Monthly Archives: January 2022

Stress vs. anxiety vs. burnout: What’s the difference?

By Lindsey Phillips January 26, 2022

A 43-year-old woman is having trouble sleeping at night. She opened her own business six months ago, and she works 50 hours a week, which leaves her little time to take care of things around the house. On top of that, her 71-year-old father is showing early signs of dementia, so she carves out time in her already-overpacked schedule to check on him throughout the week. 

It’s only natural that some things are slipping through the cracks. She missed her son’s play last week because of a work project, and as a single parent, she feels guilty if she takes even one minute for her own self-care. These stressors are affecting her personal relationships, and she no longer has time to hang out with her friends — her one source of support. 

These cumulative stressors leave her feeling overwhelmed, so she seeks counseling. During the first session, she tells the counselor that she is feeling stressed and exhausted and doesn’t know what to do. The clinician now has the difficult task of helping the client decipher if she is struggling with stress, anxiety or burnout. 

This task is further complicated by the fact that clients often conflate or confuse these issues. Julianne Schroeder, a licensed professional counselor (LPC) in Colorado and Texas, finds that clients often use the terms stress, anxiety and burnout interchangeably or flippantly — “I’m stressed,” “I’m so busy,” “I’m overwhelmed,” “I’m so burned out,” “Oh, that’s just my anxiety” — to the point that they often come to counseling unsure of what they are actually dealing with. 

There is an inherent danger when casually using these phrases, she says, because they socially reinforce the message that it is OK for people to endure constant cycles of stress and burnout. In fact, Schroeder often hears clients say, “I have a lot going on right now; it’s just stress.” But as they start to peel back the layers of negative self-talk and unhealthy core beliefs — such as not being “good enough” — that are feeding these stressors, she often finds these clients are dealing with a more serious issue such as anxiety or burnout. 

Is it stress?

Symptoms of stress and anxiety often look similar, but Schroeder points out one key difference: The source of stress is often external, whereas anxiety tends to be an internal response. Schroeder owns a private practice in Denver and works as a counselor at The Mindful Therapists, a group counseling practice with locations in Oak Cliff, Texas, and Denver. 

“Stress is the general experience of physical, mental, emotional [and] relational factors that cause the person and nervous system to feel overwhelmed,” she explains. With stress, counselors may hear clients say, “I have a lot going on right now,” but with anxiety, they might say, “I have a lot going on right now, and I don’t know how I’m going to handle it.” 

“Stress can come on somewhat suddenly [or] without warning,” notes Siobhan Flowers, a member of the American Counseling Association whose specialties include stress management, anxiety and life transitions. “It’s typically more short term in nature, and ideally … once the stressor is removed, then not too long after that, the stress symptoms can noticeably decrease.” 

Flowers, a licensed professional counselor supervisor (LPC-S) in Texas who also holds a doctorate in counseling, considers stress separate from anxiety because anxiety symptoms often continue even after the stressor is removed. She adds that anxiety can cause significant impairment such as panic attacks. 

Schroeder describes the physical signs often associated with stress as including muscle tension, jaw clenching, fatigue, headaches, restlessness, and general aches and pains. Emotional symptoms include feelings of overwhelm, frequent instances of being emotionally reactive, racing thoughts, forgetfulness and impaired problem-solving. Behavioral signs may include decreased sleep quality, changes in appetite or weight, substance use and sexual difficulties. 

Both stress and anxiety involve a sense of urgency and a desire to keep trying to “fix” the issue, says Keri Riggs, an LPC-S at New Directions Counseling and Wellness Center in Richardson, Texas. She often helps clients unpack what they mean when they say they are “so stressed out” or “overwhelmed.” She asks them to describe what they mean by these terms, where they feel the stress in their body and how the stress manifests in their life. 

Next, Riggs discusses the frequency, intensity and duration of stress symptoms with her clients to better assess the issue. She asks if they perceive their stressors as mild (e.g., being late to work), moderate, severe or catastrophic (e.g., dealing with the aftereffects of a hurricane). Multiple stressors can also compound issues, so Riggs talks about the different areas of life that can cause stress in clients: Is their stress primarily financial, relational, work-related, health-related or spiritual? She also explores if the source of their stress is acute (e.g., a flat tire) or chronic (e.g., an autoimmune disease, domestic violence, ongoing workplace stress). 

Is it anxiety? 

Besides being more of an internal response, anxiety differs from stress in its intensity and duration. Physical symptoms, Schroeder says, can include elevated heart rate, nausea and stomach pains, rapid breathing or shortness of breath, trembling or shaking, and exaggerated startle reflex. Constant worry, rumination and racing thoughts, feelings of helplessness, fear and panic are among the emotional symptoms. Behavioral symptoms include insomnia or disrupted sleep, changes in appetite, substance use, inability to complete normal daily functions, and a higher likelihood of avoidance of people and activities that cause distress. 

“The lack of belief in one’s ability to cope, utilize internal and external supports, and enact problem-solving and self-regulation skills is what separates a diagnosis of anxiety from stress,” explains Schroeder, who is also a registered teacher of therapeutic yoga. 

Riggs, an ACA member whose specialties include stress management, anxiety and women’s burnout, points out that anxiety is future focused. It’s about the “what ifs?” If a client has a flat tire and is late for work, for example, they may start worrying that they will lose their job because they were also late last week when their child was sick and because they haven’t been performing as well lately. This client quickly moves from the stress of the flat tire to the possibility of their boss firing them. This anxiety-laced thinking is the result of cumulative stressors from the past week and the client’s own internal beliefs of not being good enough. And that, Riggs acknowledges, can make it challenging to untangle stress and anxiety during assessment. 

Amanda Ruiz, an LPC in Pennsylvania, often works with clients who are stressed at work and home and feeling overwhelmed in a variety of ways. They feel lost, and although they know they are not in a good place, they are unsure of how to sort it out, she says. This feeling of being overwhelmed often manifests as anxiety: They’re not sleeping well, they’re having racing thoughts at bedtime, they don’t feel they have time for self-care, and they have poor boundaries. 

These clients come to counseling because they realize something is off and they want help, but they don’t necessarily come in using the term anxiety, adds Ruiz, an ACA member. Instead, they might say they are “overwhelmed,” “stressed” or “being pulled in too many directions.” Ruiz helps clients understand what anxiety is and how they may be experiencing it without realizing it. She sometimes reads out the symptoms for generalized anxiety disorder or the definition of anxiety in the Diagnostic and Statistical Manual of Mental Disorders and asks clients if that sounds like a more appropriate description for what they are experiencing rather than just being “overwhelmed.” 

Ruiz, founder and mental health therapist at The Counseling Collective in East Petersburg, Pennsylvania, also uses anxiety assessments such as the Generalized Anxiety Disorder scale and the Patient Health Questionnaire not just for diagnosing but also for educational purposes — to help gather a quantitative baseline for clients. She asks clients to retake these assessments every three to four months to see whether and how they are improving. After taking an assessment, the client discusses the results with Ruiz, and she often asks how accurate the assessment feels to them. Having clients see their own progress is also an effective strengths-based approach, Ruiz adds.

