The therapeutic relationship can be a very powerful relationship. In fact, power in this relationship is vital, and something ethical therapists should think carefully about. Ideally, the therapist uses the position of authority inherent to the role to empower people in therapy and encourage them toward wellness and autonomy. Unfortunately, this does not always happen. In some cases, therapists have been known to abuse the imbalance of power in the therapeutic relationship. This can of course be harmful to the people they are entrusted to help, who may not know exactly what is happening or what to do about it.

As a person in therapy, trusting your own experience and communicating about it are both essential to the outcome of therapy. If you have fears or doubts about something that happened or how you are being treated, in most cases you should speak with your therapist about these concerns. In turn, any such concerns should be taken seriously and addressed immediately by the therapist.

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Some ways therapists may go astray in the therapeutic relationship include behaviors related to boundaries, to fostering dependence, to their duty of care to you, and to acting in hostile ways. A number of specific things would be red flags. While I will discuss some of them, please know this list is by no means exhaustive, nor can it possibly be. It is important to trust your instincts about how you are being treated.

Boundaries are extremely important in the therapeutic relationship, and many are outlined in the ethical codes mental health practitioners are bound by. It is incumbent upon your therapist to maintain appropriate and professional boundaries; this is one of the ways the therapist fosters trust in the relationship and in the therapeutic process. Maintaining boundaries means your therapist should neither cross boundaries nor allow you to cross them as part of the relationship. The therapeutic relationship should empower you and enrich your life.

Examples of boundaries being crossed include:

• Violating confidentiality: Sharing your information with others, or others’ information with you.
• Attending sessions while compromised: This includes being inebriated, or conducting sessions if the person in therapy is too inebriated to meaningfully engage the therapeutic process.
• Conducting sessions while distracted: This means doing other things, such as running errands, having meals, or answering phone calls.
• Not adhering to expected lengths of sessions: Sessions sometimes run a bit late, but consistently going long or cutting short, or if you don’t know how long sessions are supposed to be, is not respecting boundaries.
• Expecting, asking for, or accepting favors or gifts: Small gestures such as thank-you cards are okay if offered, but should never be expected, and the person in therapy should never feel pressured to give anything.
• Extending invitations or accepting invitations to social events: Your relationship is professional and should be conducted within the confines of professional contexts; while we, as therapists, do sometimes receive invitations to important social events involving people in therapy and generally are very touched and honored by this, we should decline them gracefully to preserve the integrity and safety of the professional relationship, which is our first priority.
• Requesting support for their business: Therapists should not ask for donations, contributions of time or money, or any other support of their business outside of what you owe them directly for your therapy. This includes soliciting reviews for use in their marketing or websites.
• Maintaining multiple relationships: Therapists generally should not be in a therapist role for people with whom they have other significant relationships, or for people with close ties to others the therapist is working with. In small communities with very limited numbers of therapists, this can be difficult, but therapists should work hard to find the best ethical balance they can while preserving the safety of the therapeutic space.
• Any sexual innuendo, requests, pressure, or behavior: Licensed therapists are prohibited from sexual contact with the people they work with in therapy. If your therapist makes sexual overtures to you or encourages them from you, this is a serious violation of trust.

Fostering Dependence

Therapists are ethically obligated to support people in therapy in living full, independent lives to the extent this is possible for them. In some (hopefully few!) cases, therapists have intentionally fostered dependence. As a therapist, my goal is always, as I say, to “work myself out of a job,” because this means the person in therapy has achieved the goals established at the outset and moved into a better space.

Some clues that your therapist may be fostering dependence in the relationship include:

• Pressuring you to cut off ties with important people in your life who support you.
• Encouraging frequent out-of-session contacts with no reasonable clinical justification.
• Responding negatively or dismissively to positive changes you make.
• Having excessive influence over your personal choices—leisure activities, relationships, clothing choices, career choices, etc.
• Pressuring you not to disclose your therapy work to others, or seeking to isolate you from other important people in your life.
• Offering or encouraging you to use illegal or potentially addictive substances outside the boundaries of appropriate prescriptions by a qualified physician or psychiatrist.

