Therapy has become increasingly accepted as a norm for health treatment, especially since covid. As historical barriers of stigma and shame fall away, more and more people are embracing hope and change and looking for therapists to help them facilitate healing, but sometimes struggle with where to start.

One option for finding a good therapist or mental health treatment center is to ask your family, friends, or colleagues for recommendations. High praise from someone you know can go a long way in building trust with your provider.

Another option is to check with your insurance company. If you check the back of your insurance card, there is usually a number you can call and they can help with referrals for providers in your network. Better yet, go to the insurance companies Doc Find on their website, which usually allows you to add in filters for your selection and find providers nearest you.

A third recommended option is using Psychology Today's search field at www.psychologytoday.com
Many reputable clinicians use this for their marketing. You can read about each clinician in detail, view their fees, insurances taken, and specialty areas, and even watch video snapshots of them.

Of course Google can also locate someone near you, but that may be driven more by sponsoring ads than who is the best fitting provider near you.

Alternatively, crisis lines like BHR can also help link you to social service organizations, psychiatrists, and mental health facilities.

There are low-fee sliding scale therapists available through memberships at Open Path Collective.

What about the venture capital backed companies (VC) that you see the ads for a lot? These are usually the first 3-5 companies that pop on any any search result for a therapist now. There are many options for therapists available through them as well, but the controversy surrounding them is increasingly mounting, with more and more pressure to push back against the Walmart effect and risk of healthcare monopolies with conflicts of interest and how they impact your healthcare and your local community. You can read more about that here.

You don't have to go through this alone. Many people are available to help. 
A word to the wise, be patient, sometimes places may have long wait lists or be slow to return calls, if at all. It may be beneficial to reach out to multiple providers initially and see who is most responsive to your needs.

How to know if the therapist is a good fit?

An important quality is competence, does the therapist have specialized training or certifications in the area, symptom, or diagnosis that you need help with? Do they primarily do individual or couple or family counseling? How long have they been working in that area to develop a solid set of skills for complicated needs? 

Do they do in-person, virtual, or a combination of both that may make them more accessible or easier for you connect with or be vulnerable.

Does the therapist specialize in Christian counseling or are they general, non-religiously focused? Choosing a therapist that works within a framework you are comfortable with can be helpful.

If you are a member of a marginalized population, does the therapist understand those complexities or needs so that you feel safe? A therapist doesn't have to be a member of that population to be helpful, but they do need to have culturally competency or willingness to approach with openness and non-judgement.

Are you wanting only wanting validation or change? Therapy can feel really good if you are supported and the therapy gives lots of validation, but that doesn't always result in change. One major difference between a friend and a therapist is a therapist is specifically there to help you work on your goals to change, which may mean they tell you things that can be hard to hear and encourage you to do things you are uncomfortable with, for the sake of your recovery. If the therapist only validates you, it may feel good, but might not always result in the change you are seeking.

And lastly, what is the general vibe of the therapist? How do you feel about their demographics and personality?  Look over their website, their psychology today profiles and videos, do they seem like someone you could jive with?

Tempering your Expectations
Sometimes we hear about folks that therapist hop, looking for the "perfect fit," much like dating, it's not likely you will find the "perfect therapist". They are humans and can make mistakes, but are they open to learning and making change to meet your needs, or are you willing to accept that maybe they are telling you something you need to hear instead of what you want to hear? Therapists also encourage the client to do the hard work, not them. So if you are expecting them to do all the work, you may feel frustrated with long silences and delayed in progress. The more you modulate your expectations, the happier you may be about the result.

Sometimes when folks are not ready for therapy, they easily find barriers. It is a good idea to think about whether you are screening out providers who would otherwise be a fit for this reason.  When people strongly desire change and are ready to do the work, they may not overemphasize what certifications the therapist has, or how far away they are, or what times they offer, or what the cost is.  They will be willing to do anything to access the service they need at the moment and are also willing to do the hard work in the process.

Conversely, if a therapist makes you feel unsafe or judged, it makes sense to listen to your gut and move on.

Hopefully this helps and you can find your way to a clinician that helps you meet your needs. Good luck, and good health!

Authors, Megan Garza, MA, LMFT & Chris Scarberry, MA, LPC

​A question that I often hear brought up in therapy is when is it appropriate to cut off my family members? This has become a popular topic these days as generational differences, awareness of trauma, and politics divides family.

As systemic marriage and family therapists, we are trained to study family ancestral trees called genograms and look for patterns of connection, attachment, abuse, substance abuse, and cutoffs. Whenever cutoffs show up in a genogram, it tells us something important about the family dynamic and signs of dysfunction.

Generally, we discourage folks from immediately considering cutoffs vs exploring alternate options.

What are the alternatives to cutoffs
Rather than black and white thinking, that things have to be "all this way" or "all that way" or we are a family unit or we have no connection, as family therapists we often encourage people to explore they gray areas. What about decreasing length of visits or frequency of contacts? Instead of going over every holiday, maybe only go to one, and don’t stay with them, limit your time there and stay at a hotel. Maybe instead of taking all their calls, you choose selectively when to respond or you just send them cards.