Stress and occasional anxiety are expected parts of life, but if they aren’t addressed, they can both escalate into more serious mental health issues such as anxiety disorders. According to the Anxiety and Depression Association of America, anxiety disorders, which include generalized anxiety disorder, panic disorder, obsessive-compulsive disorder and posttraumatic stress disorder, are the most common mental illness in the United States, affecting 40 million adults ever year. 

Ruiz says potential signs that a client may be dealing with an anxiety disorder include persistent worry that lasts for several months, panic attacks, and symptoms that interfere with normal daily functioning (e.g., insomnia rendering someone unable to go to work). 

Clients will often notice a decrease in stress and anxiety symptoms within six months of counseling, Ruiz says, unless their condition is more severe. She often does a reassessment six to nine months into counseling, and if the client’s anxiety is still high despite implementing coping strategies such as healthier boundaries and self-regulation, then she will explore the possibility of an anxiety disorder or the need for medication with the client. 

Is it burnout? 

Burnout is not a condition that happens suddenly; it evolves over time, Flowers says. If left untreated, stress develops into chronic stress and eventually crosses over into burnout. Stress makes people feel that they have too much on their plate, but burnout makes people feel depleted, like they have nothing else left to give, she explains.

Flowers, owner of Balanced Vision, a private practice in Plano, Texas, has found that phrases such as “I’m in survival mode,” “I’m exhausted” and “I’m done” often indicate that a client is experiencing burnout.

Schroeder says people typically experience a spike in stress or anxiety for a long period of time before burnout manifests. She explains burnout as the fallout from a stressed and overwhelmed system. “Our bodies are not meant to stay in hyperactivation or fight-or-flight long term,” Schroeder says. If it does, then “the body … goes into protection mode — aka burnout.” 

Physical signs of burnout are similar to those for stress and anxiety, Schroeder notes. They include fatigue, insomnia or interrupted sleep, changes in appetite and caffeine use, tenseness or heaviness in the body, and increased frequency of illness. Some of the emotional and behavioral symptoms are irritability, feelings of apathy or numbness, sarcasm, debilitating self-doubt or self-criticism, lack of motivation, procrastination, isolation, self-medication or numbing with substances, the potential for disordered eating, and loss of enjoyment for life. 

Riggs says that burnout is often about disengagement — both physically and emotionally — and depersonalization (e.g., “What’s wrong with me? I don’t feel like myself.”). It is more internally focused, she adds. Clients struggling with burnout may be mad at themselves for not handling their stressors better. 

One of Riggs’ colleagues once described burnout as “death by a thousand tiny cuts.” It’s not often that one thing causes burnout, Riggs says. Rather, it is the culmination of several stressors that slowly build until the person can’t manage anymore. 

One way that Riggs helps clients gain greater awareness of the intensity and duration of their current stressors is to have them create a timeline. For example, a client may note that for the past four months, they have been 1) worrying about their child who is being bullied at school, 2) attending to a sick or older family member, 3) having panic attacks at work and 4) struggling with the pandemic. The timeline serves as a visual reminder of how much they have been carrying mentally and emotionally and indicates that they may be dealing with more than just a typical amount of stress, she says. It also helps clients begin to make sense of their experiences and be able to engage in self-compassion rather than self-loathing or self-blame, she adds.

Flowers, an adjunct professor of counseling at New York University, also guides her clients to be aware of all the stressors present in their life. She often asks clients to rank those stressors, from the ones weighing on them the most to the ones affecting them the least. This strategy gives clients a road map for which stressors to address first. Flowers has noticed that when clients relieve the pressure of one stressor, that action often trickles down and lessens the negative effects of other stressful areas in their life. 

Given the gradual approach and onset of burnout, clients should also adopt a long-range strategy for mitigating it rather than expecting to eliminate it overnight, Flowers says. She finds it best to start this process with an inside-out approach: Clients assess what fundamental or lifestyle changes they can make to improve their present circumstances. Then they can begin to focus on what is within their control and implement gradual changes to sustain their wellness long term, she says. 

Unlike stress, burnout is not something that people have to live with. “Burnout is preventable,” Schroeder asserts, “but everybody is not willing to [sit] with their emotional discomfort of changing [unhealthy] patterns or making hard choices such as implementing boundaries or leaving a toxic work culture or relationship.” Counselors can help clients take preventive steps to avoid burnout, she says, by helping them: 

  • Establish creative outlets and time for fun
  • Increase feelings of autonomy both inside and outside of the workplace
  • Enhance the mind-body connection and real-time awareness of personal limits
  • Identify and enact supportive boundaries 
  • Increase healthy support systems 
  • Engage in activities that support nervous system regulation (e.g., spending time outside, cuddling with a pet, breathwork)
  • Improve sleep hygiene 
  • Be aware of how much mental and emotional energy is devoted to others and work versus self 

Managing stress and anxiety

Stress and anxiety are unavoidable, and as Schroeder points out, it’s often not helpful to try to eradicate stress completely because we need a manageable level of it as humans to keep us motivated. Stress can nudge us to prepare for an important work project, for instance. However, counselors can equip clients with strategies to help them manage and cope with the symptoms of stress, which in turn can act to help prevent burnout. 

Ruiz agrees that the goal of counseling should not be “to eliminate stress but to feel comfortable and confident and competent to face those stressors in a really healthy way [so] that you can move through them and emerge on the other side.” 

“There’s this inverse relationship between stress and your level of control,” Flowers says. “The less in control you feel, the more stressed you’re going to feel and vice versa.” 

Flowers worked with a client who felt out of control and didn’t know how to structure her days and months to implement some form of self-care plan. Flowers had the client fill out her ideal schedule using a worksheet that looked like an appointment book, asking her what her day or week would look like if she didn’t have any stressors. Then the client created her actual daily schedule (including all mandatory obligations), and they compared the two. Flowers helped the client brainstorm ways to incorporate some aspect of her idealized schedule into her current one. For instance, could she carve out 30 minutes a day for an activity that she enjoyed, such as reading or spending time with friends? Did she prefer to carve out significant blocks of time to devote to self-care activities or would she rather schedule them in short bursts (e.g., reserving a few 15-minute time slots throughout the day to go for a walk)? They also discussed aspects of the client’s current schedule that she would be willing to give up if they were no longer serving her needs. 

Flowers typically tries to engage her clients in practical applications such as this in session. The stress management plan gives clients a visual depiction of how to make changes in their life as well as a sense of control over how they spend their time, she says.

Riggs advises counselors not to overlook the impact of past trauma. For example, if a client comes to counseling because they’re anxious about their company being reorganized, counselors may want to avoid jumping straight to the present and helping the client “manage” that anxiety, she says. Instead, clinicians could ask the client about their past experiences with jobs. In doing this, they may learn that this client was laid off previously and it caused them to be evicted from their home and live in their car for two months. The client’s anxiety will probably be higher because of these previous traumatic experiences, which will influence the counselor’s treatment planning, she points out. The counselor also has an opportunity, Riggs says, to talk about how the client got through the previous experience and can tap in to that resiliency to help them plan and prepare for this current reorganization.


Emotion regulation

Although people can’t avoid anxiety, counselors can help clients better manage the symptoms of anxiety and target those underlying factors and beliefs that exacerbate it, Schroeder notes. Clinicians can work with clients on their self-regulation skills and self-talk, she says. Clients may be anxious about saying no to others, for example, or they may have internalized a belief that they are incapable of completing a task or doing something that is challenging.

