Monthly Archives: January 2022

Building a foundation in premarital counseling

By Bethany Bray January 31, 2022

For many people, the phrase “premarital counseling” may conjure the image of a young, starry-eyed couple doing short-term work with a counselor or religious leader to discuss issues such as whether they’d like to have children or who will be responsible for cooking and taking out the trash.

While that scenario can and does still happen, more U.S. adults are delaying marriage. According to the U.S. Census Bureau, the median age for first-time marriage was 28.6 for women and 30.4 for men in early 2021. In 2000 and 1980, those statistics were 25.1 and 22 years for women and 26.8 and 24.7 years for men, respectively.

In addition, fewer American adults are choosing to say “I do” at all. The Pew Research Center estimates that roughly half (53%) of all U.S. adults are married, which is down from 58% in 1995 and 72% in 1960. Between 1995 and 2019, the number of unmarried Americans who were cohabiting rose from 3% to 7%.

These gradual but notable changes have led professional counselors to evolve their approaches to meet the needs of today’s premarital couples, regardless of whether they have a wedding date marked on the calendar. For Stacy Notaras Murphy, a licensed professional counselor (LPC) with a private practice in the Georgetown section of Washington, D.C., premarital counseling includes the couples on her caseload who are planning a wedding as well as those who are in unmarried yet long-term relationships.

In the two decades that Murphy has done premarital counseling, she has shifted from a top-down, topic-focused approach to a bottom-up approach that addresses attachment style and other deeper issues. This is not only because couples’ needs have shifted over the years, Murphy says, but also because recent research indicates the meaningful role that attachment plays in human relationships across the life span.

It is still important to prompt couples to talk through “big-ticket items” such as their expectations about finances, children, sex and intimacy, and the role that family and extended family will play in their lives, Murphy says. But premarital counseling should also build a foundation for couples to engage in these types of deep discussions — and navigate conflict when it inevitably arises — on their own in a healthy way, she stresses.

“All of these topics are grist for the mill,” says Murphy, an American Counseling Association member. “At the end of the day, couples want to understand themselves more deeply, and you don’t get there on your own by talking about what your goals are for retirement [and other topics]. … More so, it’s focusing on the steps that partners take to get their needs met and how those conflict and dovetail. It can be a beautiful dance.”

Getting started

Murphy thinks that in many ways, premarital counseling is couples counseling and uses similar tools and approaches. Premarital counseling has a more preventive focus, however, whereas couples counseling with married clients is often focused on repair work and undoing unhealthy patterns.

Tyler Rogers, an LPC and licensed marriage and family therapist who owns a private practice in Chattanooga, Tennessee, begins work with premarital couples by asking some straightforward questions: “Why do you want to do this?” and “What are you hoping to gain by getting married?”

Hearing couples’ perspectives on the why can help a practitioner understand more about the two partners, their relationship and their expectations, he says. If their answers tend to be more surface level, such as “this person makes me happy,” it opens the door to ask other questions and explore deeper with the couple, including offering psychoeducation about how attraction and liking someone are not the same as being “relationally competent,” Rogers notes. These discussions sometimes involve talking through why and how marriage requires “an entirely different skill set” than dating or living together, he says.

This work is still beneficial for couples who are getting married later in life or who have been living together for a while. Counselors will just need to tailor their approach to meet the couple’s experience.

“Sometimes counselors will need to help [more established] couples have a merger marriage, like the merging of two companies,” says Rogers, an associate professor of counseling at Richmont Graduate University. “Older couples [who are getting married] have less idealistic issues clouding what they think is coming [or] are more aware of each other’s problems. They might say, ‘We are really not good at talking about X’ or ‘This is how our conflicts go.’ … It’s a hybrid place of doing some marriage counseling along with premarital work. Couples may already have patterns or habits that aren’t great, but not to a breaking point.”

Practitioners may also work with couples where one or both partners have been divorced or experienced a painful breakup previously, and they come to therapy wanting to “get it right this time,” Murphy says. “These couples know a lot about themselves but also [know that they] need this partner to be very different than the one who hurt them in the prior relationship. We do a lot of unpacking what their needs are. I also acknowledge that it can be triggering for the other partner to hear a lot about someone’s ex.”