There are many times as people explore their development and really individuate from their parents and begin to develop their own sense of identity and beliefs, that they suddenly see problems in their relationship with their family members that were not fully realized prior. Or perhaps the parent is struggling with adapting to the new role of having an independent, adult child where they have less control. At that point, as growing awareness blooms into anger and contempt, sometimes prompted by an outsiders’ view of your family such as partner, teacher, friend, or therapist that the drive to cut-off a family member or make big changes in boundaries with family comes about.

When is a cutoff appropriate?
Sometimes folks have decided that the only way they can have some peace is to cut off their family members. This is especially true when family members have displayed long patterns of egregious, toxic, abusive, manipulative, or selfish behavior and are unlikely or unwilling to change, nor take accountability for their actions. 

• The narcissistic parent who keeps the focus on them and their needs and makes their children walk on eggshells and consequently develop ingrained patterns of hypervigilance and people pleasing
• The antisocial family member who physically, emotionally, sexually, and/or verbally abuses with no remorse or empathy, with pattens of lies, manipulation, and law breaking
• The chronically substance abusing parent or family member that ignores all boundaries, behaves erratic and puts your life or the life of those you care about at risk, betrays trust through lies and stealing, only initiates contact when they want something, and is a source of deep pain and shame
• The morally ambiguous, self-righteous family member who touts themself as a religious/ political/faith leader/follower, But fails to follow their teachings/preaching in favor of judgment or condemnation of people who are poor, suffering, are unlike them, immigrants, minorities, of a different faith, sexual orientation, or gender identity. E.g the parent that kicks out their child for being gay, or refuses to attend their gay child’s wedding because they “don’t believe that” or the parent that aligns themselves with white supremecist movements despite having biracial or immigrant family members (note these individuals often fall into the first two aforementioned categories).

These are all examples of family dynamics that are difficult, if not impossible to manage. Sometimes, for one’s own safety or sanity, there is no recourse but to put distance from the harmful family member. Note, a person is not put into these categories simply because you do not approve of them, or they are not who you want them to be or what you believe, they meet these criteria when they are actively inflicting harm on others through their behavior, the pattern is chronic, and there is a demonstrable unwillingness or inability to change.

Consequences of cutoffs
Sometimes I encounter clients who, at the advise of younger clinicians, have decided to cut-off their family members with formal letters, over more minor and typical family conflicts. Rather than attempting to work through the issue in family therapy, the family member unceremoniously receives a letter that that have been disowned or a list of their infractions and have been informed they are going no-contact. They problem with formally making these statements in a letter is 1) it gives the other person no opportunity to respond, clarify, ask questions, or make amends. And since many issues come down to problems with communication and understanding, this can only exacerbate the problem. 2) You cannot take back the harm inflicted by a formal pronunciation that you are cutting off a family member, thus creating or exacerbating a rejection wound.

Although many people experience family cut-offs for a time, rarely are they permanent. Most people end up reunifying with their family members within a few years. This is true for even the abusive, toxic family members, or the religiously based cut-offs.

Writing letters to harmful family members are very powerful tools in therapy for clarifying your hurt, exploring boundaries, and finding cathartic release. As a trauma counselor I have been witness to thousands of these letters over the years. However, a therapeutic exercise for the self is not the same thing as sending one of those letters to a family member and should be taken with great care and consideration. Sometimes folks who struggle with assertiveness or have fears/challenges with being communication/being heard by their family member may feel letter writing is the only option necessary, which may be true, but it’s also important to know that what is formally written may be hard to take back or make repairs from as well. There is also no guarantee they will read it.

Cautions of cut offs
If your attempt at a cut off is to get the person comply, to punish, to be more the way you want them to be, then you could be abusing the situation and using the cut-off as a tool for emotional manipulation.

If, by contrast, you are using the cut-off as a tool for safety when all methods of communication, family therapy, consultation with faith leaders, and boundary setting have failed, this is totally appropriate. This is especially true when there are no signs of positive change or willingness to change or willingness to take responsibility for the harm that has been caused, and they are in-fact doubling down on their behavior and blaming you for it. Red flags.

As a family therapist, I have witnessed the devastating impact of trauma and clients struggling to set limits with narcissistic parents who continue to ignore and cross boundaries. I have also seen the tragic result of when clients are unceremoniously cut-off by their family members and the pain, sadness, and confusion that results. Many times the person being cut-off genuinely does not recall the events they are being accused of and are shocked at the variation in perspectives. There is no easy path and the decisions you make today may impact generations to come. It's important to remember that small, consistent shifts in your behavior can change the larger family system functioning over time.

A note for parents:
Sometimes parents feel blamed a lot in the therapy process, and the fear of being blamed or judged can keep them away from participating in family therapy. This is a fair concern as parents do take a brunt of the impact when their is family dysfunction. It's important to remember that there are no perfect parents. And even the best parents are going to say or do something at some point that harms their child directly or indirectly. In family therapy we really stress the idea of a "good enough parent". In order for children to develop well, you just need a good enough parent. Most parents do many more good things than bad things. A bad choice does not automatically equate with a bad person/parent/child. Sometimes the positive contributions and the way the parent shows love is not readily recognized. For example, a child may say they did not feel love because dad did not hug them or say "I love you" or was overly strict or critical or said things that made them feel bad about themselves, but that same dad may have shown love through showing up all their sporting events, making sure to always have a job and steady income to support the family, by fixing things around the house to create a safe environment for them, by making sure they had a car to get to their job or college. How a person receives love may not be the same as how another expresses love.