Schroeder uses role-play to help her clients become aware of how their body reacts to stressors. People often find it difficult to say no to others, which can cause them to take on more than they can handle. To address this, she will have clients respond with a “no” to whatever she says during the role-play — and without clarifying the response (e.g., “No, but I can help you in this way”). For example, Schroeder might assume the role of the client’s boss and ask, “Can you work extra hours this weekend?” The client states simply, “No.” 

While doing this activity, Schroeder has the client slow down and notice how they are feeling in their body when they respond in this way. Did they clench their hands? Was their mind spinning? The next time the client has an unhealthy response, they stop and do a corrective action, such as relaxing their shoulders or taking a deep breath. 

Ruiz advises clients to pause before saying yes to something and consider if they really want to do it or if they are doing it out of a sense of obligation. She also recommends that they respond to requests with “Let me get back to you” or “Let me think about that.” These techniques allow them to be more intentional about how they spend their time and pay more attention to how they are feeling physically and emotionally, she says. 

Overthinking is a big part of anxiety, Ruiz notes, so she often uses brainspotting, a treatment developed to help survivors of trauma. The therapy helps clients bypass the cerebral cortex, the part of the brain responsible for the anxiety response, and process negative emotions without overthinking. Brainspotting works by having the clinician guide the client’s field of vision to find appropriate “brainspots” — eye positions that activate a traumatic memory or painful emotion. Ruiz, a certified brainspotting practitioner, has found this approach allows some clients struggling with anxiety and overthinking to make faster progress. 

Schroeder encourages counselors not to just talk about the importance of stress-reduction skills, mindfulness and emotion regulation but to actually create opportunities for clients to practice these skills in session. For example, Schroeder suggests they could begin or end each session with a simple breathwork activity. The client could breathe in for a count of four, slowly spelling S-L-O-W, and then pause before they exhale for four counts, slowly spelling D-O-W-N. After practicing this a few times, the client could continue this breathing pattern and add in a mantra, such as “I am allowed to take care of myself” or “Rest is productive,” after the exhale. 

Flowers has clients make a list of things they feel guilty about. After acknowledging the emotional aspect of how they are feeling and how these thoughts are contributing to their stress, clients come up with coping statements that counteract these unhealthy thoughts. If clients feel guilty about their performance at work, then the coping statement could be “My level of self-worth is not tied to productivity.” This statement allows clients to see themselves as having worth just for being who they are.

After clients create three to five coping statements, Flowers has them write the statements down or use a notes app so that they will have something tangible to use in the moments when they feel stressed. “These are the types of activities that help prevent crossover into burnout,” Flowers says. “It helps to manage stress. It helps to keep it from going from that level 1 to that level 3.”

Building strong internal and external resources 

Schroeder is always listening for external and internal barriers that may be preventing a client from progressing. If a client is stuck in a toxic work environment, for example, she pays attention to if the barrier to leaving the job is financial (e.g., they need the income to pay rent) or internal (e.g., not feeling like they deserve something better). 

Clients who are overachievers are prone to minimizing and justifying their symptoms, Schroeder adds. They may tell the counselor, “I’m just tired,” “I just need to get into a better routine,” “It’ll be better after X, Y or Z happens” or “I just need to go on a vacation.” When Schroeder hears a client say, “I’m just tired,” she quickly asks what they mean by that. This questioning may reveal an unhealthy negative thought of being “lazy” if they aren’t productive or busy all the time, she notes. 

Riggs works with clients to increase their external resources, such as a support system, and their internal resources. Two important internal resources involve learning to set and maintain healthy boundaries and to better listen to and regulate one’s emotions, she says. Clients need to pay attention to what their body is telling them. If they are getting sick to their stomach on Sunday night before going to work on Monday, then their body is letting them know there is a problem. And if they don’t do something about it, Riggs says, it will become a larger issue. 

The main difference between situational experiences of stress and anxiety and chronic experiences of stress and anxiety is the person’s level of resiliency and ability to tap in to internal resources such as emotion regulation and healthy boundaries, Schroeder says. 

Flowers finds that self-imposed and internal stress often lead to struggles with anxiety and burnout, so she helps clients prioritize their obligations and separate what is really important from what is something they may feel internal (or external) pressure to do. “There’s this myth that balance means [spending] equal amounts of time and energy in all aspects of your life all at once,” she says. Flowers advises counselors to help clients develop a more flexible definition of what balance means. “Balance is fluid; it comes in seasons,” she explains. “There may be a week or a month where you really have to focus on one aspect of your life [e.g., a work deadline], but then the next week or the next month, you can shift and devote more time and energy on this other part of your life [e.g., spending time with family].” This definition is a more realistic and compassionate way of viewing balance, she says. 

Cognitive distortions can also contribute to clients’ stress. Ruiz uses a “mental mistakes” worksheet that contains 12 common mental mistakes (e.g., all-or-nothing thinking, using critical words such as “should”) to help clients think about how their thoughts are affecting their feelings. She has clients star the mental mistakes that apply to them, and then they narrow the list down to the top two or three. Next, Ruiz asks clients to share recent examples of when they engaged in that type of mental mistake (e.g., When did they last disqualify the positive or use all-or-nothing thinking?). With her help, clients can challenge whether these thoughts are accurate and find ways to reframe unhealthy thinking. 

Internal stress sometimes occurs when clients must choose between two competing values, Riggs says. For example, the client might want to take their mother to the doctor, but doing so may cause them to miss their child’s school play. Having to make tough choices like this can wear on a client, she says. She helps clients navigate these difficult decisions and focus on how to make the best choice in that moment. Riggs finds that sometimes people make assumptions about what is expected of them, which only adds to their stress. In reality, the client’s mother might be OK with someone else taking her to the doctor, so the client could clarify the mother’s preference instead of assuming that she would be upset. 

The overlap between the symptoms of stress, anxiety and burnout can confuse clients and counselors alike. In fact, Flowers finds clients often conflate stressors and stress, so she helps them distinguish between the two with the following explanation: “Most of the time you cannot control the stressor because it’s external, but you can control the stress in terms of what is your body’s reaction or response to what is happening to you.” This understanding helps clients see how stressors happen to them but don’t have to define them. 

“We want to get the client to a place where they can respond to a certain situation or an external stressor,” she says, “and be able to look back on that experience and be proud of how they handled it,” both physically and emotionally.



Lindsey Phillips is the senior editor for Counseling Today. Contact her at


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Voice of Experience: Freud may have been right

By Gregory K. Moffatt January 25, 2022

As a young graduate student in a very person-centered program, most of my professors had little to say about Sigmund Freud that was positive, if they even said anything at all. Indeed, psychoanalytic theory is complicated and time-consuming, and much of it was based, at least originally, on Freud’s observations, experiences and speculations rather than on evidence-based study.

But I love Freud. On my office desk, I have a Freud finger puppet, bobblehead and action figure. Not because his theory and its components are correct, but because Freud got us started.

I think of Freud in much the same way that I think of the earliest pioneers in the automobile industry — Daimler and Benz, Maybach, and Ford, to name a few. Nobody would think of driving any of those early models farther than the grocery store or a local car show today. After all, many of them were open cockpit and didn’t have a fuel pump (they had to go uphill backward to ensure a continuous flow of fuel) or electric starter. They didn’t have heat, radios or safety equipment. Even into the 1900s, the windshield wiper, if it existed, was operated by hand.

