Monthly Archives: August 2022

Helping LGBTQ+ individuals — One story at a time

By Luke Romesberg August 12, 2022

“I came across your article. I’m in a desperate situation. I need help. I wasn’t sure who else to turn to.”

No matter how many times I receive email messages such as this, it is always somewhat of a surprise for me. My previous Counseling Today online exclusive “Conversion therapy: Learning to love myself againhas led me to receive a consistent array of messages from folks of all ages and geographical locations who are struggling with their sexual orientation and gender identity.

Some of the emails contain positive messages: folks who commend me on my bravery to tell my coming-out story. Many of those same people are also shocked I was able to navigate the situation in a manner that led to me having what most would consider a successful personal and professional life. However, the majority of emails I receive are from folks who are in dire need of support and are living in situations and communities where they do not have support or are unable to find support that is confidential. Without appropriate resources, many of these people are at their wits end. The struggles include being trapped at home with unsupportive, homophobic and transphobic family members; being stuck in a marriage in which one’s partner has no idea the other partner is hiding their sexual orientation; being bullied in school; or living one’s entire life with unaddressed trauma stemming from being forced to repress one’s sexual identity. (Please note that the stories and emails I share in this article have been altered to protect the privacy and confidentiality of those who have reached out. All identities remain 100% confidential.)

Conversion therapy throughout the world

First, let’s explore the current state of conversion therapy. Several places have bans against this practice. According to a article on conversion therapy bans, Brazil led the charge by introducing a ban on conversion therapy in 1999. This ban on therapy relating to sexual orientation was considered groundbreaking at the time, and it helped to set the standard for other countries to follow. In 2000, Norway issued a similar ban, and Samoa banned “registered health professionals from practicing conversion therapy” in 2007. These types of bans continued in places across the world, including in Argentina and Fiji in 2010, Ecuador in 2014, Malta in 2016, and Uruguay in 2017. In 2021, Chile introduced a medical ban and India issued “directives to prohibit conversion therapy.” This year, France and New Zealand also passed laws banning the practice.

Canada initially started banning conversion therapy practices in various provinces and territories, including Ontario, Nova Scotia, Prince Edward Island, Quebec and Yukon, and in December 2021, it banned conversation therapy entirely. The United States has had taken a similar approach. According to the Movement Advancement Project, California was the first state to pass a ban on conversion therapy in 2012, followed by New Jersey in 2013; District of Columbia in 2014; Oregon and Illinois in 2015; Vermont in 2016; Connecticut, Nevada, New Mexico and Rhode Island in 2017; Delaware, Hawaii, Maryland, New Hampshire and Washington in 2018; Maine, Massachusetts, New York, Colorado, and Puerto Rico in 2019; Utah and Virginia in 2020; and Minnesota in 2021. In addition, Michigan, Minnesota, North Carolina and Wisconsin have all partially banned the practice and signed an executive order prohibiting the use of state funding for conversion therapy for minors. And roughly 100 other U.S. counties, municipalities and communities have also issued ordinances banning conversion therapy practices. Please note that some states and districts may only have partial bans, meaning some aspects of conversion therapy may still be legal or eligible for state funding.

The good, the bad and the ugly

Although as a society we have made progress toward the expulsion of conversion therapy, we still have a long way to go, which is evident by the range of emails and stories I received after writing my online exclusive in 2017. And it is important that we do not forget those who may have been left behind or who have not had the opportunity to benefit from the successes of dismantling conversion. We must continue to recognize everyone’s unique experience in dealing with conversion therapy and other methods of identity repression. The following two stories represent a very small margin of the emails I have received from folks reaching out for guidance.

Feeling alone, scared and unsupported  

I received an email from a young person who described themselves as trans-identified and stated they had recently come out to their parents. They were met with pushback and were encountering consistent transphobic and homophobic verbal abuse. They mentioned many of the issues I had previously written about in my CT online article such as feeling as if they had no outlet to be themself. They expressed fear for their future and wondered if they would even have a future. They said that when they purchased clothing that aligned outside of their assigned sex, their parents would find the clothing and throw it in the trash. They were literally and figuratively being stripped of their transhood.

When receiving a message such as this, it is nearly impossible to not immediately feel a sense of darkness and heartbreak — not simply for this individual but also in a grander sense. Homophobia and transphobia are issues that are plaguing queer youth, and they are not issues that simply end as one gets older. Eventually the negative messages they are constantly being fed consume their thoughts, and in turn, it begins to affect their mental health, physical health and any healthy sense of self-identity they may have one once held. The lack of familial support and downright abuse day after day after day will eventually break someone down, and this theme will often continue into one’s adulthood.

After reading this email, I knew this young person was in dire need of any support and genuine kindness, and they were purposefully being kept in an environment that didn’t provide or allow for that. It is important to note that the idea of being able to provide virtual support to a minor, who needs to keep everything a secret from their family, is incredibly challenging. It can also be dangerous for the younger person as they attempt to secretly navigate the situation. This youth put themselves at risk with every email correspondence with me. They were guarded in their emails and left out descriptors such as their specific age and geographic location, which made locating exact resources impossible. However, given the description of their small town, it seemed as though these potential resources likely did not exist.

I drew from my own experience and thought of the outlets I had used when I was under the age of 18 and dealing with conversion therapy in a small town without many LGBTQIA+ resources. I turned to my honors English teacher; she was the first adult I came out to aside from my parents. At the time, I was still living in an environment where I had to be secretive about my sexual orientation. Even after coming out, I was forced to maintain the façade of being heterosexual. My teacher was one of few adults I could trust, and I genuinely enjoyed taking her class. One of our assignments involved creating a CD of songs, along with a description of each song and an explanation of how the songs applied to our life. I used this assignment as my coming out story to her. This project resulted in my teacher giving me 100 bonus points (which meant I was guaranteed an A+ in her course), but more importantly, it also gave me confidence and the knowledge that coming out would not necessarily always be met with a negative response. Even in a very conservative area with seemingly no LGBTQIA+ supports, there were still folks out there who held compassion, understanding and positive regard for those whose identity falls under the queer umbrella.

I shared this story with the youth who was emailing me. We explored potential adults at school they felt they could trust. We also discussed the possibility that someone they thought would be supportive may not be. It is impossible to predict how somebody will react even if you feel you know them very well. And as queer people, we truly do not know how somebody will handle our queerness. Sometimes the benefits of coming out outweigh the risks, but sometimes they do not.

Understanding this risk, the young person decided to reveal their identity to a trusted teacher. Luckily, their music teacher was supportive and has managed to be a consistent outlet for them to express themselves and receive kindness and support in return. Obviously, this does not fix this youth’s entire situation as they are still under oppressive and transphobic control by their parents, but it does help to lighten this hardship. My English teacher was a major saving grace for me. Without her support, I fear that I would not be typing this today. I can only hope that the youth’s music teacher is as strong of a support system as my English teacher was for me.

Although my advice for this youth may seem simple or generic, it is important to remember that even in what seems to be the darkest hour, one can still find a light, no matter how big or small. Even in an area where LGBTQIA+ resources may be nonexistent or inaccessible, there are still folks out there who possess compassion and a willingness to go above and beyond to support someone who is in need. Sometimes we must go through the incredibly difficult process of attempting to trust another person with a secret — one we have already faced so much backlash for revealing. Being met with negativity when coming out just makes the process of coming out to someone else even more difficult. The story illustrates a common theme I have seen in the majority of emails I have received: folks who feel alone and unsupported.

The struggle of coming out

I also have gotten emails from people who haven’t come out yet. I received one at 3:04 a.m. I don’t often sleep much, so I was wide awake, and I read it immediately. The email was full of desperation. The man described himself as Muslim and said that he was attracted to men. He claimed his wife had no idea and they had been married for over three decades. He said that he was on verge of losing his marriage and children, and he was desperate to make things work with his wife. He had stumbled across my CT Online article and was able to relate to it because he remembered feeling stifled as a child. However, unlike me, he had never come out to anybody. He noted that this email was the first time he had expressed his feelings.

