Online Counseling Services

We do everything online. Shop, pay bills, talk to our medical doctors, and talk to mental health professionals. Online therapy has had a lot of tomatoes flung its way, but the research speaks to its effectiveness in multiple situations.

Regardless of therapeutic platform, the relationship that therapist and client build together is the most important factor in successful therapeutic outcomes. Other factors that contribute are the client’s belief that therapy will help, the clinician’s ability to build rapport, and finally, presenting problem, and method of approach.

As early as 2012 research had indicated that online therapeutic relationships aren’t any less deep or rewarding as those formed in the in-person setting (Sucala et. al., 2012). This particular concern about online therapy isn’t something I’ve had an issue with. Not every counselor is right for every client; it is essential to get that “click” between counselor and client. Sometimes I’m not the right person for the work ahead. This happens in my online practice just as rarely as it happens in person.

The research questions we need to ask are, “What are effective online therapists doing? What skills do they have?

Not every mental health counselor belongs in the online environment. It requires a bit of tech savvy, the ability to communicate well in text and email, and to troubleshoot on the fly. That isn’t a set of skills that some therapists have or even want. Not all modalities translate well into the online environment either. Some have specific research support in the online environment like cognitive behavior therapy, and some just translate the mediums better.

Clinician flexibility is a must! Our ability to adapt is important in the in-person setting as well. Far too many times I encounter tales from clients and other clinicians alike that reveal the hazards of ill-equipped therapists in the online environment.

Thankfully, I grew up a product of the email and chat room generation. I mastered text as that technology became more common. Some of these skills have come in very handy in communicating across different tech platforms with my clients. Its not that my old “yahoo chat” skills made my clinician game strong – its that my ability to read between the lines of text on a screen, and to deliver text on a screen is a bit finer tuned than someone else’s who didn’t have that experience.

You know that person who always thinks you’re angry in text? I’m not usually that guy. I’m also not the guy who sends texts that come off as forceful. A therapist’s ability to be genuine, admit mistakes, seek feedback, and monitor therapy progress help determine outcomes too. Any ethical therapist is going to do these things in order to work with the client, regardless of medium.

Not all clients are suitable for online therapy. Crisis situations, recent suicide attempts or plans, and other considerations may mean that in-person help is the place to address particular issues. An ethical therapist will refer someone not suitable for online therapy to local resources.

Any ethically practicing therapist will utilize research proven means of intervention regardless of the platform through which they’re delivered. Research about what interventions are most helpful in the online environment are developing and its important for clinicians to stay up to date on this information.

“E-therapy” has been shown to be effective for a variety of issues (Barak et. al, 2008). Anxiety, depression, and the variations thereof have research support. In my practice I have case study support for a variety of more detailed issues. As an ethical and licensed therapist, I’m not willing or able to practice outside the realm of my expertise. If a problem doesn’t fit well in the online environment, I refer it out. Most counseling interventions used during counseling can be successfully transferred to online chat according to Barak et. al, (2008).

There are some clear benefits to online therapy:

  • Access in rural areas is increased
  • Access to qualified clinicians at a broader range of hours
  • Enhanced privacy for clients (no car to park in a therapist’s lot)
  • Fees for online services may be lower than for in-person sessions as overhead costs are reduced
  • Lower fees increase accessibility to services
  • No travel of any distance to a counselor’s office
  • Appointments can occur outside normal business hours which enhances convenience and accessibility

The factor that rates highest in the research as the most important factor in successful therapy outcomes is that of the therapeutic relationship or alliance. This alliance occurs and is part of the healing process and work that takes place in therapy. The ability to get online and fish from a much larger pond of professionals increases the likelihood that someone will find their ideal match. That match may just make the difference.

Finding a good online therapist is the same as finding a good one in person:

Examine credentials and education
Research the clinician through their state licensing board
Find out what professional organizations the therapist belongs to and review their ethics code (For example, I’m a member of the American Counseling Association and the National Board for Certified Counselors – both have ethics codes and so does my state. I adhere to all three.)
Ask questions about expertise and experience
Speak up and change counselors when in doubt

For more info check out this blog on finding a good counselor and this one on the differences in mental health professions.