Beatriz Lloret, an LPC with a couples counseling private practice in College Station, Texas, takes a two-pronged approach to premarital counseling: One part involves psychoeducation on the components of a healthy relationship, and the other part explores the couple’s attachment style and patterns. In psychoeducation discussions with couples, particularly those who don’t have a healthy example to follow from their parents or family of origin, she often pulls from the Gottman method’s “sound relationship house theory,” including its components of trust and commitment.

“Couples often feel hopeful because they’re about to get married but sometimes mixed and apprehensive about periods of disagreement. The premarital [counseling] becomes couples therapy a little bit to address those issues,” says Lloret, an ACA member. “The beauty of it is that when [clients] are willing to come and dive into it a little, things [improvements] happen fast, especially because the issues are fresh and there is not too much rigidity built up yet.”

In addition to psychoeducation, Rogers and Lloret both say that initial work with premarital couples includes weaving in questions to cover necessary topics such as family of origin, finances and money management, children, and the roles they expect to have within the relationship.

Lloret says some of the clients who seek her out for premarital counseling do so as an alternative or in addition to premarital programs in their faith communities. These couples sometimes want to discuss issues — often those that have connotations of shame, such as sexuality — that they aren’t comfortable discussing with a religious leader or in programs that use a group setting. 

Although Lloret typically sees premarital couples together for the initial intake session, she splits the couple up for the second session to work with each person individually. This helps her get to know and build rapport and trust with each partner, as well as screen for domestic violence, she says. However, beyond issues such as abuse that require sensitivity, she has a “no secrets” policy for these sessions. Clients sometimes reveal that they haven’t told their partner about a chronic illness, a financial problem or a past affair; Lloret stresses the importance of disclosing and working through these issues with their future spouse.

Ellen Schrier, an LPC with a solo private practice in North Wales, Pennsylvania, has several assessment tools she uses to begin work with premarital couples. She says underlying distress — often involving frequent conflict, trust issues, personality clashes or infidelity — is revealed through this process in roughly 90% of the couples she sees. With distressed couples, it is often the case that one partner is pursuing the other, and the other partner is pulling away, withdrawing or avoiding conflict, she notes.

Schrier considers premarital counseling to include all of the unmarried couples she counsels, including those who aren’t engaged or looking to get married. She estimates this work is 30% of her caseload. Like Lloret, Schrier often sees premarital couples individually for a session early on to get to know them and help tailor her work to their needs.

“Often the case is they come in to strengthen the relationship, but there’s more to it,” Schrier says. “As you begin to talk, you realize there are deeper issues or past infidelity. They come in looking for a little boost but actually are struggling with a big problem.”

Addressing attachment

Initial assessment and discussion about content topics (finances, children, sexuality, etc.) in premarital counseling serve a couple of different purposes. One, they provide the practitioner with information about a couple’s personalities and background and, two, they open the door for deeper discussions and work on challenges that underlie those topics, including addressing attachment, repairing broken trust or breaking cycles of conflict and blame.

“The big-ticket-item conversations have to happen, and they can be very triggering, so it’s good to have them in couples therapy,” Murphy says. “My role is to let them talk about that content but then put it into the context of how they’re talking about it. … It’s absolutely critical to teach them about their own attachment style and how that interacts with their partner’s. Across the board, teaching them how to have healthy disagreements is my main agenda. We have such stereotypes that a ‘good marriage’ is one where you don’t have any conflicts, but that is so untrue. Demystifying that process is my job more than anything else.”

Murphy and Lloret use emotionally focused therapy (EFT) with premarital couples and find it useful for helping clients explore and dig into patterns and attachment issues. Throughout this work, the counselor guides the couple as they talk through deep issues that they wouldn’t necessarily recognize or know how to address on their own. Lloret says some premarital couples choose to work with her because she specializes in EFT and attachment.

“The counselor is a moderator to prompt deeper exploration, diving into what’s really inside of you and what’s really inside the other person,” Lloret says. “I don’t give solutions — what do I know [about what] they should do? — but they do.”