Parents do however have the responsibility, as the older person with more power and authority in the relational dynamics, of being the one to reach out to their children and initiate contact occasionally. It cannot be left just up to the child/adult child. The child also has a responsibility of returning the calls and checking back in occasionally as well if they both wish to maintain a relationship. Parents do have the burden of being the bigger person, because of child's need for unconditional love from the parent.

If you are considering a cut-off, try these steps first

• Practice reflective listening skills to make sure you understand the problem
• Spend time reflecting on your favorite memories with the other person and what you would miss by not having them in your life
• Practice perspective taking- imagine what the situation might feel like from the other person's perspective
• Consider the Context- rather than judge them for their behavior, consider what events contributed to why they acted that what. Consider the influences of their family, culture, prior trauma(s), and generation with kind eyes toward them.
• Consider how that person has shown love to you in their love language vs how you wanted to receive love
• Imagine what your life might look like 5, 10, 20, 30, 50 years in the future with or without them in it and explore any regrets or guilt you might have
• Convey adequate empathy - really put yourself in their shoes and reflect the appropriate emotion needed
• Seek individual therapy from someone who is not biased toward cut-offs
• Try Family Therapy from a skilled family therapist
• Try seeking a consult with your faith leaders
• Consider attending a support group like Al-anon or co-dependents anonymous or a related group such as one's for adult children of emotionally immature or narcissistic parents
• Be cautious of others that encourage you to cut-off your family or to ignore your boundaries/safety for the sake of the family, ask yourself if/how they might benefit or if they have a bias that keeps them from being an objective resource
• Set clear boundaries and stick to them
• Use clear, assertive communication with "I statements" about what your needs are
• Try a writing exercise for yourself to clarify your concerns
• Be curious about your own role in the problem
• Be willing to take accountability for the part you may have played in any hurt feelings that have impacted the relationship
• Listen to podcasts like The Estrangement Project Podcast, The Mend Project, or We Need to Talk about Estrangement, or this TikTok https://www.tiktok.com/t/ZP8rfppao/
• Check out Resources on Psychology Today on Estrangement or the website Rejected Parents
• Read books on family estrangement

Author: Megan Garza, MA, LMFT is a licensed Marriage and Family Therapist and Supervisor at Healing Reflections Therapy

Over the holiday season people often come together with families, sometimes to celebrate, sometimes to grieve losses that tend to congregate around these times of year. As is often the case when families get together, sometimes things are said or done that are hurtful. Sometimes painful truths of the past are unmasked. People are often forced to reconcile with these new harsh truths and realities and to cope with their hurt feelings or the way they have hurt others, sometimes intentionally, but more often than not inadvertently or unintentionally, yet the hurt remains.

Dealing with the aftermath, once problems surface, means that healing and reconciliation may be needed. Some may find that their friends or family members are distant, if not not cut off from them until they attempt to acknowledge the hurt or make amends. One of the biggest challenges relationships face is when the offending party refuses really to acknowledge the harm done. A good apology is more than just saying “sorry.” Effective apologies help repair relationships, build trust, and promote healing.

Here are the key elements that make an apology meaningful and effective.

1. Acknowledge the Harm
What it means: Recognize the specific behavior that caused harm or hurt.

•  Instead of: “I’m sorry if I upset you.”
• Say: “I’m sorry for saying something hurtful during our conversation.”

Why it matters: People want to feel understood. Acknowledging what went wrong helps
validate the other person’s feelings.

2. Take Responsibility
What it means: Own up to your role in the situation without excuses or shifting blame.

• Instead of: “I’m sorry, but you shouldn’t have…”
•  Say: “I take full responsibility for my actions.” Or “I understand the harm I caused when

I _____”
Why it matters: Shifting blame undermines trust. Apologies are meaningful when they come
with accountability.

3. Express Regret and Empathy
What it means: Show genuine remorse for the impact your behavior had on the other
person.

•  Instead of: “Sorry you’re so upset.”
•  Say: “I regret that I hurt you with my words when I said ________.”

Why it matters: Research shows empathy deepens connection and helps heal emotional
wounds.

4. Offer a Plan to Make Amends
What it means: Outline steps to fix the mistake or prevent it from happening again.

•  Instead of: “It won’t happen again.”
•  Say: “Moving forward, I will communicate more respectfully, and I’d like to know how I

can make it right now.”
Why it matters: Offering amends signals that you’re committed to change, not just offering
empty words.

5. Be Sincere and Timely
What it means: Deliver your apology with sincerity, and don’t wait too long to do so.

•  Instead of delaying, take the time to reflect but apologize promptly once you realize the

harm.
Why it matters: A well-timed apology keeps emotions from festering and shows the other
person you care about their feelings.

6. Avoid Repeating the Same Mistake
What it means: After an apology, work on personal growth to avoid the same behavior in
the future.

•  Apologies lose their meaning if the same behavior continues.

Why it matters: True apologies are not just about words—they require action.
A good apology does not ask for forgiveness of the one that has been harmed. That only
further burdens the victim with guilt and responsibility.

Quick Recap:

• Acknowledge the harm.
• Take Responsibility without excuses.
• Express Regret and empathy.
• Offer Amends or solutions.
• Be Sincere and timely.
• Learn from Mistakes and grow.