Sucala, M., Schnur, J. B., Constantino, M. J., Miller, S. J., Brackman, E. H., & Montgomery, G. H. (2012). The Therapeutic Relationship in E-Therapy for Mental Health: A Systematic Review. Journal of Medical Internet Research14(4), e110.

Azy Barak, Liat Hen, Meyran Boniel-Nissim & Na’ama Shapira (2008) A Comprehensive Review and a Meta-Analysis of the Effectiveness of Internet-Based Psychotherapeutic Interventions, Journal of Technology in Human Services, 26:2-4, 109-160, DOI: 10.1080/15228830802094429

Questions to Ask Your Mental Health Provider

In keeping with my theme for this week – some more helpful info on choosing a mental health professional to work with.

You’ve been looking for a mental health professional and you’ve found one that speaks to you. You know that you prefer talk therapy as your treatment, so you’ve narrowed it down to therapists who provide it. Now what?

Contact the professional you chose and ask some questions!

  1. What is your degree in?
  2. What license do you hold?
  3. Who issued your license?
  4. What professional organizations do you belong to?
  5. I think my main issue is __________. Do you have experience working with this?
  6. What is your method or approach to [my issue]?
  7. Do you have any special certifications?

Any professional you reach out to should be happy to answer these questions and walk you through what their typical process is. If they don’t want to answer or don’t have answers to your questions, move to the next person on your list!

Decoding Mental Health Professions

For the last few weeks I’ve been working with a large online provider of counseling to comb through informative and self-help articles for accuracy. Its been a fun project to check through writing, edit, and make sure things are accurate and helpful for those who enter the great unknown of the internet with questions about mental health.

This project has shed some light on things that it would seem (judging off the articles I’m going through) are confusing for people. It adds an additional layer of stress to the hunt for information when every article you click on has contradictory information, uses different words to describe the same things, or has flat out false information.

Here you are, cruising the ‘net, and looking for information or help – and people are slinging useless advice pellets filled with confusing junk at you while you’re doing it. That isn’t helpful at all.

Some Background

My professional organizations, the American Counseling Association (ACA) and the National Board for Certified Counselors (NBCC), both work diligently to a few ends that are applicable to these issues. The ACA urges counselors to use the word “counselor” to describe their work. The thinking is that all the professionals in a field using the same word will help prevent confusion. Sadly, our claim on that word goes into a long list of people who also use the word – and without the education or licensure to do so: camp counselors, financial counselors, legal counselors (lawyers), peer counselors, faith counselors – and on, and on. The ACA has also advocated for its profession and members by working with state legislatures to protect the word “counselor” from misuse and misrepresentation. This hasn’t worked either.

My home state’s answer to this was to grant us and only us the access to use the term “licensed professional counselor”. That is both a mouthful and not much of a move to explain to the public who or what we are. Add to this that in other states “professional counselors” are called something different, like “licensed mental health counselor” (LMHC), and there are hundreds of other license names for the exact same profession across state lines. The ACA and the NBCC are both working hard to create continuity for our profession and a clear sense of who and what we are for consumers, and state boards and lawmakers simply aren’t as cooperative as they could be.

Even right here in Texas there are multiple licensed professionals that use the word counselor.

So today I am writing to demystify and decode some mental health community conundrums.

My hope, is that in the vast vacuum of the interwebs, if you are searching for mental health or emotional health help that this article finds you and helps you, even just a tiny bit.

Misunderstood Words

Psychologist, psychiatrist, therapist, counselor.

Can a psychologist see patients? Is a therapist a psychologist? Can a psychiatrist provide therapy? Can a counselor diagnose? All good questions. Some definitions and clarity for you:

Psychologist – a psychologist who uses the title ‘psychologist’ typically has a minimum of a doctoral degree in psychology. Doctorates in psychology vary. Emphasis can be on research (why we do what we do), teaching (a psych professor), or clinical applications (like in therapy). Psychologists who are licensed as practicing or clinical psychologists can provide testing to determine what the problem is when there is one, diagnosis of issues, and treatment. Psychologists don’t prescribe medication. Bottom line: can see clients if licensed, can test and diagnose if licensed, usually has a doctoral degree, works in private practice, clinics, and hospitals.