But the general mechanics of the automobile haven’t changed much since those days. The early pioneers — in automobiles as well as in psychology — got us started hypothesizing. That is why I love Freud.

I can’t deny two major contributions that Freud made to the world of mental health. I’ve used the following line a thousand times in my career: “All behaviors that are dysfunctional, that are not physiological, are defensive.” If I can figure out what people are afraid of, I have a pretty good idea of where to focus my clinical energies. Freud was the first to give us the concept of defense mechanisms, and on this one point at least, I think he was exactly right.

The second of Freud’s major contributions involves our unconscious behaviors. A psychologist who sat in on one of my homicide profiling lectures at the FBI Academy said to me afterward, “This is all so Freudian!” Indeed it was. The idea that we speak through our behaviors is fundamental in profiling, but it is also fundamental in play therapy, which is my clinical area of focus.

We must assume that one’s behavior has meaning that is often outside of the conscious thinking of the individual. That is why profiling works. The perpetrator can’t not do the thing that tells me something about him. He does it intentionally, but not with conscious thought.

To demonstrate this, I often seek a volunteer from a live audience. “Why did you wear that shirt/blouse today?” I ask. I get a variety of answers, and those answers aren’t untrue, but they aren’t the whole story.

“It was all I had clean,” a man might in answering my question.

“Oh, really?” I respond. “So, if it was pink and had pictures of unicorns on it, would you still have worn it?”

Nearly always, the subject laughs. Of course not. The reason he thinks he wore that shirt was in his consciousness, but a deeper reason for why he wore it was outside of his consciousness.

Children do the same thing in my playroom. The toys they select for the sandbox, their arrangement of the toys, and the interaction between those figures is something they must do. Psychiatrist and author Lenore Terr calls this “abreaction.”

Children must tell the story of their abuse, trauma or experiences over and over until they find resolution. Imagine you are driving to work and, on the way, you see a graphic and horrifying car accident happen right in front of you. For days you will tell the story, over and over, as you try to find a place for it and make sense of it. Like the children in my playroom, you are intentionally telling the story but not consciously intending to repeat it over and over. You must tell it.

Over time, as you find a place for that event, you have less and less need to tell the story. Finally, it becomes just a story you tell rather than a story that you must tell.

Regardless of your theoretical orientation and whether you accept the premises that I’ve proposed here, one can’t deny that Freud gave us a lot to think about. Many of his ideas have been shown to be baseless. Interpretations of dreams, for example, even if they do have meaning, have no scientific evidence to support them.

At the same time, maybe Freud was right on a few things. And maybe, just like with the benefits we enjoy because of the basic mechanics of automobiles, all of us are in some way indebted to him.

bilha golan/


Related reading, from the Counseling Today archives: “The value of contemporary psychoanalysis in conceptualizing clients


Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

How to land an internship you’re excited about in 48 hours or less

By Wesley Murph January 19, 2022

The accident happened on a sunny Saturday afternoon.

I was driving home from my internship site, where I had seen clients that morning, when I stopped at a red light. As I changed the radio station on my car’s stereo, I heard screeching tires and crunching metal.

Then, as if I were in a Steven Spielberg movie, a maroon-colored car launched over the back of my car. It landed on its side and skidded down the asphalt against oncoming traffic.

As I stared at the unfolding scene, something big plowed into the back of my car, pushing it into the car in front of me. Glass shards and taillight debris rained down inside of my car.

I glanced in the rearview mirror and saw green liquid spewing from the van that was now embedded in my car. I feared that my car would explode and that I would be burned inside. As quickly as I could, I opened the door on my car and stepped on to the slick pavement. I glanced around to make sure I wouldn’t be hit by an oncoming car and heard a woman screaming from behind the maroon car. I immediately dialed 911.

“There’s been a bad accident,” I said to the 911 operator. “I think people are hurt. Please send help quickly.”

Minutes later, several police cars arrived and began directing traffic. A firetruck and an ambulance arrived next. A first responder said the woman driving the maroon car was shaken up but was otherwise OK. Just to be safe, they were taking her to the hospital.

I sat down on the sidewalk, grateful that nobody was seriously hurt. But when I looked at my car, I knew it was totaled. I also knew I would have to find a new internship site because my site was 60 miles from my home and the majority of clients I saw were in-person.

A few days later, I emailed my internship coordinator at the graduate school I attended and told him what had happened. We met on a video call, and he said it might be three months before I was placed at a new site. “If that happens,” he said, “you may not graduate on time.”

My pulse quickened. I had been in graduate school for nearly two years, and I was six months away from graduating. I needed 150 additional direct client hours to walk with my peers, and there was no way I was going to wait three months to find a new internship site.

So, I put on my marketing hat with one goal in mind: to find a new internship site. I never imagined what would happen, but I am grateful to say that I received five internship offers in 48 hours.

I would like to share what I did so that others looking for an internship site can find one they are excited about. Or you might tweak my campaign to connect with potential supervisors and land a new job.

I can’t guarantee the results if you follow this campaign, of course. But I can say it will help you connect with counselors in your area. It will also strengthen your sense of confidence and freedom by giving you more control over your future.

Google search

The first thing you need to do is find clinical supervisors for whom you want to work.

I played around with keyword searches in Google until these searches brought me to a webpage containing nearly a hundred clinical supervisors in my area. The webpage had a picture of each supervisor, a paragraph about the supervisor, and the supervisor’s email address and phone number.

I carefully read each supervisor’s bio until I found 25 whom I wanted to contact. I then researched the various supervisors using Google to find out more about each person. I went to each supervisor’s website, if they had one, and read their “About Me” page. I wanted to make sure that I genuinely connected with each supervisor before reaching out to them in an email.

I recommend that you complete this step too. Research the clinical supervisors in your area until you have a list of folks you want to work for. Really get to know these people. What clinical theories do they practice? Have they published any studies? If so, what are the results of those studies? How did they get into counseling? Have they written any blog posts or been a guest on a podcast? If so, what did you learn from their post or podcast? Do a deep dive into these people so you can honestly say to yourself whether you would want to work with them or not.

Next, I encourage you to create an Excel or Google Sheets file to help you keep track of your campaign. I created a new Google Sheets file using these headings:

  • Full Name
  • Email
  • Phone
  • Specialty
  • When Contacted
  • Response
  • Result

I filled my Google Sheets file with the 25 clinical supervisors I liked and connected with the most. I then sent a sincere and personal email to each of these supervisors.

Cytonn Photography/

Email marketing

Here is what I wrote in the email:


Subject Line: Clinical Supervision?

Hi (First Name of Supervisor),


My name is Wes.

I found your contact information online, and I connected with you because ________. I am reaching out with a question about clinical supervision.

I am completing my master’s degree in clinical mental health from Northwestern University. I am supposed to graduate in March 2022.

Last January, I started my clinical hours at an internship site in Salem, Oregon. I live in Portland, and in August I was involved in a car accident that totaled my car. I am unable to drive to Salem to complete my clinical hours and am looking for a new internship site closer to my home.