He described himself as a “frilly” child, which I interpreted as feminine. This had caused him to be bullied at school and at home, especially by his brothers, and it led to others making assumptions about him. He didn’t include many overt details regarding his school experience aside from stating that he did not have many friends — just one other boy with whom he had sexual relations when he was about 13-15. At one point, his brother walked in on them and discovered this sexual relationship, which resulted in him being physically beaten by not only the brother who discovered them but also his two other brothers. He was beaten so badly that he spent over two weeks in the hospital, and then he returned to the same home where the abuse occurred. His parents sent him to another school in a different neighborhood, and he said that he never saw his friend again. To this day, he has no idea what happened to him. These traumatic events resulted in an immense fear; one that has spanned the course of his entire life resulting in a fruitless marriage and the need for him to hide his true identity.

I will be honest and admit that it took me a long time to respond to this email. I even wrote several drafts before finally sending my response. This was a new situation for me: Most of the folks who reach out to me are in the middle of dealing with homophobic or transphobic issues, but his situation was different because he was still struggling with his sexual orientation. I researched affirming counselors in his area and provided him with a list of folks whom he could reach out to. I was also able to find an LGBTQIA+ support group in his city. And I did my best to provide kind words. I stressed that he was not a mistake and was actually a victim of his situation. It was clear he was holding a lot of guilt about keeping this secret from his wife and that it was eating away at him and his marriage. It was important for him to realize that his options at the time of his marriage were few and far between given the immense cultural and family pressure that was put on him to marry and have a family. That pressure mixed with the severe trauma and physical abuse he faced as a child pushed him deep into the closet.

I emailed him these resources and words of encouragement, and he responded almost immediately, saying, “Thank you for everything you have brought to this world.” This statement brought tears to my eyes. I am happy to be a voice for those who cannot speak up. However, my simple response to his very complex problems hardly seemed like enough. I left this interaction feeling discombobulated. I had provided him with resources, but I was in no way equipped to provide anything further regarding his marriage. That was something he would have to work on himself. Was there more that I could have done? Probably not. Did I wish there was more I could do? Definitely.

Trudging forward and making progress

I write this update to share a very small portion of some of the stories I have encountered since openly discussing my experiences with conversion therapy. It crucial that more people gain the courage to share their experiences so the gravity of the impact of conversion therapy can be fully understood. The more folks share their story, the more we are all able to connect and support each other. We are moving in a direction that is positive, but we must continue on this path to dismantle this harmful, dangerous and potentially life-destroying practice.

I had no clue the impact that my story would have on others. It is heartwarming yet terrifying that so many people are able to connect with and relate to such trauma. It became incredibly clear that I had accidentally distanced myself from the overall desperation one feels when trapped in a similar situation. Writing my previous article helped me to relive my experiences in a way that was healing, and the responses to that article serve as a brutal reminder of how much more severe one’s situation can be. These responses also remind me that many folks are not as lucky as I am to have parents who were willing not only to admit their wrongdoings but also to work through those mistakes and come out as loving and supportive parents on the other side. They are a testament to personal growth and willingness to understand. These are qualities that we need more of in humanity, and ultimately, these are the qualities that will help end conversion therapy.


Benjavisa Ruangvaree Art/



For more on laws relating to conversion therapy, see and



Luke Romesberg

Luke Romesberg is a licensed professional counselor and certified alcohol and other drug counselor. He is a doctoral candidate in the counselor education and supervision program at the Chicago School of Professional Psychology. Currently, he works as the director of youth homelessness services at Center on Halsted and as a home study worker for the Adoption Center of Illinois at Family Resource Center.




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.

Compromising care: An occupational hazard for counseling leaders

By Lindsay Johnson and Ane Turner Johnson August 10, 2022

When we sought to interview women directors of counseling centers about their experiences, we weren’t exactly sure what we’d discover. All we knew was that we were interested in their unique leadership experience given the conflicting values between care work and higher education today.

Higher education is not that different from many other large organizations. According to Bernie Grummell and colleagues’ article published in the journal Gender and Education in 2009, institutions are influenced by capitalism and therefore are more focused on the bottom line and on employees working solely for the benefit of the organization (even if it is to the detriment of their personal lives), resulting in what is considered to be a “care-less” organization. In a 2010 article for Arts and Humanities in Higher Education, Kathleen Lynch notes that this care-lessness manifests in leaders and workers becoming cutthroat, ruthless and selfish in order to excel within the organization.

As women working in a university setting for, cumulatively, over 20 years, we have become well attuned to the differing values between care divisions and the larger institution. And we have noticed that trying to lead divisions centered on providing care, such as a counseling center, within this care-less organization of higher education is fraught with tensions and contradictions.

Additionally, gender inequities inherent to higher education produces a gendered organization with its own set of challenges. As theorized by Joan Acker, gendered organizations create and maintain overt and covert practices, cultural dynamics and social norms based on gender that hinder women, especially their movement into leadership positions. Understanding how women directors navigate leading a care work division while also negotiating their role as a “care-less leader” within a gendered organization is essential to uncovering the interaction between gender, leadership and care work within the care-less landscape of higher education.

Our curiosity in this topic spurred us to interview 13 women directors of college and university counseling centers from across the country. We wanted to know what it was like for them as leaders and how they experienced their dichotomous work environment. Using heuristic inquiry, we uncovered a culture clash between contemporary higher education and counseling that further marginalizes women leaders, particularly leaders of care work, by forcing them to compromise their care values and identities. These compromises are inevitable; to embody the role of a leader within the care-less organization of higher education, counseling leaders need to trade off some of their care roles, values and practices for those of the care-less culture. Without these compromises, counseling leaders risk their leadership status and effectiveness in the organization.

You may be reading this and thinking, “Yikes, this seems pretty bleak as a leader in the counseling profession.” Although that was our initial reaction, it also spurred us to consider how this knowledge could be useful. To us, these insights help professional counselors and counseling leaders within care-less settings prepare themselves for the internal (and sometimes external) assault on their values and identities. Also, this knowledge can help start a larger conversation within and outside the counseling field about care-less organizations and how care-lessness influences care work. In the following sections, we describe three ways in which the directors expressed they had to compromise care as a leader within a care-less context and three takeaways for counseling leaders.

Compromising care 

As mentioned previously, care-less work is born from our capitalist society that focuses mainly on profits and productivity rather than emotional connection. Bernie Grummell and colleagues in a 2009 article in Gender and Education and Henry Giroux in 2002 article in Harvard Educational Review explain that care-less organizations reward, value and idealize workers who can fully commit themselves to the job, put aside personal time and be unencumbered by any other type of duty. According to Sheila Slaughter and Larry Leslie in a 2001 article in Organization, higher education has become one such care-less organization, and therefore the presumption is that university faculty and staff, especially the leaders, will embody this ideal care-less worker. But these care-less values are in direct contrast to those of a division focused on care, such as a counseling center. As a result, leaders in these divisions must at times reprioritize their care to better align with the care-less institution. From our interviews, we found that counseling leaders often have to compromise care in the following three areas: care identities, leadership styles and practices, and care values.

1) Compromising care identities. The counseling leaders we interviewed said that compromises to care arose from the competing needs and values of their identities as a director, woman (for some this also included being a mother) and care worker (as professionals in the counseling field). As a result, they were forced to make sacrifices in their care roles given that it was impossible to effectively perform such roles while being the director of a counseling center. For example, one woman shared about her identity as a mother and how the director position affected the time spent with her children. She explained, “I get a call two weeks ago to do a suicide assessment with my kid in the bathtub, and I’m like, ‘I have to call you back, I have my kid in the tub,’ so I need to get my kid to my husband to be able to call back.” Another director echoed similar sentiments in regard to time spent with her father: “The hardest thing is I’ve been on call for so many years. … I can’t just go home and spend time with my father uninterrupted. … It can be a serious lifestyle inhibitor.” 