Psychiatrists (M.D.)– a psychiatrist is a medical doctor who went to medical school and chose to focus on the medical and biological side of mental health. Psychiatrists should have the abbreviation, M.D. behind their names (medical doctor) in most states and will be licensed in their respective states as psychiatrists. They may work in hospitals, clinics, or private practice. Their specialty is in the medical side of mental and emotional health concerns. They prescribe medications to treat mental health conditions, perform diagnosis and testing, and usually don’t provide therapy. They may work with your therapist or your family doctor while they address your mental health concerns. Bottom line: can see clients to diagnose, test, and treat (usually with medication), has a medical degree.

Therapists – this word isn’t “protected”. There are all sorts of therapists out there. Occupational, physical, respiratory…so take this word with a grain of salt and pay attention to the license, education, and eye chart behind this person’s name. This person could and should have any number of licenses: licensed as a psychologist, a professional counselor, a marriage and family therapist, an social worker. Therapists typically don’t prescribe medication (unless your psychiatrist calls himself or herself a therapist). Bottom line: if its a mental health “therapist” they may be a counselor, marriage and family therapist, or social worker using this title. If licensed each has a minimum of a master’s degree and can use talk therapy, treat, diagnose, and assess (depending on state regulations).

Counselor (LPC/LMHC) – this word isn’t as “protected” as it should be. A professional counselor has a minimum of a master’s degree in counseling, counseling psychology, or clinical mental health counseling. They should also be licensed by their state (reflected in the name eye chart) to practice. This may be LPC, LMHC, LMC, and many others. Counselors work with individuals and groups using any number of “talk therapy” methods from cognitive behavior therapy (CBT) to family systems theory. I’ll come back to theories in a later post. Counselors can also diagnose (in Texas, anyway – be sure to check in your state by contacting your state’s board of counseling), provide testing, assessments, and evaluations of many kinds. Counselors don’t prescribe medication, but they will work with you and your doctor should you be on or desire medication to help you with your diagnosis or issues. Counselors work in clinics, hospitals, community mental health centers, and in their own private practices. Bottom line: can see clients for talk therapy treatment, assess, evaluate, diagnose (in most states), and has a minimum of a master’s degree and 3,000 hours of supervised practice before licensure (in most states).

Social Worker (LMSW/LCSW) – Social workers don’t all work for ‘social services’. Many of them work as counselors in multiple settings. A social worker functioning as a therapist or counselor should have a master’s degree in social work at a minimum. “Social worker” isn’t a protected term in the way it should be. Just meeting someone who uses that title doesn’t indicate education or license. Someone calling themselves a social worker may have a bachelor’s or master’s degree. If they are practicing therapy, they should have a master’s degree and a license issued by their state. Bottom line: social workers working as therapists should be licensed by their state and have a master’s degree. Individual states will have regulations about diagnosis. Social workers are typically trained to deal with more basic needs (safety, etc.) while other types of therapists are trained to deal with higher order needs. See Maslow’s Hierarchy of needs for a picture of this. Counselors and marriage and family therapists focus on the top half of that triangle, social workers on the bottom half in most of their educational programs.

A special note on “coaching”. Life coaching and other popular forms of “coaching” aren’t, at the time of this writing, regulated by any state licensing board. A coach may have any education from high school equivalency to a master’s degree, from a certificate in coaching to none at all. The coaching profession has several organizations and people who issue trainings and certifications in it, and anyone can get one and open up a practice as a life coach. If you want to work with a coach, try finding a counselor or social worker that offers coaching services. At the very least, ask questions and do research before you sign up with a coach.


If you want or need medication-based intervention for mental health struggles your first stop should be either your family doctor or a psychiatrist. They are typically the only two professions that can prescribe medication. While its ideal that a psychiatrist oversees your medication treatment for mental health matters, it may not always be possible. There is a shortage of psychiatrists in my home state (Texas) and few of them here accept insurance. This means that many times going to your regular family doctor is the best option.