Do you know of a licensed mental health clinician in Portland who may be interested in letting me finish my clinical hours underneath their supervision?

If not, do you know someone I can contact who may know someone?

I appreciate you for taking time out of your schedule to read my email.


Very respectfully,



Notice how the first paragraph has a blank line. This is where you put the information you gathered from your research. The more specific you are, the better connection you are likely to make.

The third paragraph contains my story. It grabs my reader’s attention because it’s heart-wrenching. You may not have a story like mine. But that’s OK. You can tell your contact another powerful reason why you would like to work with them.

The results

I emailed 25 potential supervisors on a Thursday. I received 18 responses and scheduled video interviews with five of them. I interviewed with one supervisor that Thursday night, three on Friday and another one the following Monday. All five of these amazing supervisors graciously offered to take me on as their intern. Working for any of them would have been delightful, but I chose the one that aligned best with my goals.

I relayed this information to the placement team at my graduate school. A day later, the site at which I wanted to intern was approved.

I also responded to each supervisor who got back to me. I told them I was thankful that they took time out of their schedule to try to help me and that I hoped we would bump into each other at a professional conference in the future.

I made sure to sincerely thank the four sites that offered me an internship but which I politely declined. This is respectful and maintains the relationships I established with each of these generous supervisors.

I was amazed at the outpouring of support from the counseling community in my city. The counseling community in your area is likely just as supportive. All it takes is a sincere and genuine email to open a conversation with someone you admire and want to work for. Who knows what will happen? But this process gives you some control over your future instead of simply hoping that fate is on your side.



Before he began a master’s degree program in mental health counseling, Wesley Murph owned two small businesses, including one that was featured on The Dog Whisperer with Cesar Millan. He currently helps couples communicate more effectively so that each person feels valued, heard and appreciated. He also works with men to resolve anger issues and relationship conflicts that are lowering their quality of life. You can find him at


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Making every moment of clinical supervision count

By Tiffany Warner January 18, 2022

When I started providing clinical supervision nine years ago, the standard at my clinic was to use the entire session to discuss cases. Case review is foundational to the supervision process, but later in my career, I learned of alternative methods of supervision. Even when I used different methods, however, there were still too many topics to cover during the one hour of supervision per week. 

Whether one looks at the 2016 Council for Accreditation of Counseling and Related Educational Programs (CACREP) Standards or the 2014 ACA Code of Ethics, it is clear that supervisors are responsible for addressing a multitude of areas with supervisees. Unfortunately, figuring out how to cover every topic seems daunting at best and impossible at worst for many supervisors, especially when coupled with their gatekeeping responsibilities. In reality, there are too many core domains in counseling to cover in every supervision session, and this must be balanced with ensuring that supervisees discuss cases for client welfare. In addition, supervisees are often unsure what to bring up in supervision; without structure, they have difficulty identifying the most salient cases or topics. 

I know from my early experiences that this was a significant challenge. I was often trying to figure out what needed to be addressed first in supervision. I recall one example when I was working with a supervisee on the topic of self-care, but as the supervisee described their self-care practices, I could hear themes related to professional development, lack of confidence, ethical considerations and diversity factors. This moment raised many questions for me: What area do I address? Is it realistic to address them all? Do we have time to do that and discuss the supervisee’s clients to ensure quality of services? 

At this point, most supervisors, myself included, would focus on any high-risk needs, but the options are not always between low-risk and high-risk situations. Consequently, in my early career, I chose to address the areas in which I was most confident or that most interested me. This response is consistent with many of the supervisors I meet as well. 

To confront this challenge and to change my pattern of addressing limited topics, I developed a three-step method to help myself cover more topics with supervisees in the same amount of supervision time. I have found this three-step method has not only helped address a wider range of areas in supervision but also modeled for supervisees what types of issues to introduce. The development of this three-step method started when I was running internship groups in a master’s counseling program. I found it very challenging to cover all the core areas that students were trying to learn while also helping the students make the leap from book knowledge to application. However, I did not want to create so much structure that students no longer had the opportunity to discuss urgent or complex cases. Therefore, the three-step method that I started using includes: 

  1. Identifying a topic list
  2. Collaborating with supervisees on the schedule 
  3. Developing processes to incorporate topics naturally
    into supervision

This three-step method can be incorporated into individual or group supervision formats. At its core, the method is designed to help supervisees deeply apply the knowledge gained during their education. 

Step 1: Identify a topic list

Whether you are someone who loves order (like me) or prefers a more organic flow, identifying a topic list can be useful to help keep pace as a supervisor. It enables you to ensure core areas are addressed and provides an opportunity to assess the supervisee in different competencies. In a sense, this creates personal accountability by developing core areas that need to be addressed and devising a method to track them.   

The topic list I have most often used is a case conceptualization. This assists supervisees with identifying important parts of a case conceptualization, learning ways to articulate the case and working toward a cohesive understanding of the case. Several options are available for outlining a case conceptualization (see also “Case conceptualization: Key to highly effective counseling” by Jon Sperry and Len Sperry in the December 2020 issue of Counseling Today). You can use the case conceptualization format that is most familiar. However, I prefer using the following outline because the order helps students build a deeper understanding of their cases. 

  1. Background and historical information: Salient details such as family structure, relationships, historical trauma, history of mental health or addiction issues, mental health treatment and medical history.
  2. Presenting problem or concern: Client’s description of their problem, what they hope to achieve, risk factors and substance use.
  3. Testing and assessment measures: Identification of any test or assessment measures that are useful for the client, their problem or treatment.
  4. Diagnosis: Past and current diagnosis, differential diagnosis process.
  5. Multicultural considerations: Demographic information, diversity or cultural considerations for the case, important cultural components that impact treatment or mental health.
  6. Systems or developmental theory considerations: Identification of any systems or developmental models or theories that are important for this case.
  7. Counseling theory: The theories or modalities that are being used, research support for the counseling theory.
  8. Treatment plan: Description of the goals, objectives and interventions for the case.
  9. Ethical considerations: Current or potential ethical issues that apply to this case. 

Another option for the topic list is to use the 2016 CACREP Standards, specifically the eight core counseling domains found under Section 2.F.: 1) professional orientation and ethical practice, 2) social and cultural diversity, 3) human growth and development, 4) career development, 5) counseling and helping relationships, 6) group counseling and group work, 7) assessment and testing and 8) research and program evaluation. Although this topic list does not provide the ordered structure of a case conceptualization, it does cover the core areas that developing counselors need to understand and apply to clinical cases. 

One final option would be to use the various competency standards for professional counselors such as the Competencies for Addressing Spiritual and Religious Values in Counseling developed by the Association for Spiritual, Ethical and Religious Values in Counseling or the Minimum Competencies for Multicultural Career Counseling and Development created by the National Career Development Association. Using competency statements can be particularly beneficial if you are supervising within certain settings such as a religious institution or career center. Depending on organization of the competency standards, you would use each standard to help build competencies over the course of supervision. Because most competency standards include a focus in areas of knowledge, awareness, skills and ethics, you can still cover most of the areas outlined in the case conceptualization but with a focus on a particular genre or population. 