These examples exemplify the ways in which the care-less culture of higher education, and subsequent expectations of its leaders, infiltrate the personal lives of counseling leaders. The care-less culture contrasts with their care role as mothers and family caregivers and at times it was impossible to effectively perform both roles at the same time. Making personal sacrifices in their external care roles could risk their status as leaders within a care-less organization.

Counselors will also need to make professional care compromises when leading in a care-less organization. All the directors we spoke to still maintained involvement in clinical work; however, it was significantly minimized in order to manage their administrative position. One director with many years in her role explained why holding both identities (as care worker and leader) concurrently was nearly impossible. She said, “I started my role as director with a large caseload, but then I was trying to figure out how to be director and I was mediocre at both things — mediocre in the therapy room, mediocre as a director. … I can’t be doing good therapy and be thinking, ‘I forgot to approve someone’s vacation time.’ … I learned that I really needed to be more of an administrator.”

It’s challenging enough to sustain the engagement level involved in doing care work while also juggling administrative duties and expectations. Now add to that the complications that arise when working in an environment where the values of the care-less organization clash with the values of the care work being done. Therefore, being an effective administrator requires counseling leaders to make compromises to their care worker identity in some way.

2) Compromising leadership styles and practices. Another area where counseling leaders will most likely have to make compromises is in their leadership styles and practices. The directors we interviewed expressed that their leadership style is servant or feminist based, both of which are driven by care-oriented values such as collaboration, transparency and support. But at times they had to compromise those values and adapt a style that was more authoritative, political and guarded to navigate the murky waters of the greater care-less organization. One director explained why these changes needed to happen in her position: “I’m more guarded outside our office, in part because … I think there’s competition among departments. … There’s a bit of gamesmanship, so I need to be more strategic.” This statement reflects how our values as counseling leaders are compromised at times in a care-less organization to effectively do the job, such as obtaining appropriate resources.

3) Compromising care values. Counseling leaders may also have to make compromises to their care values in care-less settings. These compromises come as a result of the care-less cultural norms inherent to care-less environments. For example, students and their guardians may make demands of the university that are not necessarily in the best interest of the student’s mental health. But because the student (and whomever is financially supporting their college endeavors) are the “consumer,” the university is likely to appease these individuals. Middle managers of the institution, such as counseling center directors, are then subjected to following these decisions made by university leadership, without regard to care values. These compromises can range from keeping a student at the university when it may not be in their best interest to shrinking individual services or expanding group treatment in order to treat more students. Therefore, counseling leaders are forced to let the consumer dictate what is the care plan versus what they, as professionals, know would be most beneficial.

Lessons for caring care-lessly 

Learning how care-less contexts affect care leaders helps demonstrate the conflicts and unique challenges that arise for counseling leaders within higher education. These findings from our interviews with directors of counseling centers provides three important takeaways for other professional counselors who are already leading or will be leading counseling centers within care-less settings.

Lesson 1: Expect to feel conflicted. It was evident from our interviews with these directors that counseling leaders should expect to feel conflicted regularly when working in care-less settings. That is because care work leaders must reconcile their personal, and perhaps divisional/departmental, roles and values with those of the organization when they are in direct conflict to those of the organization. Research such as Simon Black’s 2015 article in Open Journal of Leadership supports this finding that care work leaders in care-less settings have internal conflict because of contradictory values. These leaders should also expect to feel conflicted because sometimes they will need to make sacrifices that come at the expense of their care identities. While counseling leaders may expect, and prepare for, ethical or legal challenges in their positions, the clash of personal and professional values may be less expected. By understanding this before entering the field, counseling leaders can reflect upon these compromises and prepare by doing things such as creating a plan as to when and how they may want to make such sacrifices.

Lesson 2: Expect to become flexible. As noted previously, we discovered that counseling leaders in care-less contexts often had to alter their leadership style when navigating spaces outside of their care division. Therefore, counseling leaders should expect to be flexible in their leadership approaches if they are going to get their care divisional needs met in a care-less organization. Although servant leadership can help individuals manage very challenging work obligations, as explained by Emin Babakus and colleagues in a 2010 article in Services Marketing Quarterly, it has been shown to be less effective in organizations that have more masculine-oriented values, such as care-less organizations, as described by the findings of Yucheng Zhang and others in an article published in Asia Pacific Journal of Management in 2021. When counselors in higher education lead a care division within a care-less organization, they must be ready to shift leadership styles based on what’s needed in the moment. Therefore, counseling leaders should be knowledgeable of multiple leadership styles, recognize when it is best to use practices associated with each style and be prepared to apply these different techniques. 

Lesson 3: Expect to be held accountable. The last takeaway for counseling leaders in care-less contexts is that compromising care can come at the expense of client’s or patient’s well-being and the care leader is most likely going to be held accountable. To us, this compromise is the hardest to stomach, and greatest call to action, as a care worker. We described earlier in this article how care-less organizational leaders may at times make decisions that affect care divisions and go against the values and professional judgment of counseling leaders. As a result, the clients or patients may suffer and view the care division as the culprit, and the organization is not likely to take the blame given its care-less values. This sabotages the leadership of care leaders. Counseling leaders should be aware of this when entering into care-less contexts and have a plan for how to manage conversations with leadership when such issues arise. This grim reality should also initiate conversations and more research around care-less cultures, including how they impact quality care and who accepts responsibility for such compromises to care.

In summary, it is important for professional counselors to understand that it is impossible for them to embody the values of their care worker identity while simultaneously working as a leader within a care-less organization. The inability to maintain both identities concurrently results in compromises made to one in order to embody the other. Therefore, counseling leaders in care-less settings should understand that compromises to their care identity must come in order for them to maintain their leadership role. As counseling leaders, this brings us to a crossroads. As we continue to expand our leadership into other industries, especially those that are care-less organizations, we must choose a path. We can either prepare ourselves to compromise our values and identities to fit into the care-less culture, or we can choose to confront the culture of care-less organizations. The latter choice raises several questions: Can care workers truly change the culture of a care-less organization? Do the care-less leaders need to be the ones to start a culture shift? Could counseling leaders be the catalyst for care-less culture changes? There’s only one way for us to find out.



Lindsay Johnson is a licensed professional counselor and outreach coordinator at Rowan University’s Counseling and Psychological Services in Glassboro, New Jersey. She specializes in the treatment of disorders of over-control and is the team leader for the Radically Open Dialectical Behavior Therapy consultation team at Rowan’s Wellness Center. She recently completed her doctorate in educational leadership at Rowan University. Contact her at

Ane Turner Johnson is a professor of educational leadership at Rowan University in Glassboro, New Jersey. She teaches research methods and conducts research on issues related to higher education governance and policy making.


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


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

A cognitive behavioral understanding of social anxiety disorder

By Brad Imhoff August 8, 2022

Don’t let anxiety drive the car,” I learned to tell myself.

I was standing in the hallway of the hotel’s conference center where our state counseling association was hosting its annual conference. I had co-presented with my professors at the conference a handful of times before, but I viewed them as experts who could handle anything that came up during our presentation. There was comfort in that. 

Now here I was as a doctoral student about to present a 60-minute session as lead presenter for the first time. The anxiety I had tried fending off for the past several hours (and, let’s be honest, past several days) rushed over me like a tidal wave as I looked at my watch and saw the presentation was scheduled to start in 15 minutes.

My stomach was in knots, my hands were ice cold (yet sweaty), and my thought process went something like this: “They all know so much more than I do; what am I doing here? They’ll see I’m a fraud and don’t belong. What if I run out of things to talk about? What if they ask questions and I have no answers? Great, now I’m sweating. They’re going to see I’m sweating and know I’m nervous. The sweat is fogging up my glasses and now I can barely read my notes. Do I have enough notes? What if I run out of material and have nothing to say after 20 minutes? How embarrassing. They’re going to judge me. Why am I doing this?”

Anxiety was absolutely driving the car.