For what it’s worth, some of the signs above are hallmarks of emotional abuse. You don’t deserve such abuse from anyone, let alone your therapist.

Deviations from Duty of Care

Therapists have a specific duty of care to you. This includes a legal and ethical duty to work actively toward your welfare and to be responsive to your needs.

Therapists have a specific duty of care to you. This includes a legal and ethical duty to work actively toward your welfare and to be responsive to your needs.

Some specific deviations from a therapist’s duty of care to you might include:

• Failing to respond to suicidal or homicidal ideas you express during sessions, or encouraging such thinking or planning.
• Not listening to your concerns about your well-being or your priorities in this regard, or failing to respond when you voice such concerns.
• Being dishonest or deceptive in regards to the goals, process, or prognosis of your therapy.
• Abandoning you—suddenly terminating therapy without explanation or referrals to other qualified providers, or failing to respond to reasonable needs or requests for support.

Hostile or Abusive Behaviors

Therapists may sometimes need to confront problematic behaviors or hold reasonable expectations regarding behavior of the person in therapy. However, this boundary should never take the shape of openly hostile or abusive behaviors.

Some indications your therapist is engaging in hostile behavior include:

• Expressing excessive anger at you or your behaviors.
• Using language with you or about you that is insulting, demeaning, or inappropriate—using profanity in the therapy room is not particularly uncommon, but this language should never be directed at you in an insulting way or used in ways that are frightening or offensive to you. My rule of thumb is to follow the lead of the person in therapy; if the person chooses to use profanity to express strong feelings, that is fine with me, but I do not use such language outside the context of the person’s own use of it. Strong language, whether profane or not, should not be directed at you in insulting or abusive ways.
• Yelling at you—again, raised voices sometimes accompany the discharge of strong emotions, and this can be fine and even healing at times. However, your therapist should not be yelling at you in demeaning or belittling ways, or ways that feel frightening or upsetting.
• Violating your boundaries—if you set a clear boundary about something you don’t want to discuss, your physical space or touching, or language you find upsetting, this should be respected. It may reasonably happen that your therapist might express an opinion about the clinical benefit of talking about something that feels uncomfortable to you; however, this should be a calm expression that helps you understand and feel supported rather than an angry or confrontational demand.
• Threats—you should not feel threatened by your therapist. Threatening to disclose sensitive information to others, to use it against you inside or outside of therapy, or to terminate therapy if you don’t “toe the line” are red flags. A therapist may need to terminate therapy with you if they believe it is not benefitting you or for other reasons, but this should be handled in a sensitive way that helps you to understand the reasons for it and offers other options.

The scenarios above provide a broad overview of some behaviors that may be indicators of a problematic or abusive therapeutic relationship. In some of these cases, it is conceivable that there might be reasonable clinical justification for certain behaviors. However, if you feel uncomfortable about your therapeutic relationship, you should address that discomfort—it is real, valid, and deserves attention.

If You Have Concerns Regarding Therapy or Your Therapist

If you have concerns about the safety or appropriateness of your therapy relationship, in most cases the best first step is to bring these to the attention of your therapist. In many cases, there may have been a miscommunication of some sort and your therapist will be grateful to you for bringing this to their attention so it can be addressed. (Good therapists want to help you feel better!)

If this does not seem possible or reasonable in your circumstances, you are always free to seek a second opinion from another therapist. Although it’s rarely advisable to have multiple concurrent therapists, one session to consult with a different therapist about how your therapy is going and explore the possibility of changing to a therapist who may be a better fit for you is always a reasonable step.

If you have serious concerns about how you have been treated in therapy, you can contact the licensing board for the type of professional you are working with in your state and ask what your options are. A simple web search should help you find this body. For example, searching for “counselor board state of Indiana” should help you navigate to the relevant authority that can help you with your specific questions or concerns.