My three-step method provides flexibility for you to create a topic list that fits the supervisee, setting and population. I believe the case conceptualization is a better option given its practicality to the counselor’s everyday work. In addition, it provides language and an understanding of the case that is easier to translate into documentation, billing and other business aspects of a counselor’s work. No matter what topics are used, what is important is identifying a list that fits well within your supervision model and setting.

Step 2: Collaborate in setting the schedule

The onus is on the supervisor to ensure that the supervisee is building competency, which might lead to the supervisor determining the schedule of topics. However, there is value in involving the supervisee in this process. In this second step, the supervisor brings the suggested topic list to the supervisee to establish the schedule of topics. This has several purposes. 

First, it provides opportunity to assess the supervisee and their developmental level. You can use formal or informal processes at this step. The goal is to ascertain what the supervisee understands and their current skill level. In this way, you can tailor the list to the need of your supervisee.

Second, this step helps the supervisee take ownership of their development by identifying their own strengths and growth areas, which can assist you in targeting how to incorporate each topic (see step 3 below). For example, a supervisee might show solid understanding of counseling theory but need more assistance with knowing when to use what theory. Another supervisee might demonstrate strong skills with understanding a case but struggle to create a cohesive case conceptualization. At this step, supervisees are also able to identify areas of interest that might be included in the schedule of topics. 

Finally, this step can model the process of collaborating with a client to develop goals. This creates a great parallel process in which the supervisee learns how to work together to create the goals for supervision, which translates well to the counseling room.

After collaboration, the schedule is set up to address one topic per supervision session within a specific time frame, such as over a three-, four- or six-month period. At the end of this time frame, the schedule could be repeated or a new schedule created. 

At the conclusion of this step, you’ll have a set schedule of topics that incorporates the topic list from step 1 along with the supervisee’s feedback. So, you could end up with a four-month rotation of topics in which weeks one through nine focus on going through the case conceptualization and weeks 10 through 16 focus on reviewing the supervisee’s areas of interest. Another option might be a schedule in which each CACREP standard is reviewed in weeks one through eight and then weeks nine through 16 are spent taking each standard deeper to strengthen the supervisee’s development. In this way, the creation of the schedule becomes part of the supervision process. 

Step 3: Incorporating topics into supervision

While the schedule of topics is very structured, the final step offers more flexibility. I prefer to weave the topic into the cases or questions that are already discussed in supervision. In this way, the schedule of topics can be inserted into supervision organically. It uses time more efficiently by capitalizing on what is already brought into supervision. It also enhances a supervisee’s understanding of how these topics directly relate to their current clients. For example, if the topic is “diversity considerations,” you might pose questions during the case discussion or use an existing case to explore the topic deeper. Because this process is more organic, it requires that you quickly formulate the best plan to incorporate the topic. 

To help explain this process better, I’ll offer a case vignette of a supervision meeting. In this example, the topic of the week is the “presenting problem or concern.” The supervisee has brought up a particular case that has been difficult for her because she does not think progress is being made in treatment. The supervisee has been discussing a client who has sought treatment for depression but reports continued depressed mood and lack of motivation. In addition, the client reports a history of addiction but has been clean for six months. The supervisee and client have been seeing each other for five sessions. 

This supervisee has struggled in the past with clients who lack motivation. So, prior to this portion of the supervision session, the supervisor and supervisee focused on the countertransference that the supervisee experiences with clients with low motivation. At this point, the supervisee has had the opportunity to work through the reason for bringing up the case, and the supervisor sees an opportunity to bring in the scheduled topic. 

Supervisor: As I mentioned earlier today, this week’s topic is the presenting concern, and it seems like this client might be a good fit for the topic. As you have mentioned, the client seems to lack motivation. Tell me about what the client’s presenting concern is or how the client would describe their problem.

Supervisee: Well, when we first started, he said he wanted to be less depressed, but we have not really worked on that much. He doesn’t seem to want to talk about anything when he comes in.

Supervisor: So, he identified reduced depression when he started. What other things did he mention?

Supervisee: I can’t think of anything. 

Supervisor: Let’s see if we can’t expand on that a bit. It is common for clients to not have a clear description of what they want when they first start. Based upon your meetings with the client, what do you think the presenting problem or concern is?

Supervisee: I guess that is part of the challenge when I meet with him. I am still not sure. I guess he wants to reduce the depression, but it has been so hard to discuss this with him.

Supervisor: So, we have already established that he lacks motivation, which is common with people who are depressed. I wonder if we can be more specific and think about how you might describe the problem from either a behavioral, cognitive, affective or interpersonal lens? 

Supervisee: Well, he has mentioned several times wanting to see his children again. He stopped seeing them after his last relapse. This might be a behavioral problem that he doesn’t see his children. 

Supervisor: Great. How have you explored this area with him so far?

Supervisee: We haven’t done much. When he brings it up, I ask about what he can do to make that happen, and he just becomes upset. 

Supervisor: Well, it sounds like there might be some deeper challenges there, but let’s finish up with the presenting problem. You have at least one possible goal for the client. I wonder if there are others.

Supervisee: When he talks about wanting to see his children, he has mentioned several times about how he is a failure because of his past substance use. So, I guess there could be something there regarding a cognitive-based problem. 

Supervisor: So, it seems like there are maybe more specific concerns that you could bring into session.

As this vignette makes evident, the supervisor addresses the main concern brought to supervision and uses the same client to also address the day’s topic. This leads to an even richer conversation with the supervisee around some barriers to treatment, such as unclear goals. By using the existing client to discuss the topic, the supervisor is also able to skip repeating the case information, which utilizes supervision time more efficiently, and connect the topic to the clinical issues that the supervisee is wanting to address.

I prefer a more organic incorporation of the topics, but for some supervisors with less experience, this may be too challenging at first. Another option is to have set time during supervision to cover the topics. This could include doing activities such as role-plays, reviewing the major content in the topic area, selecting a client who fits well with that topic or using vignettes to discuss a topic. For example, if that week’s topic is “background and historical information,” the supervisor might role-play how to conduct an intake interview. If the week’s topic is “diagnosis,” the supervisor could include a vignette to help the supervisee work through differential diagnosis. This process can be useful when working with supervisees who are early in their development as counselors. However, it can also seem forced or too basic for more advanced supervisees or require setting aside time that might already be limited. 

Another aspect to consider when choosing the process for incorporating the schedule of topics is the background knowledge that the supervisee possesses. Some supervisees come to supervision with a strong understanding of the different topics, whereas others are early in their development or didn’t receive much prior training on the topic. In these instances, taking time to provide a short training or refresher may be useful. For example, if the topic is “test and appraisals,” you might consider reviewing validity, reliability and the process for determining an appropriate test. 

Finally, you have the option to use some or all of the processes identified here. You could consider providing a short training on the topic, identifying key questions and bringing those questions into the cases discussed during supervision. Ultimately, as a supervisor, you will determine which process fits best with your development as a supervisor, your supervisee and your setting. 

Benefits and problem-solving

An additional benefit of this three-step method is that it assists you in knowing what core areas have been addressed throughout supervision. It is easy to be unaware of the developmental areas that are missed with supervisees, and structuring supervision in this fashion can help mitigate this potential issue.


This can then translate well during evaluation times to allow for a more robust formative evaluation process. For example, some evaluations used in state licensure require that a supervisor specifically address the counselor’s diagnostic competency. The supervisor who uses this three-step method can be confident of their assessment of a supervisee’s diagnostic skills. 