A Final Thought

Any professional you go to for help with your mental health concerns should be willing to answer questions from you about their education and qualifications. If you go to work with any sort of ‘therapist’ – counselor, social worker, or psychologist, ask what theory or method they use when working with clients. If the person you contact doesn’t want to answer questions, keep looking.

If you’ve got questions relating to the counseling profession or mental health professions in general, I’d love to hear them in the comments.

Happy hunting!



By using this site you agree that you are not receiving psychotherapy or counseling services through the viewing of this site. You acknowledge that contact forms are delivered via email and that email contact is not completely secure or fully encrypted.

“Sitting” with Painful Emotions

When strong emotions like fear, sadness, anger, and other “hurts” come up, they can be painful. Feeling these emotions is painful, so many of us choose not to really feel them. They’re there, the event that triggered the feelings is still there, but most of us immediately try to get rid of them. We distract ourselves with alcohol, a movie, TV, drugs, friends, sleep – any number of things that are little escapes from the pain.

We’ll turn to anything to get “rid” of the feelings, but we really aren’t getting rid of them at all. We ignore and distract and dismiss. Its natural to want to reduce suffering and avoid pain whether it is emotional or physical. Its difficult to accept emotional pain and do nothing to stop it or fight it.

A lot of us learn from parents and early caregivers that having “fits”, bottling up, distracting, stuffing emotions down, or even using substances or engaging in self-harm is the way to handle painful feelings. We’re often taught as children that expressions of anger or disagreement or hurt can only be expressed in certain ways or not at all. When that carries into adulthood, problems develop.

We think that we’re minimizing pain with whatever behavior we’re engaging in, but really we’re amplifying it. In to short term a drink or self-harm may feel like it stops or releases or relaxes the emotional pain we’re in, but in the longer term, the pain spikes. Guilt or shame about self-harm, substance use, or knowing we didn’t “deal with” an issue can strike. Emotions that aren’t experienced and expressed are sort of stored for a later time. The emotion and its related pain stay present, having never really been allowed to surface and be addressed.

When we fight painful feelings, we judge it, push it away, avoid it, and then it triggers other painful emotions. It amplifies over time and through continued use of poor coping mechanisms we usually don’t develop the healthy coping mechanisms we need to properly address emotional pain in the future.

Sitting with uncomfortable emotions is the key to really allowing them to pass. This means allowing them to happen, not judging them as good or bad (or inconvenient or anything else), not judging ourselves for having them, and resisting the pull to get rid of them as quickly as possible.

An example:

A week ago you and your cousin made plans to spend time together and see a movie, but he cancels when another friend offers he and his wife a gift certificate for a hotel and dinner that had to be used that same weekend. Your feelings are hurt because you made plans in advance and were looking forward to the time with them, and ultimately you feel like you got dumped because they got a better offer.

You might be telling yourself, “It makes sense that he’d go because it’s a rare opportunity; I’m stupid for feeling hurt; I need to get over it.” That sort of thinking and self-talk creates additional feelings of frustration and anger with yourself on top of the original hurt. Pause instead and spend some time sitting with your feelings. That sort of thinking or self-talk would look like this, “It makes sense that I’m hurt because I was really looking forward to our time together; I feel hurt that he chose the weekend getaway over me, and its OK that I feel that way, most people would.”

While this different manner of self-talk and thinking won’t stop the pain, they do prevent addition of more pain.

Here are 3 tips for sitting with emotions:

  1. Observe emotions. Sit with emotions by noting what emotions are there and what you’re experiencing. Using the example above, this might sound like, “I’m feeling hurt that my cousin chose to go on the dinner and hotel night instead of spending the planned time with me. I’m worrying that this means that we aren’t close. I feel like I want to cry. Now I’m noticing that I’m judging myself because I don’t want to cry. I feel anger that I want to cry. This is uncomfortable, but I’m alright. I can tolerate this. This is temporary.”
  2. Validate emotions. Validating emotions is to accept them. You don’t judge them, so no additional pain is triggered. Refusing to validate emotions might have us tangled up in additional judgement. Refusing to validate can have us saying things like, “Damn, I feel angry with my cousin, and I’m so sad that I want to cry! What is wrong with me? He’s my cousin and I know I’ll see him some other time!” With that comes self-judgment, anxiety about the relationship, and more pain. If you validate that would look more like, “I’m angry and sad about my cousin choosing to break our plans right now.” From there you can focus on problem-solving. “Do I need to discuss this issue with my cousin?” Or, maybe you’re just especially sensitive to this because of other things going on in your life, and those issues and related emotions need to be dealt with first.
  3. Focus on present. Focusing attention on the present instead of spending time in the experience or event that has just passed and created the painful feelings can be helpful. Fixating on the feeling may involve focusing on the feeling or on the details of what happened, when there are things going on in the present moment that will be helpful to focus on. Pick a few things in your moment to observe: things you can hear, see, touch, taste, and smell. Yes, the event happened and created some painful feelings, but you’re in this moment right now – and this moment is ok! Find a few things about the moment you’re in to refocus yourself.

Sitting with emotions is difficult. That’s why so few of us do it! It is a skill that can be developed over time with practice. Allowing yourself the time and space to try can be very beneficial!


Do You Self-Sabotage?

I hear about self-sabotage from my clients pretty frequently. Its true that we self-sabotage at times; we all do things that make little sense in retrospect or bring about the exact opposite of what we were hoping for. Sometimes we do things in direct contradiction to the goals we’ve got our sights on.

Before diving into working on self-sabotage, I invite you to consider that it isn’t so much “sabotage” as it is self-protection. Everyone has a survival instinct built into their brains, and it gets activated by fear. It kicks into action to try to protect us from getting hurt or experiencing pain. This survival and protective fear response is really helpful if we’re being threatened and need to fight, flee, or faint to protect ourselves.

Throughout our lives we have various experiences that can teach us to re-program that response. It stops kicking in only when we’re physically in danger and can start to activate when we’re threatened with emotional hurt too. Sometimes we internalize (after painful experiences) the ideas that certain emotions are bad, unbearable, or can’t be handled. Emotional injuries do hurt, after all.

Over time we may find ourselves operating from those ideas, which means that our protective stress response comes in and promotes thinking and behaviors as if there is a physical threat, when in reality our fear of emotional pain has caused us to switch into survival mode. This mode draws us into behaviors that we sometimes label as “self-sabotage”.

Areas You Self-Sabotage

Relationship based self-sabotage is common. We naturally don’t want to be hurt by those we love and care about. Finding the beliefs you internalize that may have you acting in ways that aren’t helpful or supportive to your relationship goals is a first step toward addressing self-sabotage.

Below are some beliefs that might trigger fear or resistance to taking action that supports you, your relationships, or your goals:

• I’m not lovable.
• Once someone knows me, they’ll leave me. I always get left.
• I’m not relationship material.
• I will lose my freedom. I have to give myself up to keep the relationship.
• Being rejected is too painful to handle. I don’t want to take the chance of being hurt.

For a lot of people, fear of rejection is a primary motivator for self-sabotage.
Work related self-sabotage is also linked to fear of rejection. Below are some beliefs that may trigger self-sabotage when it comes to work:

• If I fail, it means I’m stupid and worthless. Everyone will think I’m stupid.
• Everyone tells me to work and succeed at work. If I don’t I will let them down, so I better stay small and stay in my “lane” or risk failure.
• I deserve to start at the top and won’t take anything less.

There are many thinking patterns and beliefs that can stop us from taking the right action or keep us stuck. Spend some time thinking about your thought processes in relationships and work. Identify thinking that may not be helpful to you. You can also check out this list of cognitive distortions to dig into this issue further.

Some other fear based beliefs that may keep you stuck:

• Success or failure defines my worth as a person.
• I’m an inadequate person.
• I can’t handle rejection.
• I have to give myself up to be loved.