Why do some people suffer after a traumatic event while others do not?

This is an important question in the world of trauma psychology, one that is being extensively researched. We know, both anecdotally and empirically, that, given exposure to a critical incident, some people will be negatively affected by it, while others will move on and be essentially fine. For example, several young people of similar age and background can be deployed on the ground in the same unit in Iraq or Afghanistan, be exposed to roughly similar experiences, and some will return stateside, move ahead with happy and fulfilling lives and be fine, while others will experience some level of disruption associated with their service.

Why is that?

The answer to this appears to be largely the same as the answer to so many other quandaries in the field of psychology: the unique combination of genetic constitution and set of life experiences for any given individual. It’s the old “nature vs. nurture” question, and, as is typically the case, the answer seems to be “yes, both influence outcome significantly.”

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As with so many things, it seems clear that we inherit a genetic constitution that may leave us more or less at risk of developing lasting problems after trauma exposure. Recent studies indicate that, with similar levels of trauma exposure, individuals who have close family members who have struggled with trauma-related problems are more likely than those without such a connection to struggle after trauma. This link seems fairly strong.

However, one generally does not experience trauma-related problems without … trauma. Life experiences do not occur in a vacuum, and trauma-related concerns are certainly no exception. Sometimes when we talk about trauma, we talk about a “dose-response relationship,” which simply means that a person’s response to trauma is directly related to the amount of exposure he or she has. Because of the differing “doses,” a person who experiences a single-incident trauma of brief duration (a car accident, for example) is at less risk of lasting problems than a person who experiences chronic exposure to ongoing traumatizing events for a lengthy period of time (such as child abuse or neglect).

Life experiences do not occur in a vacuum, and trauma-related concerns are certainly no exception.

This is not to say that people who experience a single car accident do not develop significant problems; they can and, unfortunately, sometimes do. However, the likelihood of ongoing struggles increases as the amount and severity of exposure to trauma increases. So, a person’s history of trauma and learned coping skills combines with his or her genetic constitution to create that person’s level of risk and resilience.

Sometimes when we talk about trauma-related struggles, we talk about trying to find ways that we might “inoculate” people against developing serious negative outcomes after a traumatic event. Of course, there is no shot or medicine that will achieve this; what we mean when we say this is that we hope to create a set of life experiences that will reduce a person’s vulnerability to troubles by increasing his or her resilience level. Essentially, we want to start to establish—prior to trauma exposures—habits and ways of being and relating to the world that seem to be associated with better outcomes after trauma exposures. For example, habits of thought are important in structuring how we perceive the world. A tendency to blame extensively or to personalize others’ behaviors may reduce resilience, so, with an eye toward increasing resilience, we may try to shift habits of thought in a different direction.

Of course, unlike “inoculation” in the true sense of the world, none of these will provide any real immunity. At present, there is no such thing—bad things happen to good people unexpectedly, and sometimes, in spite of everything, that person will encounter struggles associated with that. But we know that some habits can and do increase the chances that, upon exposure, the individual will be able to incorporate the experience and continue living life without major disruption.

Our knowledge about this grows every day, and we continue to work toward a more complete understanding of how to assist survivors of trauma. Both before and after traumatic incidents, there are interventions that we have identified that we know can meaningfully reduce suffering; this being so, it seems worth the effort to continue pursuing them as best we can, in spite of the imperfect state of our knowledge.

Trying to find the right mental health professional for your needs can feel daunting. There are so many providers out there, and it’s important to find a good one.

Many choose to begin their search on the internet. That’s a good start! But looking through search results may feel confusing. Most of the names have letters behind them, but what do all those letters mean? How can a savvy consumer use them to choose a counselor or therapist?

Here’s a brief guide to some of the common credentials in mental health licensing in the United States. Some of these credentials relate to the state licensing and certification standards for practicing professionals.Thus, they may vary somewhat from state to state. But in most states there is some similarity in qualifications required for licensure. If you are interested in knowing the minimal level of qualification for practice in your state, you can often find this information from an Internet search for your state and the specific credential you are interested in. You can also contact your state’s licensing board directly for more information.