Social anxiety disorder

As its name implies, social anxiety disorder can be understood as an intense fear of, and overwhelming distress in, social situations. Situations that involve scrutiny, being observed, and real or perceived evaluation create extreme discomfort and dread for individuals with social anxiety. Common examples that trigger social anxiety for these individuals include speaking or performing in front of others, interacting with unfamiliar people, dating, being interviewed, initiating conversation and being at the center of attention. The underlying concerns are largely centered on judgment, negative evaluation and the potential for embarrassment. There is a persistent worry about appearing inadequate, humiliating oneself or being evaluated as awkward, boring, weird or any number of other negative descriptors.

As if the discomfort associated with social situations were not enough, social anxiety disorder also involves a fear of exhibiting anxiety symptoms. There is anxiety about being anxious. People who are overly anxious often sweat, blush, tremble or stumble over their words and fear that others will notice this and judge them for it. They may have racing thoughts, a quickened heartbeat, muscle tension or a dry throat, all of which can impede functioning at their best. When this happens, they become hyperaware of their internal experience and focus less on the task at hand and what is going on externally.

Take, for example, someone who is on a first date or someone interviewing for a job. They might have sweaty palms from feeling anxious and then be consumed by worry about having to shake hands. Rather than mentally preparing for a positive greeting or being excited about an introduction, the person might ruminate on the thought, “If I shake hands, they’ll feel the sweat and think I’m gross, but if I don’t shake hands, they’ll think I’m awkward.” This creates the sense of a no-win situation that might lead a person to avoid such situations altogether. 

Another example is a young student who raises her hand to participate in class and feels her face getting warm as she begins blushing. She is rehearsing in her mind what she wants to say but now turns her attention to the anxiety symptoms she is experiencing — worried that others might notice them too. Her embarrassment intensifies and her fears are actualized as her peers giggle and comment on how red she is turning. Not only does she feel anxious about speaking up, but it is confirmed to her that her anxiety symptoms are on full display for others to see and judge. She decides it is safer to just not raise her hand in the future.

Many readers can relate to these scenarios because most people experience anxiety in some social situations. It would be rare to go on a first date, present in front of an audience or go into a job interview without feeling some level of anxiety. With social anxiety disorder, however, the anxiety is excessive and out of proportion to the situation. Furthermore, the anxiety creates extreme distress or impairment. That is, it gets in the way of typical functioning. 

Individuals are very likely to use avoidance behavior to not have to engage in social situations or they may tend to escape situations once in them (e.g., leaving a social gathering shortly after arriving). Social situations feel as if they are being endured and survived as opposed to enjoyed. This can create various challenges related to employment, educational opportunities and relationships. When anxiety gets in the way of life in this way, treatment with a professional is warranted.

When considering the treatment of social anxiety disorder, I tend to conceptualize it as a three-pronged approach that involves understanding the disorder, learning to accept and value oneself, and reconstructing the reality clients have built for themselves. The latter two processes are very much intertwined, and all three are fluid and ongoing as clients learn about their anxiety, discover new ways of thinking about themselves and begin to engage the word differently. As they do all of this, they are practicing new skills with an aim toward interacting and functioning more effectively in their daily lives.

Understanding the disorder

Understanding social anxiety disorder begins with psychoeducation. This process is very reciprocal, however, because counselors learn from clients too. Clients who struggle with social anxiety are well aware of the discomfort associated with it, having experienced it daily for much of their lives. Still, counselors can work through the features, symptoms and diagnostic criteria with them to help put a name and label to their experiences. 

While this is being done, clients are asked to share how the various features of the disorder have played a role in their lives. This becomes a parallel process of educating clients on the ins and outs of social anxiety disorder while they educate counselors on their individualized experience with it. This joint effort builds rapport and trust and sets the tone for a collaborative partnership throughout treatment. It also helps normalize the challenges clients have encountered due to their anxiety, puts a name to what they have experienced and may help them feel less alone in the struggle.

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the onset of social anxiety disorder occurs most often between the ages of 8 and 15, and people go an average of 15-20 years experiencing symptoms before receiving treatment. This means clients have likely avoided and missed out on many opportunities going back well into childhood. 

The counselor should explore these opportunities. Doing so can be beneficial for several reasons. First, it gives a clearer understanding of the disorder’s role throughout clients’ lives and how it has affected their quality of life. Second, it offers insight into the areas each individual client may struggle with most — at work, in school, initiating friendships, building intimate relationships and so on. Finally, the historical challenges and missed opportunities can provide motivation for truly engaging the therapeutic process now. Building this motivation can be especially important when it comes to the gold standard for anxiety treatment — exposure (discussed later in the article). 

I like for clients to consider this question: “In light of all the missed opportunities you have described, I wonder what life will be like moving forward if anxiety continues to lead the way?” With an eye toward collaboration, motivation and building hope, the counselor may follow up with, “I want to help you take back control from this anxiety.”

When anxiety leads the way and controls our behavior, it becomes problematic. It creates impairment. Anxiety itself, however, is actually healthy and helpful. Being anxious about an important exam motivates us to study for it. Having anxiety about an upcoming business presentation focuses our preparation and encourages us to give it due attention. Feeling anxious about an upcoming networking opportunity might indicate that we value relationships and view social connection as important. 

Part of educating clients is helping them understand the benefits of anxiety and learning to distinguish helpful anxiety from the excessive anxiety they experience. The former motivates us and helps us prepare, whereas the latter paralyzes us into inaction.

Don’t let anxiety drive the car

Back to the opening story. The anxiety had stopped being helpful long before my presentation began. It was excessive and paralyzing at times. When I was anxiously preparing to begin a conference presentation, I would start implementing a handful of interventions to try to get rid of the anxiety. I would quickly run through them, expecting one to be the magic pill that would make me feel better. It was not a helpful way to view anxiety, and when none of the interventions made it disappear altogether, I was left feeling even more anxious. I had a combative relationship with the anxiety; it was overwhelming me, and I was fighting as hard as I could to make it go away. Only when I accepted that it was going to be there did I experience some level of freedom from it.

“Don’t let anxiety drive the car” was the phrase and visual that came to my mind. It became my imagery for managing anxiety. Anxiety was coming along for the ride — there was no doubt about that — but it did not have to be all-consuming and control where we went, whether we went at all or how we got there. 

Instead of creating an inner conflict that I was battling and trying to overcome, I began to externalize the anxiety and invite it along. I had a mental image of me sitting in the driver’s seat and opening the passenger door to welcome it. Essentially, I was saying, “I know you’re going to be there, so get in and let’s go.”

Externalizing the anxiety and inviting it along meant that I was no longer fighting against it and consistently losing. Rather than fearing the symptoms and engaging the racing thoughts, I could simply acknowledge them, accept that they would be there and make the decision to continue forward anyway. To keep things light and in perspective, I might even say to the anxiety, “It sure would be nice to just put you in the trunk.” For some anxiety-inducing situations, that can be a good way to monitor its severity. Is it tucked away in the trunk and mostly out of mind? Is it in the back seat just riding along? Or is it sitting in the passenger’s seat trying to grab the wheel and take control? 

Once we understand that anxiety is not something that is going to disappear, we can turn our attention to navigating our lives despite its presence. We can learn how to lessen its impact and manage it when it becomes excessive and unhelpful.

Acceptance of oneself

If I think poorly of myself, it naturally follows that I will expect others to think poorly of me too. How could I expect others to view me in high regard if I do not see myself that way in the first place? This is important because social anxiety is largely focused on how we think others perceive us, which leads to the presence of anxiety when around others.

Therefore, the second prong to the treatment approach is to help clients better accept and value themselves. Counselors can explore with clients their natural dispositions and work with them to understand and value their individual strengths and personalities. People with social anxiety may long to be extroverts or overvalue outgoing personalities, despite themselves being quiet observers who are rejuvenated by alone time and drained by social interaction. It is important to recognize these tendencies, not only to manage client expectations but also to highlight the value of these tendencies and reframe them. A client who puts herself down for being too reserved may learn to recognize how this plays a role in her being such a good listener with her friends. A client who longs to be more outgoing may learn to recognize how his quieter demeanor has made him more observant and intuitive.