Having couples talk about their family of origin and the examples of marriage and relationships they’ve seen in their lives can be a good starting point for attachment-focused work with couples. Research shows that attachment patterns that humans form in early life repeat in romantic relationships, Lloret notes.

Murphy says, “I repeat over and over: ‘I’m not asking questions about your childhood to vilify your parents. They did the best they could. [And] it’s actually a good sign that you’re asking for help. But it’s important to talk through what you have experienced and what you believe.’ We want to get very clear about those expectations and desires and how to talk about them.”

Rogers believes it is important to relay a message to premarital clients who haven’t had healthy or stable examples of relationships in their life that “it’s not your fault; you didn’t choose that.” A counselor can help couples focus on the fact that they don’t have to repeat those experiences in the family they create.

Couples can also seek out other couples that they would like to emulate. Rogers sometimes asks clients to think of people they know whose relationships they admire and then to connect with them as “marriage mentors.”

“Ask them to have dinner with you, and pick their brain and learn from them,” suggests Rogers, an ACA member who previously worked as a Protestant pastor.

At its core, premarital counseling should help clients explore and learn about themselves and “the process of couplehood,” Murphy says. Relationship education is some of the most important ground to cover, she emphasizes. The crux, Murphy says, is helping clients understand that human attachment draws us to want connection and support from others. Counselors can then help teach clients how to give and receive that with a partner in a healthy way.

“At the end of the day, [couples] need to really know each other deeply and take care of each other. … It all comes down to ‘is there someone in this world that has my back?’ That’s the basis of attachment: to be secure, to know that there is someone in this world who thinks we are special, a home base,” Murphy says. “Premarital couples don’t always have a lived experience of worrying about that, and my job is to establish that that’s why we’re here or [to] remind experienced couples [of that]. At the end of the day, it’s the same lecture [both in premarital counseling and couples counseling] about the role of attachment in our lives.”

But sometimes partners can become too attached. Some couples who are in the early stages of their relationship have an attachment that Lloret describes as two hands with interlaced fingers. It’s very hard to move one hand independently when the fingers are so tightly interwoven, she explains.

“They need to [learn to] feel comfortable with a certain amount of emotional distance. They need to find patterns of interaction that are healthy while feeling supported, but also maintaining their own independence,” Lloret says. “It’s common to see these issues in premarital counseling, including communication issues, arguing and misunderstanding. They often label it as a communication issue, but it’s really trying to differentiate while maintaining a bond [and] feeling seen and heard and understood while keeping connection.”

Bridging differences

The number of Americans marrying someone with a different cultural background than their own is increasing with each generation. In 1967, 3% of married U.S. adults had a spouse who was a different race or ethnicity. That number has since grown to 11% of adults being intermarried in 2019, and the percentage is even higher (19%) among newlywed couples, according to the Pew Research Center.

Murphy says discussions about culture and cultural differences between a couple — and the friction, misunderstandings or other challenges that may arise from these differences — can fit naturally into conversations about family of origin and relationship expectations. Here, as with other topics, it’s important for counselors to dig into why clients feel the way they do.

“The goal has to be to keep it curious instead of feeling that your partner’s family does it ‘weird’ or ‘wrong,’” Murphy notes.

Prompting premarital clients to share about how their family celebrates holidays can be a good way to introduce these topics, delve into client expectations and uncover potential sticking points that the couple hasn’t addressed yet, Rogers says. It can also be an opportunity to talk with the couple about how holidays — and other aspects of marriage and long-term relationships — can involve a blend of preferences from the two partners instead of being all one way or the other.

Another important aspect of these discussions involves asking couples how they think their partner views their culture, adds Rogers, who leads trainings on premarital counseling through the Prepare/Enrich program. He sometimes prompts clients by asking, “What aspects of your culture are important to you? What would you like your partner to embrace a little more or understand a little more?” 

“Generally, it’s a conversation they’ve had already without realizing they were having it, in the form of disagreements about things such as family, money or traditions, [and] without realizing that it’s tied to their identity and feeling that their partner’s objection to their stance is a rejection of their culture,” he says. 