• Registered psychotherapist: Some states have a database that lists people who provide services but do not have formal training in the field. This type of registry aims to provide some level of regulation for people who provide counseling services but do not have credentials. Among these people may be those who call themselves a “life coach” or simply a “therapist.”
• CAC: A certified addictions counselor has some level of training in the specific dynamics of addiction. Credentials necessary to achieve this certification vary by state. But they are often minimal. For example, in Colorado, CAC I and CAC II require a high school diploma or GED. A CAC III (the highest level) requires a bachelor’s degree. [fat_widget_right]
• MA: Master of arts is a fairly universal designation. It indicates the person has a master’s degree. If it is used to indicate professional competence in psychology, it should be in a field related to psychology. A master’s degree generally reflects two years of post-bachelor’s study.
• MS: Master of science also indicates a degree held.
• MEd: This stands for a master’s degree in education.
• MC: This stands for a master’s degree in counseling.
• LPC/LCPC/LPCC/LMHC: These acronyms stand for, respectively, licensed professional counselor, licensed clinical professional counselor, licensed professional clinical counselor, and licensed mental health counselor. These are all licensed by the state. Generally, a person must hold a master’s degree, complete a certain number of post-degree training hours under supervision, and pass a licensure exam.
• LAC: In some states, a licensed addiction counselor has been licensed as an addictions counselor and has specialized training in this field. In some states, this certification requires a completed master’s degree.
• NCC: A national certified counselor has completed a master’s degree, post-degree supervision, and the national counselor examination. This is a nationwide credential. It is consistent from state to state.
• LMFT: This stands for licensed marriage and family therapist. 
• LCSW: This stands for licensed clinical social worker. 
• EMDR: Some (but not all) professionals who have completed training in eye movement desensitization and reprocessing therapy and are qualified to offer it use this credential. To receive training, clinicians must be students or graduates of a psychology-related, graduate-level training program, as per The EMDR Institute, Inc.
• EdD: This indicates that the holder holds a doctorate in education.
• PsyD: This means the holder has completed a doctorate in psychology degree. The focus in a PsyD program generally emphasizes less research than in a PhD program and often requires less original research by the student.
• PhD: A person with a PhD holds a doctorate of philosophy degree. For practicing mental health professionals, the degree should be in the field of psychology. In most cases, a doctoral degree reflects a minimum of four or five years of post-bachelor’s study. The national average is seven years of study.
• MD: A person with an MD has completed medical school and holds a doctorate in medicine. People offering mental health services should have completed a residency in psychiatry and be a board-certified psychiatrist. Most psychiatrists prescribe medication as part of their practice. Some limit themselves to medication-related issues. But some do also offer therapy. Psychiatrists complete four years of post-bachelor’s study in medical school and a residency of at least four years.
• LP: Some licensed psychologists use this credential to indicate their status. But it is not standard, so many others do not. Licensed psychologists must hold a doctoral degree and have completed at least one year of full-time internship in clinical practice. They must also have passed a licensure exam, completed extensive post-doctoral training under supervision, and be licensed by the state. In most states, the term “psychologist” is legally protected and reserved for those who have completed these requirements. In addition to counseling offered by other types of professionals, psychologists may offer psychological testing and assessment services.
• ABPP: This means a person has been board certified to practice in a specialty by the American Board of Professional Psychology. To be certified, a professional must be a licensed psychologist, hold an accredited doctoral degree and have passed a licensure exam. The completion of post-doctoral training under supervision and additional specialty-specific practice and examinations are also required. Providers must also hold a state license. The ABPP is a national certifying body, so this credential is the same in every state.