It is also possible that social skill development is necessary for some clients. Areas may exist in which clients can improve their role in social interactions. Those who have social anxiety have spent years avoiding social situations and have not practiced and honed their skills in the way that others who are more socially comfortable have. Take, for example, a child who plays a sport or musical instrument. If this child shows up to practice two days each week while all the other children practice five days per week, those who have practiced more will have developed better skills. Similarly, an individual who has not had much practice in social situations may need to develop and practice skills that have not regularly been used. The counseling relationship is an opportunity for clients to become more competent with initiating conversation, recognizing social cues, speaking clearly, making eye contact, practicing how to show interest in others through prompts and questions, and any number of other social skills. With improvement of skills and competency comes more confidence.

Self-esteem activities are another useful tool in the process of helping clients accept and value themselves. One that I particularly like is having clients consider five different aspects of themselves: physical, spiritual, emotional, intellectual and social. Clients are asked to identify personal characteristics within each area that they value and appreciate in addition to identifying some areas for growth. Using this approach makes the abstract concept of self-esteem more concrete and can help clients create a more balanced and holistic view of themselves. As counselors observe this process, they can also keep an ear out for particularly negative language or self-talk.

Reconstruction of reality

Throughout the steps noted in the previous sections, clients are beginning to understand themselves better and view themselves differently. The third prong to treatment — helping clients reconstruct their reality — continues this effort. Here, clients really begin to explore their self-talk and maladaptive behaviors. 

This process is easier said than done. Clients often come to us with low self-esteem, and there is no switch to flip to instantly have them think better about themselves. To emphasize it as an ongoing process, counselors can present it as “chipping away” at old ways of thinking and starting to entertain new ones.

Negative self-talk: One of the first steps in this process is exploring our clients’ negative self-talk and inner critic. This is that voice in our mind that continually criticizes us for not being good enough. It is hard to develop a healthy sense of self with such a critic living within. 

To emphasize the importance of healthier self-talk, counselors might pose the following scenario to a client: “I want you to think about the person you love most in this world. It could be your child, your partner, your niece or nephew, or any person you just absolutely love. Now, tell me how that person would develop mentally and emotionally if you talked to them the same way you talk to yourself.” 

Often, this becomes a rhetorical question that, in my experience, generates tears for many people. They recognize that they would never talk so harshly and critically to someone they love, and they recognize their loved one would not develop into a healthy, confident, high-functioning person if they did. This helps make clear the connection between our self-talk and our self-esteem. If we want to be healthy and confident, it is helpful to talk to ourselves in a way that promotes that. 

Again, this does not mean our clients will flip a switch and miraculously begin thinking only in helpful and healthy ways, but it does lay a foundation for monitoring their thought processes; identifying negative, unhelpful self-talk; and beginning to choose kinder ways of speaking to themselves.

Monitoring negative self-talk becomes another collaborative process. Counselors can prompt discussion by simply asking about it (“What were you telling yourself in that moment?”) and by pointing it out in the present (“I am hearing a lot of negative self-talk as you discuss this. Can we pause to look at that?”). This process teaches clients how to train their own ears to catch it as well. They can begin to monitor their self-talk outside of the counseling office and use interventions such as thought records that they write down and bring back to session. When reviewing such records, counselors can help clients brainstorm new thoughts to interject as healthier ways of thinking. Over time, this practice can give rise to clients monitoring and replacing negative self-talk in real time on their own.

Core beliefs: To further enhance the treatment process, counselors would do well to connect their clients’ thoughts to the idea of core beliefs. Core beliefs are those that develop early in life and become deeply held, foundational views of ourselves, others and the world in general. These tend to take the shape of absolute statements such as “I am _____” or “The world is _____.” Everyone has both positive and negative core beliefs, but the negative beliefs tend to be more prominent, especially for people experiencing enough distress in life to seek counseling.

Early childhood interactions, especially with caregivers, play a significant role in the development of these beliefs. Take, for example, a client who as a child was told by her parents that she was always in the way, she was a “mistake baby,” and they wished they had never had a kid. A profoundly negative message such as this is repeated in various ways throughout the client’s life, so she develops the belief that “I am worthless and unlovable.” One can imagine the implication of this belief on her thoughts and how it interferes with developing healthy relationships throughout life. A second example might be a client who experienced significant traumas early in life and develops a belief that “the world is unsafe and dangerous” or “people are manipulative and untrustworthy.”

Clients are generally not going to walk into the counseling office and tell us their core beliefs. They are usually unaware of this concept, and their beliefs operate more implicitly. Clients’ thought processes and self-talk very much lend insight into what their beliefs may be, however. As we listen to clients share stories about their day-to-day lives, recall memories from their past and especially make “I” statements, we can hear how their language is shaped by core beliefs about being unlovable, incapable, inadequate and so on.

I like to think of core beliefs as root systems. Any flowering plant needs a healthy root system to produce healthy flowers or fruits. An unhealthy root system will lead to unhealthy plants. Similarly, a client’s negative core beliefs will naturally result in negative thought processes. So I want to help my clients reevaluate their root systems, or core beliefs, to establish a healthier foundation that can give life to healthier thoughts about themselves and the world around them.

When working with clients on restructuring how they perceive themselves and others, we cannot expect an immediate switch from negativity to positivity. They have spent their entire lives with these negative core beliefs as a foundation and, once made aware of them, can often provide significant evidence as to why they think their beliefs are true. Our job is to help clients chip away at those unhelpful core beliefs and begin to find a healthier balance. 

We can do so by helping them discover alternative ways of thinking about themselves and then intentionally looking for evidence to support those newer, healthier ways of thinking. This evidence might come from a reinterpretation of past experiences or be found by intentionally looking for it moving forward. For example, a compliment from one’s boss may no longer be shrugged off as obligatory and undeserved, but instead lead to ownership of a job well done — thinking to oneself, “I did do good work on that project. I’m glad it was recognized.” The new evidence and ways of thinking begin to plant the seed of a new core belief of “I am capable” or “I am enough.”

Exposure: The previously discussed interventions for helping clients view themselves differently build motivation and courage for what comes next — exposure. Exposure is generally considered the gold standard for anxiety treatment, which often comes as bad news for those who experience anxiety. It can be hard to hear that engaging in the very situations that create anxiety is ultimately the best way to reduce that anxiety. Avoidance feels safer in the short term, but it impedes us in the long term. 

The inconvenience of this reality is why I like to start treatment with understanding the disorder and developing a better acceptance and valuing of oneself. As we do these things and establish a strong counselor-client relationship, clients grow more willing to expose themselves to situations that require a lot of bravery.

Exposure therapy does not mean identifying what causes our clients the most anxiety and having them jump right in. On the contrary, it is a process of identifying situations that cause varying levels of anxiety and working through them systematically. We can help our clients create a list of situations that create anxiety for them and rate them on a 1-to-10 scale. At the bottom of the list (1) is something that evokes mild anxiety symptoms; at the top (10) is a situation that causes significant anxiety. 

These lists are extremely individualized, but examples may include waving to and saying hello to a neighbor across the road as a lower anxiety situation and attending a networking event where the client doesn’t know anyone as a higher anxiety situation. Between the two are many situations that induce increasing levels of anxiety that can be worked through one at a time, from least frightening to most frightening.

Clients work through the list systematically with the support of the counselor. It may begin with simply visualizing the scenario together in the counseling session and thinking through how it might go, discussing what clients feel as they think about it, and talking about how to best approach the real scenario outside of the counseling office. This imaginal exposure can introduce clients to the process, allowing them to first navigate it from a distance and deal with some of the feelings associated with it prior to engaging the real scenario. 

The idea behind exposure is that clients learn to engage situations that make them uncomfortable as opposed to continuing patterns of avoidance behavior. As they do so, they build a tolerance for discomfort and learn to take control of the anxiety, moving forward even with it present. Successfully engaging situations will help develop a sense of accomplishment and self-efficacy that motivates them to continue working toward more challenging situations. 

Clients will also notice a reduction in anxiety symptoms if they engage situations many times before moving on to a more challenging one. Clients do not need to feel 100% comfortable and confident before engaging the scenarios or moving on to the next one, however. They may need to learn that the anxiety will sometimes come along for the ride. Clients just need to make sure it isn’t driving the car.