Culture ties into how people express love and relate to those they love in many ways, Lloret notes. This includes everything from expectations about gender roles in marriage to a person’s comfort level around discussing sex or displaying affection in public. For example, in Latin American culture, a male partner may be taught that showing possessive behavior and jealousy can be a way to express care and love. But a female partner from an American background might find these expressions overly controlling.

A counselor’s role is to guide clients as they break down the meaning behind feelings and behaviors and explore why aspects of their culture and traditions are important to them, Lloret says.

“When they take the time to clarify what the expectation means, break it down and explore how they make sense of it, and then find ways to compromise and give and take [with their partner], that’s when the beauty comes,” she says. “It’s either explaining, ‘I can’t give this thing up, but it doesn’t mean that I don’t love you,’ or ‘I will compromise because I love you.’ It’s deeper conversations that create connection rather than getting stuck on the differences.”

Building a firm foundation

Premarital counseling should always aim to provide couples with the tools they need to navigate future disagreements and differences on their own. This includes learning to compromise and respond to each other in ways that are not reactive, judgmental or assumptive, Rogers says.

For example, perhaps one partner wants to live close to their parents and have them involved in the couple’s life, whereas the other partner would prefer to maintain some distance from the in-laws. A counselor can serve as a moderator as the couple talks through why they are in favor of or opposed to something and what compromises they are willing to make. Rogers suggests having clients identify specific solutions such as not allowing the in-laws to have a key to the couple’s home or agreeing to limit dinners at the in-laws’ home to twice per month. That approach is more tangible, he says, than one partner saying something vague such as “Don’t worry, my parents won’t be over all the time.” 

“In premarital counseling, I’m trying to help them learn the process of being a patient, curious person to find out why their partner doesn’t think the way that they think when they don’t agree,” Rogers explains. “A lot of that is teaching them how to communicate why they have the position that they do and encouraging them to do some digging without judgment. … Whatever the issue is, there is a deep why, a reason why they hold these feelings close. The counselor’s role is to help them understand their own why and explain it to their partner, while at the same time being open and accepting [of] their partner’s why.”

Schrier says that couples in premarital counseling often need to learn how to fully listen and acknowledge their partner. “A lot of people don’t have that important skill of listening to someone without reacting … [and] understanding each other’s position and validating it, valuing it, without escalating, getting overwhelmed or angry,” Schrier says.

“Sometimes they need to learn how to have one person speaking at a time without the other person interrupting or adding on to what the partner is saying,” she says.

Schrier uses various activities to help couples practice these skills, including one that has the partners take turns being the “speaker” and the “listener” as they respond to prompts such as:

  • Name three strengths and three challenges in your relationship.
  • What would you like to have more of and less of in your relationship?

Schrier says these conversations help clients with skill building and help her identify things to focus on with the couple. In the process, couples often find things they agree on such as needing to work on communication or making time to have fun together, she adds.

Equipping couples with an expanded emotional vocabulary can help in this realm as well. Clients often fail to realize or fully describe their feelings when in conflict with their partner, Schrier notes. For example, a client who wants more connection from their partner may express that as blame: “You don’t spend enough time with me.”

Schrier has a detailed list of “feeling words” that she gives clients to help prompt more constructive and respectful dialogue. She also sometimes suggests that during disagreements, clients ask their partner (using a nonaggressive tone), “Can you say that in a different way?”

Perhaps a towel left on the bathroom floor triggers an argument between a couple. Initially, the person who discovers the towel may feel intense anger toward their partner, who dropped the towel. But skills learned in counseling can help the person realize what they are feeling beyond anger, she explains.

“Saying ‘I feel disrespected or devalued’ is a better way to talk about it and less reactive. It’s more empowering to say that than to say, ‘You make me angry.’ It gives their partner more to understand and change,” Schrier says. “It’s a way to slow the conversation down a little bit so they can better understand their partner instead of assuming they know what [their partner is] feeling.”