While apologizing may be hard and requires the strength of being vulnerable and swallowing your pride, when done well, the reward is worth it. Keep in mind though, if you are only apologizing as a tactic to get more of YOUR OWN needs met, the other person may see this as a manipulation tactic and may not be willing to accept it. True apologies and amends come from your own desire to heal the person you hurt, sometimes out of a commitment to faith or justice to do right, and they acknowledge that when you attempt to heal others you also heal yourself.

If you are still struggling and need help, our counselors at Healing Reflections Therapy are also available to help mend the broken divides. Check out our Meet Our Therapists page to find a clinician that best fits for you.

​Author: Megan Garza, MA, LMFT

We spoke in an earlier post about the important elements for success in therapy, one of which was finding a therapist that was a good fit.

With the rise of mental health platforms run by tech corporations that have a wide social media presence, there has been a new vogue of treating your therapist like online dating, the minute something is uncomfortable you should get out, swipe left, keep shopping, there’s always another one ready to pop up and take their place.

Wait! Hold on just a minute. 

There may be some valid reasons to terminate your relationship with your therapist, but there may also be some good reasons to stay that you may not have considered.

When to go
As therapists, we frequently hear horror stories of past therapists- be it unethical practices, unorthodox practices, or interventions that did more harm than good. A therapist that crosses boundaries to have sex with a client, or exploits the therapeutic relationship for their own gain, or abuses their power are all serious causes for concern. If a therapist is displaying overtly unethical or illegal behavior, then the relationship needs to end.

Ruptures in rapport: A Forgivable Offense?
Most complaints about a prior therapists usually arise not because the therapist is inherently bad, but because of differing perspectives/worldviews, cultures, generational differences that lead to feeling, hurt, invalidated and misunderstood. For example, a client not liking the words chosen or boundaries set, or feeling uncomfortable with being held accountable in session, the therapist breaching trust by fulfilling their legal obligation to make a hotline report, or recommending medication or hospitalization; or a therapist making a human error in scheduling, missing an email or call, looking sleepy, forgetting something client previously said, being distracted, conflict over a billing error, snacking during session, seeming too casual or not casual enough, or perceiving the therapist as not on their side enough. These slights, however unintentional can hurt, but whether or not it is worth ending the therapeutic relationship over may be complicated.

​Ruptures in rapport are common, especially as the relationship deepens and therapy reaches newer levels of trust and patterns of earlier relationships begin to play out in the therapeutic relationship. While most licensed therapists are well meaning and do their best to serve their clients with the tools they have, they are also human and have their flaws. Some are wounded healers who are still in the middle of their own journeys, others come from a place of privilege or have not sufficiently done their deconstruction and decolonizing work. Both may inadvertently harm the client. Ideally, therapists should spend some time in their own therapy as well as supervision and consultation doing self-of-therapist work prior to seeing clients, if not on an ongoing basis. 

Ruptures as Opportunities for Corrective Emotional Experience 
Therapy is a microcosm of the rest of the world, meaning that problems that play out in the external world often find a way to play themselves out in the therapy room as well. Challenges in the therapeutic relationship are opportunities for a corrective emotional experience that one may not otherwise have had with others in their life. For example, if you are upset with you therapist for something they said or how they handled a situation, your ability to confront them can be the first time you may feel able to use your voice and challenge someone who has hurt you, but in a safe way (hopefully). In this way, addressing conflict and dissatisfaction with your therapist is both courageous and encouraged, and can be an empowering and healing, and deeply transformative process with breaking patterns in the clients’ life. 

Political Betrayal by Your Therapist
There are times when a therapeutic relationship just isn’t the right fit, for example there is a recent discussion about folks leaving their therapist after learning their therapist voted in a way that went against their rights. Essentially, the therapist has violated the clients' trust with their betrayal and failure to protect their rights. Traditionally, therapists are trained to be neutral and not bring their stuff into the room and not share much about themselves personally- but arguably anyone who works with marginalized populations and sexual or religious trauma survivors needs to NOT be neutral about protecting the folks they serve. They have a fiduciary responsibility to care about their clients not just in the therapy room, but who they are as people. In this way, the political is very personal, so sometimes a political/cultural/gender/racial/religious match may be necessary for building trust and eliminating harmful bias.

When To Pause before a break-up-When Attachment Wounds Run the Show
The "swipe left" method for choosing/leaving a therapist is particularly problematic if the client has concerns with attachment. What do we mean by that? Healthy attachment develops from our early caregivers. When we feel safe and our needs lovingly cared for, we develop a secure attachment, which enables us to have healthy, secure trusting relationships in adulthood. When our needs are not met, or we grow up in unsafe/traumatic, unpredictable, or chaotic environments we may develop anxious, avoidant, disorganized or insecure attachment styles that hinder our brain development and adult relationships. In children, they may be given a diagnosis known as RAD, Reactive Attachment Disorder, commonly seen among foster and adopted kids where there is a disruption to the early attachment relationships. This article talks more in-depth about the disastrous consequences of early attachment wounds and the impact it has on one's ability to attach to future care-givers. 
https://www.theatlantic.com/magazine/archive/2020/07/can-an-unloved-child-learn-to-love/612253/ .  Mary Ainsworth, Margaret Mahler, Harry Harlow, and John Bowlby were among the early pioneers of attachment theory and more modern books by Dr. Bruce Perry have talked about this concept. At the end of this article there are some videos that talk about these foundational attachment studies and why early attachment relationships are so fundamental to development. 