Brad Imhoff earned his doctorate in counselor education from Ohio University and currently serves as the director of the online Master of Arts in addiction counseling program at Liberty University. His scholarly interests include the understanding and treatment of social anxiety disorder, substance and behavioral addictions, and counselor well-being and self-care. Contact him at

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.


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.

Increasing mental health access through school and community partnerships

By Jessica Holt August 5, 2022

In 2014, I shifted from working as a professional counselor in a mental health agency to working as a school counselor in the metro Atlanta area. I had experience working with adults and children who had emotional, behavioral and substance abuse disorders, so I thought that transitioning to the school system would provide a much-needed break and keep me from burning out.

I told myself, “This is going to be so much better because I’m going to have a regular schedule and lots of breaks. No more managing crises, being on call, treatment planning or dealing with severe problems.” But I was wrong. Although my role and job title changed, I was still seeing a lot of the same issues, especially self-harm, anxiety and depression.

In addition, working with middle school students requires a lot of energy, flexibility, patience and compassion. You are helping young people at a pivotal time in their personal, social and academic development. They are beginning to learn what is most important to them and create their identity. Combine that with peer pressure, hormones and more rigorous classes and your job as a school counselor seems never-ending.

The current challenges in schools

School counselors, much like teachers, were already suffering from high levels of burnout, fatigue and stress before the COVID-19 pandemic. And the last three years have only made the situation worse. At my school, more students are struggling with depression and anxiety and have less resiliency or grit. Many of our students’ families are also dealing with unemployment, homelessness and financial issues.

All these factors have the potential to affect students’ behavior, mental health and interactions with others. I have noticed an increase in the number of students who engage in self-harm as well as students presenting with suicidal ideations. My school district has a specific protocol for school counselors to follow if a student presents with suicidal ideation. This includes using the Columbia-Suicide Severity Rating Scale, communicating with parents and guardians, referring to crisis services and creating safety plans when students return to school. But this protocol only addresses part of the problem: the suicidal ideation and the need for a safety plan. It doesn’t address the presenting problems of depression or anxiety, nor does it help students develop coping skills to prevent future crises.

Kenny Eliason/

My school also administers a survey to students in the fall and spring each year to assess school climate, student resiliency, social-emotional learning and other topics. The survey results from the previous school year help guide social-emotional learning curriculum the following year. The survey data from 2020-2021 revealed that many students at my school lacked coping skills and grit, so the school system has taken several steps to help students with these issues, including weekly social-emotional learning lessons, wellness campaigns and an anonymous reporting system that allows parents and students to report students who are at risk (e.g., engaging in self-harm, experiencing child abuse, being bullied). 

The Georgia Apex program

My school district was chosen to participate in the Georgia Apex Program during the 2021-2022 school year. This state-wide program, which is funded by the Georgia Department of Behavioral Health and Developmental Disabilities, promotes collaboration between community mental health providers and schools to make mental health services accessible to students and their families.

The program’s goals include early detection of adolescent behavioral health needs, increased access to mental health services for children and youth, and coordination between mental health providers and local school districts. This is a wraparound (comprehensive) program that includes behavioral health assessments, psychiatric/nursing services, individual and family therapy (school-based and community), and community support services (e.g., case management).

My school district partnered with two local mental health agencies so that three schools, including mine, could have a school-based professional counselor onsite to help students who present with a variety of issues, including anxiety, depression, self-harm and suicidal ideation. Kasey Ross, a licensed professional counselor (LPC) who is employed by a mental health agency in north Georgia, is one of the two school-based therapists my school district hired. She works two days at the middle school, two days at the high school and one day at her mental health agency (with the option to come to the school that day if needed).

“When we can detect behavioral health needs early, we can help reduce admission to higher levels of care, reduce unexcused absences and reduce disciplinary actions as well,” Ross says. “Additionally, the program is available at schools, homes and other community places, which makes it flexible and convenient for many families.”

The Apex referral process

School counselors often have large caseloads and limited time to work with each student. This can make it difficult to help students with more severe issues. In addition, school counselors are seeing an increase in students who need mental health services.

This is where the Apex program comes in. The school counselor can gather more information about the student’s personal needs and can give the student and their parents/guardians information about the Apex program. With the parent’s/guardian’s permission, the school counselor can then refer a student to the Apex therapist who has partnered with the school. The referral includes student demographics, presenting problem(s), insurance information (if they have any) and contact information for the parent/guardian.

The program is primarily for students who have PeachCare (Georgia’s version of Medicaid); however, students who do not have insurance are also able to receive services for up to 60 days, and the Apex therapist helps to connect them with local resources to obtain insurance. The school counselor can also refer students who have private insurance, and the Apex therapist can also help connect them with providers who accept their insurance.

Having a school-based therapist in our building, who is accessible four days out of the week, has been a game changer. This program allows school counselors such as myself to help students who might not otherwise receive the care they need because of our high caseloads. Even if we were allowed to provide therapy to students, we simply don’t have the time because our work is solution-focused and brief. Now, after meeting with a student who is in crisis, I can refer them to the school-based therapist, which is often a huge relief for the student’s parents.

And the process is quick and easy. I can give the student the information packet for Apex and do the online referral while they are in my office. The school-based therapist typically reaches out within 24 hours to set up an intake appointment, where they will do a behavioral health assessment and then develop a treatment plan. The therapist discusses with the student and parent/guardian when they will provide therapy and how often, and because the therapist is connected to the school, they can access the student’s school schedule and arrange counseling sessions so they do not affect students’ academic performance. For example, I have several students who meet with our Apex therapist during their electives. In addition, the Apex therapist can also meet with students and families in the community, including at the library, at the therapist’s clinic or in the students’ homes.

The benefits of the program

The Apex program appealed to several parents of my middle school students because it made counseling accessible, convenient and affordable. The community-based mental health provider, Ross, was able to help these students in some way.

One student, for example, reported feelings of depression and anxiety because her parents were going through a divorce and her mother had been diagnosed with breast cancer. As her school counselor, I was able to meet with her and gather more information about how this had been affecting her at school and home. After meeting with the student, I called her parents to tell them about the Apex program and how it could benefit their daughter. They agreed and asked me to send the information home with her and to also go ahead and do the online referral.

The next day, Ross contacted the parents and scheduled a first session with the parents and the student for later in the week. I continued to check in with this student throughout the year, and she said that the counseling sessions had helped her to feel less depressed and anxious.

There are many advantages to the Apex program. According to Ross, “the benefits of school-based mental health services include increased access to mental health services, improved attendance and academic performance, increased engagement at school and a reduction in mental health stigma. In addition, there are typically fewer classroom disruptions, less disciplinary referrals, less course failures and a decrease in inpatient hospitalizations.”

Three schools in our district currently have an Apex therapist. Ross, the therapist working with my middle school and the connected high school, has a caseload of 32 students. Our district also plans to expand this to two elementary schools next year. Ross notes that her agency also provides Apex services to six other counties and has helped 294 students so far. “We are growing and will be able to help even more students and their families next year,” Ross says.

I hope that the funding for this program (and others like it) will continue because it has made a positive impact on the climate at my school and the lives of my students.



Related reading: See Counseling Today‘s August cover story (in which Holt is quoted), “Responding to the youth mental health crisis in schools.”


Jessica Holt is a licensed professional counselor and has been working as a counselor since 2010. She is starting her ninth year as a school counselor. She primarily works with middle and high school students to help them meet their academic, social and emotional needs.


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.

Growing up between cultures

By Lindsey Phillips August 2, 2022

Kurt Bannert, a licensed professional counselor (LPC), left his home in Texas to move overseas at age 10. When his parents told him they were moving to Serbia for missionary work, his initial reply was, “That sounds awesome. You guys have fun. Don’t forget to call or write me or send pictures about how it goes, but I’m not going.”

Bannert’s family was unable to go straight to Serbia and lived in Bosnia for a few months at first. He remembers leaving the warm, 90-degree weather of Texas and moving to a cold city filled with snow and people who spoke a language he didn’t understand. 