Professionals who are licensed as counselors, physicians, or psychologists may be licensed in more than one state. States have different continuing education requirements. Licensed mental health professionals are required to maintain current knowledge and practice by completing a certain number of CE credits every year. This helps people seeking help know that potential providers have met the requirements for education and practice and are familiar with the standards for ethical practice. It also assures consumers that care providers are held to these standards to maintain licensure.

One red flag is when a clinician’s status does not match their education level. For example: John Doe, MA is listed as a “registered psychotherapist.” This does not reflect the licensure status for a master’s-level clinician. That certification would be LPC, LCPC, LPCC, or LMHC, depending on the state. Another example: John Doe, PhD is listed as an LPC. LPC reflects master’s-level study, not doctoral level study.

There could be many reasons for such a discrepancy. Many of these reasons pose no problem, but some do. A short-lived discrepancy may simply reflect the period of transition while a recent graduate completes post-degree hours under supervision. But it may reflect something more concerning. It may mean there is some reason the person is not eligible for the license that best reflects their  degree. Perhaps John Doe’s degree is actually in biology, but he decided to change careers. Since his degree is not relevant and does not reflect training in the field, it does not make him eligible to be licensed. Or perhaps John Doe received a PhD from a nonaccredited online university. Because this would prevent him from meeting minimum standards for licensure, he’s practicing under a license reflecting his master’s-level training. Again, this may be nothing to worry about. But some people may wish to ask potential providers about certifications before choosing to receive services from them.

Be aware that it’s perfectly reasonably to ask any potential providers about their training, clinical background, experience, and license. By doing so, you are being an informed and conscientious consumer of mental health services. Wise clinicians will encourage this type of consumer advocacy and gladly answer your questions. We want to help you find the best provider for your needs. We know a good fit is a critical element in successful therapy outcomes.

Best of luck in your search!

* Editor’s Note: The above list is not, nor is it meant to be, an exhaustive list of all mental health credentials and degrees. Credentials, degrees, and licensing requirements can vary from state to state and country to country. On September 17, 2014, the GoodTherapy.org editorial team edited the above list to include LCSW, which was not included in the author’s original list.

When a friend or loved one has been impacted by a traumatic event, it can be distressing and confusing to stand with them and watch them try to deal with the effects of such an experience. It can also feel overwhelming to the person trying to help or support when they don’t feel as if they have the tools necessary to respond to the traumatized person.

If you are wondering what you can do to be supportive to a person dealing with a recent trauma, here are some places to start:

1. Listen. Telling our stories is powerful and healing for human beings. It helps us to make sense of what has happened, to consolidate our memories of the events, and to feel heard and supported. Doing what we sometimes call “active listening” can be really important to survivors of trauma. This means devoting your attention to the act of listening carefully—without judging, interrupting, or making self-referencing comments. Asking questions is, however, an important part of active listening, as it shows that you are interested in getting the details right.
2. Don’t judge. Try to assume a stance of curiosity about the person’s story. Judgments are a heavy burden that trauma survivors become all too familiar with. Don’t add to this burden. Often, the person is struggling with internal judgments about the trauma and their reaction to it. You can help by simply supporting the person without implying that they should (or shouldn’t) have done something differently, that they did the right thing or the wrong thing, or that there was anything about the event(s) that was good or bad. The words in italics are words to avoid when discussing with a survivor the event(s) they are dealing with and/or how the person is coping in the aftermath.
3. Don’t pathologize. It is normal for human beings to feel grief, pain, rage, despair, and/or fear after a traumatic incident. Often, people will work through this on their own after a period of time, come to understand the event(s) in a way that works for them, and resume their typical engagement in everyday life. Give them a few weeks—don’t label what they are going through or make it sound like an “illness” or “disability.” As therapists, we don’t view having this response itself as problematic; we start to see a problem only if, after a couple of months, these responses are still interfering with the person’s ability to engage in daily life. In that case, you may wish to speak with the person about finding some professional support, but do so in a nonjudgmental way that is open to and hears the person’s thoughts about this.
4. Take care of yourself. Being a support person for a person dealing with deep pain can in itself be distressing and overwhelming. Sometimes this can even result in what we call “secondary traumatization”—feeling the effects of the trauma yourself. Give yourself permission to do the little things that nurture you and bring joy as you provide support to a person in distress. Be mindfully aware of your own level of distress, energy, and need for support. Learn a little bit about normal trauma responses (such as avoidance, arousal, and intrusions) so that you can understand what is happening. If you feel it might be helpful, you might consider seeking professional support for your own needs and keep yourself grounded. Give yourself permission to feel distressed, frustrated, overwhelmed, or confused, and take care of your own needs about this so that you are able to continue to be supportive when you would like to without making the trauma-affected person the target of your own pain or frustration—this can be a difficult cycle that causes more pain for everyone.