Couples who aren’t able to do this sometimes get “stuck on a hamster wheel” of arguing over the content (in this case, a dropped towel) rather than the feelings of a disagreement, she adds. When this happens repeatedly over time, it can lead to contempt, resentment and distance in relationships.

“It’s so much easier to work on problems when you’re coming in [to premarital counseling] with a spirit of friendship, instead of years later coming in as adversaries with years of misunderstandings and hurt feelings,” Schrier says. “It’s better to do it on the front end and be preventive.”

Premarital counseling can also open the door for couples who need deeper long-term work, Murphy notes. Premarital clients who are not able to fully resolve challenges before their wedding date may need to return for further counseling after they are married or when a life change, such as having a child, upsets the couple’s equilibrium.

“Premarital counseling can be the appetizer to a later full meal of deep couples work that is needed, sometimes years later or with a different clinician,” Murphy says. “It’s important [for counselors] to normalize getting input from different sources throughout the life span.”

Preventive care

Although premarital counseling often covers some of the same ground as couples counseling, there is one major difference: clients’ attitudes. The counselors interviewed for this article said that premarital work is rewarding because most clients are optimistic, enthusiastic and willing to strive to make changes to strengthen their relationship. In addition, growth and improvement often occur quickly.

“Premarital counseling is preventive care in a lot of ways,” Rogers says. “It can be some of the most rewarding, fun work to do with couples. … So many other mental health issues could be helped if we can help people have healthy relationships. We can be instrumental in pushing the ball forward to start marriage off on the right foot rather than addressing things only when they’re in a bad situation.”



Let’s talk about sex

One of the most important “musts” to discuss with couples in premarital counseling is sexuality. This is an area that couples who are older or who have lived together for a while may think they have figured out and don’t need to cover, says licensed professional counselor (LPC) Tyler Rogers.

Rogers sometimes jokes with premarital couples, saying, “John Lennon was wrong. Love is not all you need.”

Couples may have “the basics” of sexual intimacy mastered but need psychoeducation about how a healthy sex life will need to evolve and change over the course of a marriage. There will be times in life when sex isn’t easy and effort has to be made to foster intimacy, Rogers says. It’s important for practitioners to ask premarital couples about their sexual history and expectations regarding sex and, if they are sexually active together, to ask questions to ascertain their level of sexual wellness. Manipulative behavior such as withholding sex can indicate an area that needs more attention in therapy. Factors such as past sexual trauma or pornography use can complicate this issue, Rogers notes, especially when it is undisclosed between partners.

“There can be feelings of shame or guilt, especially if things are not disclosed until after they are married,” he says.

Tensions or misunderstandings regarding sex can cause distress that spills into other areas of the relationship for couples who otherwise have healthy connection, notes Beatriz Lloret, an LPC with a couples counseling practice in Texas.

Lloret says that where she lives, many premarital couples choose to delay sexual experiences — and important related discussions — until after marriage. Clients who fall into this category, many of whom are in their 20s and come from conservative, Christian backgrounds, often explore feelings and judgments regarding sexuality, she says. For some, discovering that their partner has certain sexual preferences or expectations carries a negative meaning or assumption for them. As with learning how to handle conflict in premarital counseling, practitioners may need to equip clients with tools to listen and respond to their partner about intimacy without being reactive or accusatory, Lloret says.

“For couples who don’t get to explore their sexuality until they’re married, once they open the door to this whole universe of sexuality, there’s a chance for a huge mismatch. Sometimes people have very different ways of expressing themselves and relating to pleasure, and it can create a big disconnection,” Lloret says. “They often need to explore judgment in a way to open their heart to the human being they’re in love with and the wiring that is sexual pleasure for that person. [It’s] getting judgment out of the way. There’s no one technique or easy way to do that, but the focus should be on being open and nonjudgmental.”



Bethany Bray is a senior writer and social media coordinator 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.