He says this experience left him feeling bitter, angry and depressed. “I was angry at my parents. I was angry at God,” he recalls. “I was really mad. I felt it was unfair. I didn’t ask for these things to happen. I didn’t have a choice.” 

Over time, Bannert assimilated into Serbian culture and made local friends. But during high school, he mostly stayed in his room and messaged his friends from the United States, which he says caused his parents to worry that he was depressed. They decided to send him to an international boarding school in southern Germany, where he was surrounded by kids who had similar experiences of living abroad.

As a child, Bannert, who owns a private practice (Third Culture Therapy) in Longview, Texas, had heard the phrase “third-culture kid” (TCK), but he says it wasn’t until he attended this international boarding school and met other TCKs that this term really started to make sense for him. 

TCK, a term coined by sociologist Ruth Useem in the 1950s, describes someone who has spent a significant portion of their developmental years outside of their parents’ culture. A study conducted by Ann Cottrell and Useem in the 1990s revealed that American adult TCKs are often more successful than their homegrown peers, with 44% earning a bachelor’s degree by age 22 and 85% being bilingual. A 2011 survey by Denizen, an online magazine geared for TCKs, found that 30% of TCKs have a master’s degree and 10% speak four languages. 

But this success can often come at the cost of feeling lonely and dislocated. The Denizen survey also found that 70% of respondents weren’t planning to stay or weren’t sure if they would stay in their current city for more than two years. This number increased to 92% when asked if they would stay there for five years. The stressors that come with being a citizen of everywhere and nowhere can lead to anger or depression (as was the case with Bannert), unresolved grief and loss, an uncertain sense of belonging, or issues with relationships.

Cross-cultural identity 

For TCKs, a nomadic lifestyle is often a normal way of life, which can leave them wondering where exactly they belong. They may feel they are “citizens” of many places yet struggle to pinpoint “home.”

As a child, Josh Sandoz, a licensed mental health counselor with a private practice in Seattle, Washington, often wondered about his own cultural identity. He is a U.S. citizen who was born in Seoul, South Korea, and his parents’ jobs caused him to continuously shift between living in Seoul and different parts of the United States. 

When parents make the choice to raise kids internationally, they often don’t realize or think about how they are creating a cross-cultural family, where individuals have different cultural frames of reference, Sandoz says. Parents may assume that their children share the same cultural identity that they do, but this is not always the case. He advises counselors who work with TCKs and their caregivers to initiate conversations around what this cross-cultural family looks like for them.

The TCK population is the epitome of cultural complexity, Sandoz continues, because of their unique and individualized experiences. So he cautions counselors not to make assumptions about a client’s cultural sensibilities based on what they presume to be their ethnicity, race or citizenship. A TCK client can hold divided or multiple loyalties, and these loyalties can be in conflict with each other, explains Sandoz, who founded the International Therapist Directory, which helps internationally mobile people find therapists knowledgeable about third-culture experiences. 

For example, Sandoz knew a TCK who was born in the United States, lived in Europe during elementary school, moved to South Korea for middle school, attended high school in Singapore and went to college in the United States. In college, friends constantly told him to “just be himself,” but he wasn’t sure what that even meant. Was he supposed to be his European self, his East or Southeast Asian self or his North American self?

A TCK may look or sound like they are from the United States, says Denese Marshall, an LPC and advanced alcohol and drug counselor with a private practice in New Canaan, Connecticut, but they have not had the same experiences as their U.S. peers. They may not have gone to football games on Friday night or watched the same TV shows, for example. So they don’t necessarily feel like they “belong” even when they are in a country where they are a citizen. 

In fact, Marshall acknowledges that the question, “Where are you from?” can cause some TCKs to freeze with fear or become anxious because they aren’t sure how to answer. She works with clients and their families to help these kids have a prepared response, such as “My parents are from this city, and we are currently living in this country.” 

Sandoz agrees that the “where are you from” question can be problematic or complicated for some clients, so as a clinician, he avoids asking it. Instead, he asks clients, “Where all did you grow up?” This question is more open-ended and unassuming, he explains, and it allows the client to explore all the cultures and geographic locations with which they identify.

The idea of identity is layered for TCKs, says Aishwarya Nambiar, a doctoral candidate in counseling education and supervision at William & Mary. These individuals are still trying to figure out where they belong, she notes, and some are doing this while also navigating their marginalized identities. 

One of Nambiar’s research interests focuses on how to infuse the TCK experience within the counseling education curriculum because she finds that counselors often do not understand the complexity involved in TCKs’ identities. As a result, TCK clients can feel misunderstood in sessions. She, along with her colleague Philippa Chin, presented on this topic at the 2021 annual conference of the European Branch of ACA. Adult TCKs often come to see Bannert because they are struggling with understanding their personal or national identities now that they are no longer living abroad. To help them begin to unpack all the layers of their identity, he hands them a family crest with four blank quadrants and asks them to fill it in with their identities. Most of the time, clients leave one of the four quadrants empty, Bannert says, because they feel there is more to them and the story they are developing.

Counselors need to be aware of the nuances associated with the TCK lifestyle, Nambiar stresses, because each TCK experiences a unique set of challenges and benefits. If clinicians are aware of these individualized experiences, then they can provide these clients with a space to process and consider all the layers of their identity and how it affects their experience, she says. 

Preparing for transitions 

There are two big transitional developmental periods that many TCKs experience: the transition back to their country of citizenship and the transition from college into adulthood. Marshall often works with parents during this first transitional phase when they are moving back to the United States after living abroad while their children were younger. 

Marshall encourages TCK parents to plan ahead for this transition to reduce some of their child’s anxiety around the move. Here are a few techniques she often suggests to families as they are preparing to reenter their country of citizenship: 

  • Help TCKs become familiar with things that peers in their country of citizenship might have experienced. Explaining cultural references (such as the animated series SpongeBob SquarePants) to them can help prevent them from feeling blindsided.
  • Find a way to continue one of the child’s extracurricular activities, such as playing a sport or participating in a Cub or Girl Scouts program.
  • Contact the child’s new school to see if they will help facilitate activities between classmates or teammates. Even if the school can’t coordinate an activity, they may be able to put families in touch with others who will be attending the school.
  • Have TCKs put together a small book filled with images of where they used to live to serve as a reminder of what they experienced and to take away the “mystery” of that life for the new kids they will meet.
  • Look at pictures of the new town, school and house if possible. Google Earth can be one great way to explore a new area virtually.
  • Ask TCKs to create a time capsule or memory box of special things from the place they are leaving (such as a small toy, a little snip of their bedspread, or photos or video recordings of familiar places).

Sandoz advises counselors working with adult TCKs to be curious and explore these types of transitions to see what each experience was like for them. To learn more about his clients’ transitional experiences, he often asks questions such as “What was it like for you in fifth grade when you moved from Amsterdam to New York?” It may also be helpful for clients to create a timeline or visual map of all the moves and transitions, he adds.

As TCKs transition out of college and enter their late 20s and early 30s, Sandoz says that it’s not unusual for them to wonder, “What now?” This is another transitional time when counseling can help clients as they process and identify what they want to do as an adult. This is a natural part of development, but being a TCK adds layers of complexity, he explains.

Counselors could also connect TCKs with resources such as seminars on these types of transitions. After his senior year of high school, Sandoz had the opportunity to attend a seminar on the transitions of TCKs. “More than anything, it was a very emotional experience just to be with others who were also transitioning … and just share stories and think about what we were going through,” he recalls. 

Regaining choice 

Constantly moving may cause some TCKs to unconsciously internalize that their own wishes do not matter and that things just happen to them, Sandoz says. If a TCK was excited because they just made the soccer team at their school but then finds out their family is moving again, for example, they may be upset about relocating to a new country where they may not be able to play soccer. The situation could cause the child to internalize that their wishes do not matter, Sandoz says.