Carl Rogers, famous for developing the Humanistic client-centered psychotherapy treatment method commonly seen as the foundation of most clinical practices wrote about his theory of change in “On Becoming a Person” where he compared the role of the therapist to that of a healthy soil for a tree to grow. In order for someone to grow and flourish, there needs to be a healthy, nurturing soil. Although the home/family environment might not have been provided enough sustenance for early growth, healing/growth in the therapeutic realm can be made through a secure attachment with the therapist by way of empathy, genuineness, and unconditional positive regard.   

So while for some people the task may be to find the “right fit” with the therapist, for others their challenge is deeper- to work through their attachment wound and allow themself to connect/share intimately in a therapeutic relationship, to not run away as the relationship deepens as a form of self-sabotage (i.e., I will leave them before then can leave me, So I won’t be hurt again), and to be able to appropriately address and work through conflict in order to make repairs to be able to have enduring relationships. This process of challenging patterns helps build new neural networks in the brain, to make repairs from earlier setbacks.

Trust and Attachment Takes Time
For some folks, the real work in therapy may not begin for 6 months to a year until they have worked with the therapist long enough to “test them” to ensure the therapist will not reject or abandon them, only then do they start to show their therapist their deeper wounds, pain, insecurities and problematic behaviors. Not surprisingly, this same pattern can emerge in romantic relationships, where the partnership seems like bliss, so they rush to marry or move-in together quickly. Once the partner has them on the hook, suddenly their personality and behavior shift. One begins to see an entirely different side of the person than they did before, and in some cases it may seem like a Dr. Jekyll/Mr. Hyde situation. The other partner often feels confused and betrayed. 

A Note About The Impact of Sexual Trauma on Attachment Wounds
One common scenario where attachment wounds play out with women in romantic relationships is when there is a history of sexual trauma. In the wake of the trauma she may experience distorted beliefs in which she believes it is her fault, is damages, unloveable, unwanted, or not good enough. This leaves her feeling hurt, sad, lonely, and isolated. As a result she may end up hooking up with various people in a serial fashion combo of trauma re-enactment, maladaptive coping, attempts to reclaim power, and self-fulfilling prophecy. Eventually she ends up with a hook-up that turns into a situationship that turns into a relationship. It starts out hot, but once the relationship gets to a point of stability and safety, the sex life turns cold and avoidant. The couple starts fighting more as he is frustrated and hurt from the rejection and she is feeling pressured and coersed into unwanted and painful sexual activity which cause her to further lose interest and avoid any attempts at intimacy, for fear it will lead to demands/pressure for sex. This pressure is a trauma trigger that feeds back into her original negative beliefs about herself that she is damaged/unloveable/only good for sex. The antidote is recognizing those patterns, and encouraging the partner to create a safer space while the she works to challenge her distorted beliefs and anxiety about triggers. If the couple can work through this together, they can have a deeply satisfying, intimate relationship. If they cannot address it together, there is the risk that the pattern will be repeated with the next partner, and the next. The same can be said about the therapist, if conflicts in therapy room are not addressed, there is a risk that pattern will present with the next therapist and so on.

So, before you fire off that email to break-up with your therapist, really sit and be curious. Ask yourself:
Is this about them, or is this about Me? 
Is this similar to a pattern in your life with other providers, family members, friends, or romantic partners?  
Am I leaving to avoid conflict? 
Am I leaving to avoid connection? 
Have I done the work to give them the opportunity to change or demystify their process or apologize?  
Are they safe?
Do they respect my dignity and autonomy?
Is this therapeutic relationship doing more harm than good?
Were they having an off day when something happened that hurt your feelings or do you feel hurt more often than not when meeting with them? 
Am I expecting perfection?
Did they tell me something I did not want to hear, but maybe needed to hear?
If I don’t trust them, do I feel I can trust anyone?
Am I ready to make changes to myself and the patterns I am in?

Barriers to Change, Lack of Readiness and Low Motivation 
While we are talking about reasons people stop therapy, sometimes it's because of the therapist, sometimes it's because of client attachment concerns, but sometimes it's lack of readiness or willingness to change.  When people are at the pre-contemplative or contemplative stages of change, the might throw up all kinds of barriers to attending services, like needing things to be "perfect", requiring just the right time slot, location, proximity or services; or just the right therapist demographics of race, gender, religion, level of experience/certification/degree, or lived experience; minimal cost, and just the right modality. While all these things certainly can help as previously discussed, when folks are creating barriers that sometimes set it up to where no one can fulfill their needs, and they thus get to avoid the therapy process by escaping it but claiming no responsibility. They may also create further barriers to change by not thinking about their therapy after/between sessions, not doing homework, etc. We find that when people are really desperate and motivated for change, most those barriers fall away and all people are really left with is “Can you help me?” And “How Soon can I get in?” Research is clear that the number one predictor of positive outcomes in therapy is not the therapeutic modality, it is the alliance with the therapist. Attachment matters. Readiness to change matters. Attachment to your therapist matters. Take time to see if they are trustworthy. Decide if you are really ready. If they are trustworthy, and you are ready for change, take time to consider before you leave. 