What the No Surprises Act means for counselors

By Lindsey Phillips January 28, 2022

The American Counseling Association’s January town hall focused on the No Surprises Act, which aims to increase transparency in medical costs and protect clients from “surprise” medical bills caused by out-of-network care. Catherine Brandon, a partner at ACA’s lobbying firm Arnold & Porter, discussed three main requirements of this act, which went into effect on January 1:

  • Prohibiting balance billing or surprise billing (i.e., when a health care provider bills a patient for the difference between the amount the provider charges and the amount the insurance pays) for out-of-network providers in an in-network facility
  • Requiring a good faith estimate (GFE) of expected costs before scheduled services for uninsured and self-pay clients
  • Ensuring continuity of care and accuracy of provider directories

Balanced billing

Sometimes people carefully select an in-network hospital and medical provider only to discover their medical bill is much higher than they expected because they unknowingly received medical care from an out-of-network provider during their stay. This balanced billing requirement aims to prevent that potential sticker shock by prohibiting providers who are out-of-network with a client’s insurance from charging more than their in-network costs when clients receive care at the in-network facility.

Billion Photos/

This aspect of the act will probably not apply to most private practitioners, Brandon noted during the town hall held on January 19, only those providing services outside their private practice at in-network facilities. So, if a counselor works at a hospital or performs telebehavioral services while a client is staying in a hospital, for example, then they could only charge the client at the in-network rate, not the out-of-network rate.

Although the act does not dictate the out-of-network payment amount between the insurer and provider, it did establish an informal dispute resolution process to oversee any potential disputes on payment.


One of the key provisions affecting counselors is the requirement to provide a GFE to uninsured and self-pay clients before services are rendered. It is the responsibility of the provider to ask clients if they will file a claim with their insurance to know if this rule applies to them, Brandon said.

The GFE should include a clear description of provided services, including diagnostic and expected services codes, and the expected charges associated with each service. Assigning a diagnosis code before seeing a client could pose a problem and ethical issue, but ACA suggests using a general diagnosis code such as “no diagnosis” before the first session, and then counselors can issue a revised GFE after the intake assessment.

The Centers for Medicare & Medicaid Services has a Good Faith Estimate template form that counselors can use to ensure they include all the appropriate information.

The time frame requirements for issuing the GFE are as follows:

  • No later than one business day after the date of a scheduled appointment that is three to nine business days away.
  • No later than three business days after the date of a scheduled appointment that is 10 or more business days away.
  • No later than three business days after the date of requested services without a scheduled appointment. (Another GFE must be provided within these time frames if the client decides to schedule an appointment.)

Counselors can provide clients with a single GFE for recurring services (such as ongoing counseling visits), which is good for one year. But if the information, including costs, services needed or billing codes, changes at any point, then providers must issue a new GFE no later than one business day before the next scheduled appointment.

The GFE is just an estimate; it is not legally binding and may change at any point. However, if the actual charge is more than $400 above the estimate, the client has the right to dispute the charge through the new patient-provider dispute resolution process.

In addition to orally telling clients about the availability of the GFE, counselors should include a notice on their website, in their office and on-site where scheduling or questions about costs occur. And counselors should retain a copy of the GFE with the client’s record for six years.

Continuity of care and provider directories

If a counselor’s contractual relationship with a client’s insurance ends (i.e., they are no longer in network with the insurer), they must continue to accept the in-network rate for 90 days after the health plan or issuer notifies the client of the change in network status. This provision only applies to continuing care clients, Brandon noted, which include those undergoing treatment for a “serious and complex condition” — one that is “life-threatening, degenerative, potentially disabling or congenital” and requires “specialized medical care over a prolonged period of time” or that is “serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.”

This law also stipulates that health care providers who have a contractual relationship with an insurer must submit up-to-date provider directory information to the insurer. And providers must reimburse insured clients who inadvertently relied on an incorrect provider directory and received out-of-network care or paid more than the in-network sharing amount. Counselors could protect themselves and shift the liability to the insurer, Brandon said, by stating it’s the insurer’s responsibility to maintain an updated directory in their contract with the insurer.

The U.S. Department of Health and Human Services has not yet issued regulations that would further explain and define these requirements. This means there is currently not much guidance on these regulations.




Watch the full video of the town hall on the No Surprises Act at ACA’s YouTube page:


Learn more about the No Surprises Act and these specific provisions from the following resources:



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.

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.