Navigating the aftermath of a traumatic event can be difficult for everyone affected—those directly involved in the event and those in the position of continuing to love and support people through their pain and grief. These tools are a place to start for those of you wondering how best to support a traumatized person. It is important to remember that being such a support person is a wonderful gift and a difficult place to be, and to give yourself the permission to struggle with it, to care for yourself and your needs during this time, and to seek your own support and care when you need it.

Last month I wrote about avoidance, one component of trauma-related struggles for many people. Another one of the primary things therapists consider when exploring trauma-related problems is what we call “re-experiencing.” When the natural healing process after a traumatic experience does not go smoothly, one of the things that many people will find themselves struggling with is the fact the memories of the traumatic event won’t seem to settle in and fade into the background, instead remaining very charged and intruding frequently into day-to-day life—re-experiencing.

Re-experiencing happens in a few ways. Some people find that they have unavoidable nightmares related to the event. This can be so distressing that some people find they avoid going to sleep at all. Others find that thoughts about the event and its aftermath trespass unbidden in their minds during their waking hours; we call these “intrusive thoughts.” Some find that memories from the event pop up and that they cannot control when and how these memories occur, sometimes in response to specific environmental cues and sometimes seemingly at random.

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When these types of memories begin to plague a person, they can be quite distressing. This is because the way our brains form memories during a critical incident is physiologically different than the way they form the more pedestrian memories of our day-to-day lives. When the memories associated with a traumatic event are formed, they tend to be stored as sensory memories: we remember the sights, the smells, and the sounds the way we experienced them during the event. The part of our brains that stores these memories does not comprehend language and it does not read clocks—there is no sense of orderliness or reason about the memories, and there is no sense of relative distance in time. When the memories occur, our brains interpret it as an urgent sense of danger and distress in the present moment, and the sensory nature of the memories adds to the sense of urgency associated with them.

While our logical brains recognize that the memories don’t make sense and are not rational, they cannot communicate this to that part of the brain reacting to the sense of urgency created by the memories, since they do not comprehend the orderly, reasonable input of language created by our rational brain. This dilemma—understanding that there is no comprehensible or logical reason to feel distressed, yet feeling extremely distressed and trapped by the memories that won’t stop intruding—can itself be extremely distressing to the trauma survivor, who may feel like he or she is “going crazy” or “losing it” when the memories and distress they engender won’t abate.

If this overwhelming cycle of re-experiencing, distress, and confusion about what’s happening is causing difficulty for you or a loved one, it’s important to know this: you AREN’T crazy and you AREN’T losing it. You are experiencing a normal response to an abnormal event. However, if after a few weeks have passed the memories still intrude with urgency, it may be that your normal healing process has become stuck. In this case, speaking with an experienced therapist skilled in this area may be a good choice for you.

Moving forward from this place can feel overwhelming for some, but know that it most certainly is possible. It won’t always be easy, and confronting those memories requires courage. However, doing so in the safe and contained therapeutic environment can be very effective in helping the brain get the memories sorted out and “put away” in an adaptive and functional way so that they no longer intrude on and disrupt day-to-day functioning. It is worth the investment of time and energy it will take to move on to a place of healing and put the past where it belongs—in the past.