The biggest challenge to using the three-step method can be the appearance of rigidity. As any supervisor knows, there are times when high-risk or urgent clinical needs take precedent over any other topic in supervision. Using a topic list does not preclude you from addressing urgent needs; there is space to change course in supervision and not address the topic. 

In fact, the topic list can produce the identification of urgent needs more regularly by training the supervisee on the different areas that should be addressed in supervision. For example, regularly bringing in ethical considerations can move the supervisee from seeing the ethical standards as rules and toward realizing how ethics standards apply to specific cases. This in turn can help supervisees move beyond just addressing confidentiality and abuse reporting to also recognizing potential boundary issues and scope of practice questions. 

The three-step method and group supervision

We have focused mostly on the use of this three-step method in individual supervision. However, there is value to using it in group supervision as well. 

In group supervision, managing time is even more challenging because multiple supervisees are vying for space to address clinical issues. Often, the goal with group supervision is that supervisees will learn as much from each other as from discussing their own caseloads. By establishing a topic list and schedule, you can be sure that more topics are covered for the benefit of multiple supervisees. 

Regarding the earlier vignette, if this conversation took place in a group setting, the other members would have the opportunity to listen and offer feedback on how to address countertransference and the role the presenting problem can play in treatment, even without bringing up their own cases. This could result in these supervisees being more likely to incorporate the presenting problem in other cases. 

Using the three-step method as a supervisee

The role of the supervisor is to teach, model and assist the supervisee in development as a counselor. But even if you are not providing direct supervision — if you are receiving supervision instead — you can still use this three-step method in your own development. 

This could include developing your own schedule based on the case conceptualization provided to you in your training or the competencies that you want to improve. After creating the schedule, you can use that to determine different topics that you want to address in supervision while prioritizing the high-risk issues and supervisor instruction. In this way, you can receive the benefit even if your supervisor uses other models of supervision. 

Supervision is a beautiful process of becoming a seasoned counselor, and as a supervisor, I have had the honor of walking with many supervisees through this process. I take this charge very seriously, which is why I emphasize providing a well-rounded supervision experience. Using this three-step method, I have found success with engaging supervisees on many fronts more efficiently while providing practical application of a counselor’s core functions.



Tiffany Warner is a licensed professional counselor and board-approved supervisor who specializes in working with severe and persistent mental illness. She is currently working as adjunct faculty at Multnomah University and is pursuing her doctorate in counselor education and supervision through the University of the Cumberlands. Contact her at


Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Overcoming counselors’ hesitancy to engage with autism

By Jennifer Jenkins January 17, 2022

According to estimates from the Centers for Disease Control and Prevention’s Autism and Developmental Disabilities Monitoring Network, approximately 1 in every 54 children are identified with autism spectrum disorder (ASD). As the number of diagnoses continues to increase, there will in turn be an increased need for services, including mental health services.

As a licensed associate professional counselor, AutPlay therapist and registered play therapist-in-training, I am familiar with the mental health needs presented in those with ASD. As a mother of two children with ASD, I also have a personal perspective that gives me an empathetic understanding of the autism world and the families of individuals with autism. 

There is a famous saying in the autism community credited to professor and researcher Stephen Shore: “If you’ve met one person with autism, you’ve met one person with autism.”
But what does that mean, and how does it relate to the world of counseling?


ASD is a neurodevelopmental condition characterized by severe and pervasive impairments in communication and social interactions and repetitive and stereotyped patterns of behaviors. ASD is a spectrum disorder or heterogeneous and not linear, meaning that individuals are autistic in different ways. In other words, ASD symptoms fall on a continuum and present in various combinations, with some individuals showing mild symptoms in an area and others showing more severe symptoms. This is important for counselors to consider because every single person with ASD can present with their own complex and unique symptomatology. It is also meaningful to note that ASD is a lifelong diagnosis and affects the entire family. 

In plain language, individuals with ASD can be described as literal, direct, honest, persistent and loyal. Additional reported characteristics include the individual being uncomfortable with direct eye contact and preferring specific textures of food and clothing. Typical behaviors include stimming, which can consist of rocking, flapping of the hands, pacing or verbal repetition. Unexpected events or changes in routine can cause distress in individuals with ASD, and their social/emotional skills are behind, exaggerated or even nonexistent. That being said, it is important to remember the heterogeneous nature of ASD; not all of the characteristics will be present in every individual with ASD. 

The autism community

Interestingly, a substantial amount of dissension exists in the autism community as a whole. As the mother of two children with ASD who are very different yet similar, I have many parental opinions. My children, who are actually autistic, have their own views on autism. Furthermore, the medical community has opinions on autism, and then those individuals who are autistic have their opinions. So, who is right? How do we tell the difference, and what is our role as counselors? 

It is critical to consider all evidence-based research practices and the opinions of stakeholders (i.e., medical professionals, parents, and individuals with ASD). However, it is important to know how we, as counselors specifically, can help and what role we can play to assist the ASD population. 

Within the autism community, there are individuals with ASD who dislike applied behavior analysis (ABA) therapy; they want the word disorder to be changed and have very insightful opinions. In addition, there must be a standard in identifying autism in the medical community. Some commonality through the newest definition in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders is the best attempt to have a standard definition for ASD for all stakeholders. Finally, parents of children with ASD, like myself, have a variety of opinions. As a parent, I want to hear the voices of those who are actually autistic, but I also know that certain therapies did work and helped my children achieve as much as they have so far in life. 

As counselors, it is essential to think of our helping role and how we might have a positive impact on the mental health of individuals with ASD. 

ASD and mental health

So, what mental health needs do individuals with ASD really have, and are those not just symptoms of the ASD diagnosis? Although that is an intriguing suggestion, it is just that — a suggestion. The research on ASD and mental health reveals that psychiatric comorbidity for children with ASD is as high as 70%-75%. The most common areas of comorbidity are anxiety disorders, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder (OCD), depression and eating disorders. Overall emotional regulation can be internalized (anxiety, depression or OCD) or externalized (tantrums, crying and acting out). 

Anxiety and depression in ASD are common, and clinical studies have found that clinically significant anxiety symptoms are associated with increased irritability, sleep disturbance, disruptive behaviors, inattentiveness and health problems. Anxiety in ASD can exacerbate typical ASD symptoms such as social impairment, negatively affect daily living skills and adversely influence relationships with teachers, peers and family. Failure to recognize or treat anxiety associated with ASD leads to unhelpful management of symptoms, whereas treatment can improve independent function. 

Depression is four times more likely to occur in individuals with ASD than in their neurotypical peers. Typically, depression occurs more in the teen or adolescent years and carries into adulthood. Studies on depression and ASD have found that depression increases with age due to social and communication deficits combined with perseverative behaviors. 

Emotional regulation is another core area of concern. Emotional regulation is the concept of controlling the intensity of one’s emotions, at either a conscious or unconscious level, before or after a triggering event. In describing emotional regulation as it applies to ASD, Rebecca Shaffer and colleagues, writing in the Journal of Autism and Developmental Disorders (2019), concluded that emotional regulation can be adaptive or maladaptive. Adaptive regulation implements effective coping strategies, whereas maladaptive regulation is associated with behavioral challenges. Overall, children and adolescents with ASD struggle with emotional regulation, thus reducing their ability to cope with current and future stressors. 

