation out there about ADHD, and people without the condition can be quick to judge those who do have it. It’s important to remember that everyone is different, and that ADHD is a real condition that should be treated with understanding and respect.

    What do you wish more mental health professionals knew about ADHD?

    ADHD is like a Rubik’s Cube, only it’s a puzzle that never seems to be solved.

    I wish mental health professionals understood that ADHD is not just a childhood disorder. While it’s true that ADHD is often diagnosed in childhood, many adults are also living with the condition. And unfortunately, adults with ADHD often go undiagnosed and untreated, which can lead to a host of challenges in their personal and professional lives.

    I wish mental health professionals were more aware of the signs of ADHD in adults and were better equipped to provide appropriate support and treatment.

    What do you hope readers get from your book?

    Just want people to take what they want from the book and hopefully they can take something useful or have more understanding of ADHD.

    Tell us about your podcast?

    The first episode is one that’s been on our minds for a while – ADHD. Yes, the condition that everyone thinks is just an excuse for bad behavior or a short attention span. I Was lucky enough to get Amy on my podcast, Life In Chaos, where we chatted all things ADHD and what its like to live with ADHD.

    Neurodivergent Accommodations List

    Recently, a friend shared with me a list of accommodations that therapists can recommend for neurodivergent clients. (To clear up any possible confusion, when I use the term “neurodivergent,” I’m using the broad definition meaning anyone and everyone whose brain falls outside of typical. This includes any and all DSM diagnoses. Not everyone uses this definition and that is okay! I err on the side of inclusivity.)

    high angle photo of woman on ladder
    Photo by Samantha Garrote on Pexels.com

    This list was written by Kate Kowalczik, LCSW, who was kind enough to give me permission to share it here. Kate developed a document that provides education about requirements for accommodations and a master list of various accommodations someone might benefit from at their school or workplace. This is a vital resource for any mental health provider who helps clients get accommodations and for any individual who wants to know a bit more about their rights.

    I have it bookmarked under my clinical resources and refer to it for determining the right wording for accommodations letters. I also use it with clients to show them what their options are when they know they need an accommodation but aren’t sure where to start with their request.

    Check out the list here, and thank you Kate for putting together this resource!

    The End of CareDash

    I have some wonderful and amazing news for everyone who has been following the CareDash saga. I’m a little bit behind schedule here since this update is from February – sorry, I follow a lot of issues and don’t always see every single alert. I’d like to thank my colleague who gave me the heads up that there was an update.

    Friends, WE DID IT. CareDash is NO MORE!

    low angle photo of fireworks
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    The American Psychological Association Services Inc (a division of APA) took action. According to their press release:

    APASI will not stand by while psychologists’ professional reputations are being exploited. We immediately went to work to combat this egregious corporate behavior.

    They sent a cease and desist, and following months of back-and-forth, CareDash is no longer creating falsified profiles and routing traffic to other platforms.

    Thank you everyone who pushed this issue!

    Home Office HIPAA Agreements

    Disclaimer: I am not a lawyer. Nothing I say can be construed as legal advice. This post contains my story of how I handle maintaining client confidentiality while working from home. Consult with your attorney and malpractice insurance provider when making decisions about your own practice.

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    Photo by Matthias Zomer on Pexels.com

    While I have been doing telehealth since 2016, I did not work from home as a therapist until 2020. One of the first things I did was complete continuing education on ethical issues for therapists with home offices. The presenter opened with a story.

    Apparently, there was a therapist who did telehealth from her home office. She separated from her husband and ended up in a contentious divorce. Her ex-husband, in a fit of vindictiveness, contacted her licensing board and said that he had been able to overhear some of her sessions. He claimed that she did not take enough steps to stop him from doing this, and she was sanctioned by her licensing board and fined for HIPAA violations.

    I would like to think that my husband wouldn’t contact my licensing board, but I am sure this therapist thought the same thing.

    The presenter said that the way to avoid this kind of complaint is to have a Business Associate Agreement which states that your spouse agrees not to access any Protected Health Information (PHI) from your home office and agrees to protect any information they do access in a way that is HIPAA compliant. The presenter said it helps if your spouse has HIPAA training to make sure they understand what this means. This also applies to anyone else you are living with – roommates, family members, et cetera, anyone who might overhear a session or see a piece of paper with a client’s name on it.

    Fortunately, my husband is already HIPAA trained, and we found a free template for a Business Associate agreement online. We had to tweak it, since BAAs usually speak to sending and receiving PHI, which is not relevant to this situation. That was not hard to do, so I’m sharing the PDF that we put together. Again, I’m not saying anyone should use this as a template, but I am sharing it as a reference.

    Basically, my husband agreed to the following:

    1. He will not attempt to access any PHI.
    2. He will not disclose any PHI he happens to access.
    3. He will let me know of any breaches to this.

    And I agreed to:

    1. Keep him up to date with my privacy policy
    2. Follow HIPAA

    If you work from home, you need to maintain confidentiality and protect your clients and license. This is one step I’ve taken in my business.

    Now I just need to convince the cats to sign one.