​

Author: Megan Garza, MA, LMFT

A common misunderstanding in the therapy realm has to do with all those confusing alphabet soup of letters after the providers name- LMFT, PsyD, PhD, MS, MSW, MD, NP, MFT, LPC, PLPC, LCSW... and so on. Even as someone who went through years of school, multiple graduations, and career highlights, admittedly my family still mislabel my title and don't understand the work I do.

So what do all these letters mean and why does it matter to you as a person seeking mental health services? Many people frequently get confused about whether they were seeing a psychologist or a psychiatrist, which can lead to a lot of frustration and disappointment when they are expecting an hour long psychotherapy session, but instead get a doctor's appointment that lasts 5 minutes and are given a prescription for antidepressants, or vice vera.

Well, for starters these letters are basically indicators of their years of education, specific degree, specialization. They may even tell you about the philosophy and values of that profession.

Your Medication Prescribers
MD- Your psychiatrist is usually and MD. They went to medical school and specialized in studying the brain and its impact on mental health. Visits with a Psychiatrist are usually 5-15 minutes once a month or every few months for adjusting medications based on symptoms. Occasionally you will find old school psychiatrists (think Fraser Crane, Dr. Freud, or the dad in Growing Pains) that still do psychotherapy on top of prescribing meds, but that is far less common these days.

GP -or general practitioner also has an MD and also frequently prescribes basic medications for anxiety for depression or anxiety in cases that are less complicated.

NP - Your nurse practitioner is a nurse  (RN) with specialized clinical training that can often prescribe meds for mental health and usually works in conjunction with an MD.

Your Testers, Forensic Evaluators, High level Administrators, Psychotherapists
PhD- This is where you typically find Psychologists. These individuals have doctoral degrees usually in clinical psychology, Marriage and Family Therapy, Education, Social Work or a related field. They have typically 10+ years in academia after high school completing their education with  scientific research components, teaching, and writing/publication. Clinical Psychologists may provide psychotherapy, but often you find them doing a host of other jobs. They are highly trained in diagnosis, testing, and various forms of evaluation. There also other Cognitive Psychologists and Industrial/Organizational Psychologists who specialize in other areas of psychology, but do not usually provide therapy.

PsyD or EdD- These individuals also have a doctorate in either psychology or education, or counseling usually, but their programs were more clinical and less research focused. They have 10+ years in education, but their training was highly specialized to working with clients or students in the field rather than the research lab.

Your Master's level Therapists/Psychotherapists/Counselors
These folks make up the bulk of who is providing therapy today

MA means they have a Master of Arts degree
MS means they have a Master of Science degree

MSW- These folks have a Master's degree in Social Work- They have a 4 yr Bachelor's degree + 2-3 year Master's degree with a strong social justice component.
LCSW- These folks are Licensed Clinical Social Workers- They have a  4 yr Bachelor's degree + 2-3 year master's degree with a strong social justice component but they also have added clinical training and experience to work with clients and have passed their licensing exam. They usually are opposed to diagnosis, but in practice diagnosis is often required to billing purposes.


LMFT ( or MFT of FT in some states)- These folks are Licensed Marriage and Family Therapists. They have a a 4 yr Bachelor's degree + a 3 year Master's degree in therapy interventions with a specialization in relational and family system therapies. They have specialized clinical training and passed their licensing exam.
PLMFT- These folks are provisionally Licensed Marriage and Family Therapists. They have a 4 yr Bachelor's degree + a 3 year Master's degree with a specialization in relational and family system therapies. They have passed their licensing exam, but have not yet completed their required 2+ years of clinical training prior to being fully licensed. They work under the license of a supervisor.
SMFT- These folks are working toward their provisional License as a Marriage and Family Therapist. They have a 4 yr Bachelor's degree +a 3 year Master's degree with a specialization in relational and family system therapies. They have not taken/passed their licensing exam yet, and have yet to complete their required 2+ years of clinical training prior to being fully licensed. They work under the license of a supervisor.

LPC- These individuals are Licensed Professional Counselors with a 4 yr Bachelor's degree + 2-3 year Master's degrees in Counseling or a related field. They have very similar education requirements to MFTs, but they tend to focus more on the individual, so they don't usually have the additional specialized training for working with kids/couples and families unless they sought that out separately.
PLPC- is a Provisionally Licensed Professional counselor who has completed their Master's degree and have passed their licensing exam, but are working on completing their 2+ years of post-degree clinical experience.

Bachelor Level support workers
BA Bachelor of Arts- 4 year degree
BS Bachelor of Science- 4 year degree

Your Case Worker or Support worker or Tech usually will fall into this category. They don't have a license or any specialized clinical training beyond education and work experience. These are the "trench workers" who usually work very hard, for little pay, and see high volumes of clients.