How You Self-Sabotage

Self-sabotage can look different for each of us but some common patterns may be:

• Keeping yourself isolated.
• Rushing into relationships.
• Giving yourself up to the point of resentment in relationships; becoming angry due to feeling like you’ve lost yourself, and then ending the relationship intentionally or overtime with angry outbursts.
• Not sharing yourself enough to create real connection.
• Putting off looking for work you really want.
• Staying in a job you hate. (Resentment builds, anger starts, you begin to lose yourself, and may quit or become ill from the stress associated, leading to issues at work.)
• Giving yourself up at work, allowing yourself to be used, not setting clear times for work and home or fun.
• Keeping yourself uneducated or refusing opportunities for learning, promotion, and growth, which stops you from doing what you really want to do.

Getting Unstuck

• Pay attention to self-judgements. Self-judging is a big factor in self-sabotage. When you notice self-judgement and ask your logical, rational, Spock-like self what the higher truth really is.
• Examine whether your definition of self-worth comes from “success” or effort. Decide and commit to defining your worth by the loving acts you put into the universe and toward yourself, rather than the outcome of “success”.
• When experiencing failure, note what you feel you’ve “failed” at and be intentional about looking for successes. Maybe your sales pitch didn’t get a lot of products sold, but it did provide practice for your craft, new contacts, etc. Look for opportunities to learn more, for areas you may want to grow in.
• Learn to be as compassionate to yourself as you are to your friends and loved ones. When you are able to allow feelings of pain to come and be met with kindness toward yourself rather than self-blame and self-judgment for them you will start to embrace a higher truth. You’ll show yourself you’re willing to take loving action toward yourself.

Doing the work of introspection, thought monitoring and challenging, and building tolerance to the distress of your fears, is difficult – yet empowering. It is a high form of self-love, and will help you on you way to loving relationships and happier work experiences.


Green Time

Spring is here and summer is on the way. Every store in town has plants for sale along with all the plant food and gardening tools we could possibly need. The weather is finally pleasant enough that most of us are able to get outside and enjoy it. The bright colors of flowers and leaves and the warmer weather aren’t just pleasant to our senses – they have some pretty impressive health benefits too.  

Countless studies have shown that spending time in nature and outdoors is good for us generally. Some studies have looked specifically at the healing powers of nature and “green time” like gardening and found that views of nature from hospital rooms and even paintings or pictures of nature in hospital rooms can speed recovery time following surgery. Its true that nature is great medicine!

With the season for all things plant and garden at hand, here are some awesome reasons to get outside to play, plant, read, or walk.

1.       Gardening increases life satisfaction, vigor, psychological wellbeing, sense of community, and cognitive function. Plant some things at home or find a community garden run by a local group or church where you can spend some time!

2.       Gardening decreases stress, anger, fatigue, and symptoms of depression and anxiety.

3.       Gardening can also help reduce Body Mass Index or BMI for those concerned with health related to weight and BMI.

4.       Just walking in nature can lead to lower risk of depression. Most people live in city and urban areas and as such more and more of us are away from nature and sources for quality green time. City dwellers are at a 20% higher risk for anxiety, and 40% higher risk of mood disorders compared to people in rural settings. People born and raised in cities are twice as likely to develop schizophrenia. Living in a more urban setting doesn’t have to get you down – having house plants, planting trees where you’re allowed to, and visiting community parks and gardens can do the trick.

5.       Spending time outdoors is grounding. The earth is a pretty solid thing. When we experience overwhelm or feel lost, digging in the dirt, hiking through hills, and spending time outdoors can reconnect us to things that don’t change.

I’d love to see pictures of your gardening projects, hiking trips, and hear how “green time” has impacted your life!

Some Resources:

Soga, Gaston & Yamaura (2016). Gardening is beneficial for health: A meta-analysis. doi:  10.1016/j.pmedr.2016.11.007

Gigliotti C.M., Jarrott S.E. Effects of horticulture therapy on engagement and affect. Can. J. Aging. 2005;24:367–377.

Gonzalez M.T., Hartig T., Patil G.G., Martinsen E.W., Kirkevold M. Therapeutic horticulture in clinical depression: a prospective study of active components. J. Adv. Nurs. 2010;66:2002–2013.