Individuals with ASD have difficulty with social and emotional understanding related to adopting the perspective of others or perspective-taking. Some research on individuals with ASD who have demonstrated higher levels of adaptive emotional regulation has also shown greater prosocial behaviors and increased social development. 

Evidence-based practices

ABA is considered the “gold standard” in the treatment of children with ASD. ABA is an empirically evaluated treatment that effectively reduces inappropriate behaviors and increases learning, communication and appropriate behaviors. The professionals who have the education and training to utilize ABA in practice are called board certified behavior analysts (BCBAs) and registered behavior therapists (RBTs). These professionals are trained in how and when to use specific approaches, with the BCBA establishing the plan and the RBT executing the plan. If the behaviors of an individual are deemed maladaptive or socially unacceptable, they can be altered or changed by applying ABA principles. 

Although ABA is considered the gold standard, there are some limitations to ABA, such as defining socially acceptable behavior, which depends on the culture. Additional limitations can include waitlists to access ABA services, the time commitment for services (many BCBAs will recommend a minimum of 10-20 hours of ABA per week for individuals), and financial considerations, because these services are not consistently covered by all insurance plans. Within the field of ABA, researchers such as Justin B. Leaf and colleagues, writing in Behavior Analysis in Practice in 2017, have expressed concern that the training and assessment content is not extensive enough or consistent with current research for appropriate training in the overall implementation of behavior therapy. 

Finally, it should be noted that ABA is a behavioral approach and does not address the mental health needs of children or adolescents with ASD.

What about CBT?

If I received a nickel for every time that cognitive behavior therapy (CBT) was suggested for my children with ASD, I would be a very, very rich mom. As a counselor, I understand the robust research basis of CBT, and I even use it in practice. So, why would I have any thoughts other than, “Yes, use CBT”? 

In the world of ASD, children who understand their diagnosis even a tiny bit are told that they think differently, that their brain works differently. With CBT, we would suddenly be telling them that their thoughts are irrational. The mom in me is like, “Great, my children are going to need therapy on top of their therapy.” 

In my practice, I have heard from many other ASD families and caregivers who have also been told to try CBT. They question whether their child possesses the mental understanding to comprehend CBT techniques. CBT is talk therapy. In addition, there is the question of whether CBT is developmentally appropriate. CBT requires more complex, symbolic, abstract, metacognitive, consequential and hypothetical thinking, consistent with the greater cognitive sophistication of adults, not that of children or adolescents with ASD.

Counselors’ hesitations

There is limited research on counselors working with the ASD population and, again, ABA is typically the first treatment modality suggested. However, ABA is a behavioral treatment and not appropriate for social-emotional and overall mental health needs. 

So, why are counselors hesitant? One of the first concerns is that individuals with ASD do not respond the same way to treatment interventions as neurotypical children do. That means that services are unprepared to adapt, support and treat this population. Some counselors mention a lack of training. Most counselors feel comfortable treating anxiety and depression, but the lack of training and understanding of individuals with ASD prevents some counselors from engaging in therapy with this population. Another concern counselors may have about working with the ASD population is that the therapy process can be challenging due to a lack of clear treatment goals, complex presentation, considerable time spent on care coordination and a slow rate of progress. 

The good news? Despite these challenges, many counselors have reported a willingness to serve the ASD population, especially when provided with better training and interventions. 

Therapeutic alliance and ASD

The counselor’s magic wand! The therapeutic alliance is a known contributor to treatment outcomes in counseling. The therapeutic relationship between child and counselor strongly influences the productiveness and progression in the child’s journey to personal growth and self-healing. 

For children with ASD, the therapeutic alliance is thought to account for a significant portion of therapeutic outcomes. Overall, the therapeutic alliance encourages clients’ compliance with treatment and motivates them to engage in optimal emotional processing. Finally, the therapeutic alliance is essential with children with ASD because it:

  • Serves as a model for relationships with others
  • Provides them an environment in which to learn and practice social skills and receive feedback
  • Helps them improve their overall functioning by providing them with a better understanding of themselves and others 

A therapeutic working relationship is best established with a child through play, and building this relationship is an essential element of any therapeutic process. 

Play therapy

Play is an instinctive way of expression and exploration for children. Play acts as a medium of expressing a child’s inner world and needs and allows the child to alter reality and make it more manageable. Play is critical because it provides a platform for the child to express symbolically what they are unable to put into words. 

As defined by the Association for Play Therapy, play therapy is the “systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development.” 

Play therapy has been shown to be effective in addressing a wide range of children’s presenting problems, including emotional and behavioral issues. In play therapy, children use toys, art supplies and sensory media (e.g., clay, play dough, sand) to communicate through action rather than through words, thoughts, feelings and experiences. Play therapy can be directive (structured/focused) or nondirective (humanistic) in nature. 

Play therapy has been established as a developmentally appropriate intervention for children and adolescents, in contrast to the traditional counseling approach of talk therapy. Play therapy is appropriate for children because of their limited ability to think abstractly. Play is considered the natural form of expression for children, allowing them to work through issues that are appropriate to their developmental level. Play is naturally reinforcing, making it an easy way to engage children in working on their difficulties. 

Counselors use skills in play therapy such as tracking to follow along with play and stating aloud what the child is doing in order to show attending. Play therapists restate things said in play, help summarize and organize what is happening in the play and reflect back feelings when expressed by the child. 

Play therapy and ASD

Given the heterogeneous nature of an ASD diagnosis, a diverse intervention may be the best option to treat the variabilities. With a child with ASD, there is a need for therapeutic flexibility, which calls for a therapist possibly changing their style of work, expanding their theoretical orientation and actively seeking approaches that can best address a particular child’s needs and concerns. Play therapy is appropriate for children with ASD because it provides opportunities to engage in play activities, improving empathy through the development of social, language and cognitive skills and overall relationships. 

Another challenge with children with ASD is communication. Through play therapy, toys become the child’s primary means of expression, giving them the ability to project their feelings on ambiguous stimuli. When play occurs in a safe, caring and culturally sensitive environment, children can freely express themselves. This expression allows them to work on self-esteem and social anxieties without fear of breaking the rules. With play as a therapeutic technique, children have the opportunity to learn about their world through inquiry and exploration. 

There are various theoretical underpinnings for play therapy, including psychoanalytic and Jungian play therapy, child-centered play therapy, cognitive-behavioral play therapy, filial play therapy, Theraplay and AutPlay therapy. This is not a comprehensive list of all the play therapy modalities. Counselors can easily find a natural theoretical connection with play therapy. 

Play therapy certification is a post-licensure credential and includes the following credentials: registered play therapist, registered play therapist supervisor and school-based registered play therapist. Play therapists undergo extensive training, supervision and education in play therapy to earn these credentials. The Association for Play Therapy ( is the national professional society that governs the play therapy credentials. It also provides many resources for professionals, including extensive research, training and education.


Jennifer Jenkins is a doctoral candidate in the counselor education and supervision program at Capella University. She is a licensed associate professional counselor and former school counselor. She works in a private practice in Warner Robins, Georgia, where she specializes in helping clients and families with developmental disabilities. Contact her at


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