Certificate holders
A Lifecoach is a person that helps direct a person to make important decisions in their life. They have no specialized education/degree requirements, no exams, nor is their a governing regulatory body that gives that a license or oversees them to guarantee ethical practice. They typically receive a certificate as a life coach and often train under another life coach. This area is often controversial because the lack of oversight and lack of public knowledge about the professional competencies of the lifecoach. There is a concern that people may be taken advantage of by individuals that label themselves lifecoaches, but may in fact be doing their clients harm due to their lack of training, skills, or boundaries outside of what that they believe themselves to have. Conversely, many licensed therapists also double over as lifecoaches and offer coaching as a separate part of their practice. Some people who find mental  health stigmatizing may shy away from "therapists" but may proudly seek out a "lifecoach." Lifecoaches should avoid diagnosis and attempting to provide therapy. Their work is usually skills and decision based (e.g. a career coach) and should not involve diagnosis, or attempts at therapy. 

Hopefully after reading this you have a better sense of the kind of provider you are seeking or seeing (and maybe what label you should actually call your family member).  Sidenote, though it may seem like these words are interchangeable, it's actually illegal/unethical for these professionals to call themselves by a title that does not belong to them so as not to misrepresent themself. A psychologist cannot call themself a psychiatrist and a lifecoach cannot call themselves a therapist unless they have a Master's degree and clinical license. As you become a savvier consumer, the more likely you will ensure you have the satisfactory treatment experience you are expecting.

by Megan Garza, MA, LMFT

A popular point of discussion on social media these days is narcissism. It seems like everyone's parent or ex has been deemed a narcissist.

While in some ways the discussion can be helpful in recognizing abusive behaviors that can impact one’s own mental health, the overuse of the term has taken away some of its power and can lead to misunderstandings. Although it is common these days to toss around phrases like “my ex was such a narcissist” to such an extend that it seems like everyone dated a narcissist. However, the actual presence of Narcissistic Personality Disorder only occurs in 1% of the population.

A person can exhibit moments of narcissism ( arguably all of us), but not be a Narcissist.

So what does a Narcissist in clinical terms look like? The classic signs of NPD include:

1. Sense of self-importance
2. Preoccupation with power, beauty, or success 
3. Entitled
4. Can only be around people who are important or special
5. Interpersonally exploitative for their own gain
6. Arrogant
7. Lack empathy
8. Must be admired
9. Envious of others or believe that others are envious of them

Someone who may be very full of themselves, vain, or overly self-confident. They may have little insight into themselves. The may have little empathy for others and see themselves as the victim in situations where they are the offending party. Often people initially find them very amiable and “charming” is the word that repeatedly comes up in domestic violence circles. They have a way of drawing people to them with their charisma and enigmatic personality, but often their words and gestures are hollow with little sincerity, thoughtfulness, or follow-through. Because they make such a great first impression they can easily trick judges, police, family, and others in authority into believing that they are just a great, well meaning person and their counterpart is suffering from mental illness (enter gaslighting). 

Narcissism and its role in Domestic Violence
Just because your significant other said you were exaggerating or doesn’t recall your side of the events does not mean they are gaslighting you. Gaslighting is a strategic way certain abusers systematically try to make their partner think themselves crazy. It is designed to break them down. Most relationships have couples that widely misperceive or misinterpret events, where one may be experiencing cognitive distortions and have a hard time separating feelings from facts or another may be bad at reading or responding to emotions non-defensively...that does not make them gaslighters or Narcissists.

Gaslighting came from the old classic 1944 film “Gaslight” where the main character attempted to convince his wife she was crazy by stealing things from the home and accusing her of stealing or misplacing things, then telling her she had a poor memory, and climbing into the ceiling and adjusting the gas in the ceiling lights and acting like it wasn't happening to convince her she was going insane. It came to be known as a specific form of domestic violence, though can be used by anyone in power/authority, or looking to gain something from someone else for malevolent means. 
It essentially is intentionally saying/doing things to make someone believe they are going crazy…usually in effort to gain control over them/their things/or to just be antisocial and abusive and  enjoy others suffering.

Narcissists may use their charm and charisma to get others to align with them against their victim. The victim feels crazy and their self esteem and self-concept are eroded. They may exploit the victim's vulnerabilities to their own advantage physically, financially, or emotionally. Narcissists have more than average encounters with HR, police, civil and criminal suits, protection orders in which they see themselves as the wronged party. They may cry, pout, sulk, yell, namecall, deflect, project, deny, become puffed up, enraged, and incredulous if their behaviors are pointed out. One noted hallmark is the tendency to accuse others of the very behavior they themselves are exhibiting while admonishing it in the other person (kinda makes you feel crazy, right?). If they do admit what they have done wrong, it will be your fault because you “made them do X”, or you “made them feel Y”.  Ultimately, they will usually take the stance of “it’s your fault.” I.e. "It’s your fault I cheated because you were not having sex with me enough.”

 Charming Narcissists may start out with lovebombing and seeming like the perfect person. When getting lovebombed it might feel like you are the main character in your favorite romcom and you likely will feel very special, but usually after 1 year or so of after they get their partner “on the hook” with marriage, housing, loans, or a child their veneer begins to fade and the other side starts to emerge- sometimes classically known as the Dr. Jekyl/Mr. Hyde personality.  The victim tends to spend a lot of time in ever shortening cycles of domestic violence idealizing the perfect periods and struggling to see the holistic pattern that tells much more about the overall personality structure of their partner and the waning hope for change. Partners, employees, and children or narcissists tend to develop a lot of insecurity about themselves, are highly attuned to slight reactions from others in a “walking on eggshells” approach to maintain survival and avoidance of further pain.