To counterbalance this, he often advises parents to allow TCKs to make small choices to give them autonomy and independence in areas where they can have control. For example, maybe the child gets to pick what the family eats one night each week or which restaurant they go to. 

Bannert agrees that allowing TCKs some form of choice helps offset the fact that they did not have control over the decision to move to another country. It can sometimes be challenging for parents to understand how their kids feel, he explains, because they processed and dealt with the consequences of moving when making the decision. The kids, however, did not.

Parents also have to give kids space to make choices independently — even if that means they mess up occasionally, adds Bannert, who oversees a mental health program for the Ore City Independent School District in Upshur County, Texas. If not, when they get to college or move out on their own, they may not know how to make their own choices.


In fact, lack of choice during childhood can even result in an inability to make decisions as an adult. Sandoz says he’s known some adult TCKs who specifically partner with people who will make decisions for them. Counselors can help clients realize that it’s OK to have preferences and empower them to get to know more about their own agency, he says. 

TCKs learn to adapt and assimilate to the various cultures that they live in, but this can also  make them unsure about their own preferences, Sandoz says. “And sometimes there’s not a lot of focus given to getting to know oneself [in that way] or giving oneself permission to hold those kinds of preferences because there can be such a high value for blending in,” he adds.

The counselor’s role, Sandoz says, is to ask questions and listen to get a sense of whether this behavior of allowing others to make decisions is something the client is choosing or whether it’s a pattern that is getting repeated based on their past experiences as a TCK.

Bannert says sometimes his TCK clients look to him for all the answers because they are used to having choices made for them. If this happens, he focuses on helping them regain agency and encourages them to find the answers on their own.

Unresolved grief and loss 

Saying goodbye to people and places is so commonplace that TCKs often don’t even recognize they are experiencing grief when they leave, says Nambiar, a resident in counseling in Virginia. 

Bannert’s adolescent clients struggle with grief when they move away to college, and because they are TCKs, the grief is complicated by the fact that they are often moving to a new country and adjusting to cultural differences in addition to leaving behind their family, he says. He helps them recognize the grief associated with this transition and advises them to say goodbye to the people, place and culture. If a client is struggling to say goodbye because of some internal conflict, then Bannert may have the client do the Gestalt empty chair technique or write a goodbye letter to someone or someplace to help them better understand their thoughts and feelings about leaving that country. 

Some families do allow grief to be a part of the process when moving, Sandoz says. They eat at their favorite restaurant one last time, they say goodbye to their friends, and they give themselves permission to be sad. But other families just pack up and go. They don’t allow the children time to mourn, he continues, because they don’t realize how hard it will be on them or they assume the children are too young to remember it. Not allowing for grief could put the child in danger of repeating that dynamic when they get older, he adds. 

Sandoz advises counselors to acknowledge the loss associated with moving. For example, he may tell a client, “Growing up as a TCK, you’ve probably had a chance to say a lot of hellos and goodbyes. What has that experience been like for you? Were you able to say goodbye? If so, what were those goodbyes like?”These questions allow the clinician and client to notice areas where the client experienced grief as a child and where they may still be grieving, he explains. 

Being in a household that doesn’t allow for them to express their feelings around these transitions, Sandoz notes, can lead to unresolved grief that TCKs carry into adulthood. But therapy presents an opportunity for the counselor and client to create “a relationship together where there is freedom to actually feel those things and express those things and sometimes actively grieve losses that maybe were experienced years and years ago but were stored up somewhere inside all this time,” he says.

Parents may inadvertently minimize their child’s sadness or grief by focusing only on the positive aspects of living abroad. Children may be told they should be happy about this “great life” or the next adventure, for example, but this often results in unresolved loss, Marshall says. It may be challenging for some parents to let their children feel sad, she admits, because they often want to distract their child or refocus on the positive to make them feel better. Counselors can work with parents to help them resist this urge and instead acknowledge the loss and give the child the space to feel and process all the emotions they may have about the move, she says. 

Counselors can also work with parents and caregivers to help them and their children recognize and grieve the losses that come with transitions. It can be tempting for families to downplay or overlook a young child’s grief at moving away from what is familiar and comfortable, Sandoz says, because they assume the child won’t remember the grief that comes with moving. A three-year-old child, for example, is just becoming familiar with the language and routines around them, so moving overseas to a country where the sights, sounds and smells are all unfamiliar would set the stage for this child to experience many types of losses simultaneously, he says. 

Nambiar acknowledges that therapy can help TCKs accept the challenges and realities that come with this lifestyle as well as find the beauty in it. “You can be sad that you have to say goodbye to these people,” she explains. “But you can also recognize that you’ve had a lot of experiences now and you’ve met so many different people and you’ve grown because of that.” 

Rethinking relationships 

This mindset of constantly moving affects the way TCKs view relationships. Although a transient lifestyle allows TCKs to connect easily with others, Nambiar says, it can sometimes be difficult to maintain the relationships they have made when they have to move again. 

Marshall has noticed that her TCK clients may not put a lot of effort into developing close relationships. For example, they may not see the point in attempting to resolve a conflict with a friend because they assume that in a few months one of them will move away. 

It’s common to see more shallow or disrupted relationships with the TCK population, Marshall continues. She once knew a TCK who had attended 14 schools in 12 years. As an adult, this woman lived in the same town for more than 30 years, yet she hadn’t developed any close friendships because of this ingrained mindset that she shouldn’t get too close to anyone in case she had to move. Someone who is struggling to form or maintain relationships like this could benefit from counseling, Marshall says, because it could help them process the loss around moving and learn how to develop deeper connections and be vulnerable with others. 

These interpersonal issues and conflicts often resurface later when the TCK becomes an adult. Several of Bannert’s adult TCK clients have come to counseling because they are struggling with romantic relationships. “They tend to act like someone who has been abused or traumatized,” he says. “Whenever someone starts to get close to them, they break it off because they’re afraid to be intimate. … They’re so afraid they’re going to lose something good that’s outside of their control.”

Bannert works with TCK clients to help them be more vulnerable and form healthy boundaries within relationships. They tend to share a lot of details about their life really quickly, he explains, because they grew accustomed to having to get to know someone fast before one of them moves away. This approach of sharing too much too fast, however, can scare someone who didn’t grow up as a TCK, so he helps clients learn appropriate boundaries when first getting to know someone who is not familiar with a TCK lifestyle.

Marshall also encourages the parents of TCKs to use technology to promote healthy relationships for their children. Video chats and social media can become tools that allow TCKs to stay connected with long-distance friends and help them develop deeper connections even after relocating, she says. Parents often have valid concerns about social media use, she adds, so she takes time to clarify that staying in touch in a structured, meaningful way is more beneficial than simply “following” someone on social media or “liking” what others post.

Putting down roots

TCKs often have many homes but do not have one place where they feel settled, Nambiar says. Home is everywhere and nowhere. 

Some TCKs may struggle with feeling grounded, Bannert says. They may be “stuck” — living in transitional housing or jumping from job to job out of a fear of what it means to “settle down,” he explains. Bannert once knew a TCK adult who refused to unpack even after living in an apartment for almost two months. The man couldn’t shake this restless feeling that he may move, even though he had just signed a two-year contract for his job.

Bannert encourages his clients to find ways to root or ground themselves in some way. To help with this process, he sometimes asks clients to create a vision board of their five-year plan so they can find something they can work toward, which helps grounds them. 

Bannert and Marshall both agree that this notion of being “settled” or “grounded” does not have to refer to something physical, such as a 30-year mortgage. Clinicians working with TCKs may have to help clients expand this concept and reimagine ways they can ground themselves despite undergoing constant transitions or feeling restless. For example, TCKs could ground themselves in a relationship by staying connected with a close friend online, Marshall says.

Bannert admits he still has moments of restlessness and a strong desire to travel, but he takes his advice to heart and finds ways to ground himself. He has one object that comes with him during every move: a plaque containing the words of a Serbian prayer. “That’s the first thing that gets hung up and it’s the last thing to come off the wall,” he says. “It grounds me.



Lindsey Phillips is the editor-in-chief for Counseling Today. Contact her at


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