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.

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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.

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.

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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.