Gaslighting vs Perceptual differences
By contrast, Most relationships involve 2 people disagreeing about something because of their own past experiences, internal thought processes/distorted views of the world, and resulting different perceptions of the experience. In most cases, people are not intentionally trying to convince someone they are crazy-though this may be the inadvertent result.

Take for example the Michael Brown shooting. They had 64 witnesses and their perceptions and reports of their experience differed wildly. Sure, some may have been motivated by secondary gain to report the way they did, but they were by far not outliers (https://www.motherjones.com/politics/2014/11/inconsistencies-what-happened-during-michael-brown-shooting/)

There are famous experiments in cognitive psychology where people can be engaged in a game of basketball and a man in a gorilla suit can walk straight through the court and when asked later about it, most players and witnesses of the game will not see it, because they are focused on the ball (https://www.youtube.com/watch?v=vJG698U2Mvo). A person could easily say “wow, did u see that gorilla?!” And the other person might be like “what are you talking about? There was no gorilla.” An argument ensues and one or both may feel crazy and this is where pop psych gets it wrong-someone might say-“you are gaslighting me.” This is not true, unless the person was intentionally trying to make the other person think they are crazy.

And the added piece with cognitive psychology research by Elizabeth Loftus teaches us that people are especially bad historians. Our memories are very fallible and maleable to suggestion, which is why eyewitness testimony is considered the weakest/most unreliable form of evidence, despite people having the most confidence in it (https://www.science.org/content/article/how-reliable-eyewitness-testimony-scientists-weigh#:~:text=As%20Loftus%20puts%20it%2C%20%22just,that%20their%20memory%20of%20an).

So, when thinking of gaslighting, ask yourself about the overall behaviors and intentions of this person. Do they generally mean you goodwill even when they are not trying to lovebomb or get something from you in a manipulative fashion? Do they try to help/support/lift you up/encourage your dreams and best version of yourself? Or do you usually feel bad/smaller/more out of control in ways that is usually inconsistent with how you view yourself/others/the world.

Narcissists in Therapy
Joseph Burgo in the book “The Narcissist you Know” talks about different types of Narcissists, the ones that want to be held in high esteem, famous, or revered and will happily step on anyone who gets in the way of achieving their goal. Dictators, politicians, and some actors and models have been known to fit this mold. Others have a veneer of wanting others to see them as great, but they are much more shallow and easily wounded and resort to lashing out when that is not validated. They are likely to throw a fit, use injurious words to cut down anyone that might see through the veneer and cut the person out of their life entirely. Some may be philanthropers or nurses, teachers, or ministers, or police , or even therapists where they are in the position of being admired and praised, but the people that are closest to them like their partner, parent or child may have a very different experience of them than their public persona.

Narcissists are not historically known to show up for therapy unless court mandated or coming in with their partner for couple/family therapy. It is sometimes said that narcissists in therapy only become better at manipulation and therefore a clinician that recognizes the perils should proceed with caution. In these settings they tend to first focus on winning over the therapist by being a “good client” or they finger point all issues as originating with their partner/boss/family member/ex/etc and take no accountability for the work they need to do on their end to make repairs. Essentially, they take the stance of wanting the therapist to validate their concerns as the injured party and try to co-opt the therapist to get the other person to take the responsibility for the problems in the relationship. They may seem agreeable to homework, but have little follow through if the expectation is for them to focus on change within themselves, yet be simultaneously demanding of change and work from their partner. They usually do not see their hypocrisy and are emboldened by their narcissistic injury to overlook their injurious behaviors.

Theories of what causes Narcissistic Personality Disorder
Theories on the roots causes of NPD vary. Sometimes it develops because they grew up in entitled settings where they were pushed to be “the best” and likewise developed little empathy for anything/anyone that did not meet those standards. Conversely, some were treated so poorly from developmental/attachment trauma that they develop a false sense of self/veneer to convince themselves they were ok to steal themselves up from the outside threats. This is the narcissism that is much more fragile, because if they allow their guard to come down and see their own flaws, their core sense of self may be at threat. They may be vulnerable to experiencing the extreme pain of their early trauma, so they fight hard to allow those vulnerable feelings from being experienced.

Traits vs personality disorder
Maybe you have read this and thought you for sure know someone who is a Narcissist, but to be clear, the pervasiveness and chronicity and truly heinous impact of this abuse is what makes it unique. You likely have someone who treated you poorly, made you question yourself, did not validate your feelings, took advantage of you, or behaved poorly during an argument and did not share the same perspective as you, but it does not necessarily mean they are a Narcissist. If you reflect, maybe there are times you could say the same for yourself too. This popsych mislabeling is a disservice to real sufferers of narcissists, and gaslighting. Your ex- boyfriend  may be a selfish ass, but probably isn’t an actual narcissist.  We need to be kinder to one another and more magnanimous sometimes in how we interpret others actions.

Fore more readings on the subject, you can read here:

www.mayoclinic.org/diseases-conditions/narcissistic-personality-disorder/symptoms-causes/syc-20366662

https://emedicine.medscape.com/article/1519417-overview?form=fpf

Gaslight(1944).www.youtube.com/watch?v=QJtJsFdpRm8

The Narcissist You know by Joseph Burgo

By Megan Garza, MA, LMFT