Tag Archives: stress & anxiety

Treating anxiety in children

By Lisa R. Rhodes August 7, 2023

A counselor sits in a circle with a group of kids. The counselor has a notepad and pen and is giving two of the kids high fives.


Childhood is quickly becoming a time of increased worry and emotional distress. According to a Department of Health and Human Services study published in the Journal of the American Medical Association in March 2022, the number of children aged 3 to 17 diagnosed with anxiety grew by 29% between 2016 and 2020. In fact, medical and mental health professionals have become so concerned about the increase in childhood anxiety that last October the U.S. Preventive Services Task Force called for health care professionals to begin screening for anxiety in children aged 8 to 18.

Counselors who treat children for anxiety, specifically those aged 6 to 12, say the rise in childhood anxiety is due in part to the fast pace of modern society as well as the onset of COVID-19. “Our culture [is one] of busyness, constantly moving with lots of good opportunities, but almost too many good opportunities, keeping kids busy with structured learning instead of learning through observation and play,” says Hannah Pitman, a licensed professional counselor (LPC) at Abundant Life Counseling Services in Austin, Texas. “Kids are forced to make so many more microdecisions every day that their brains get on overload. They are constantly in communication and contact with everyone … at any time.”

A child’s life used to be less complicated, she continues. They went to school, played during recess, came home, ate dinner and went to bed. But today, there are more activities for children and more decisions to make. For example, after school, do they go to gymnastics, play soccer, attend piano lessons or chat with friends on social media?

“As our culture has [evolved], decisions and opportunities have grown,” Pitman says, noting that a child’s brain needs these opportunities to be given by parents in smaller doses so there will be less psychological stress for them.

Pitman and Aileen Elsaesser, an LPC at Sunstone Counseling in Alexandria, Virginia, note that genetic and environmental factors both play a role in children developing anxiety and displaying anxiety-related symptoms (e.g., feeling nervous, having temper tantrums, catastrophic thinking). Elsaesser says children who grow up in an environment where parents or caregivers display anxious behaviors or who have experienced a stressful event (e.g., moving to a different state, being in a car accident, losing a loved one to a terminal disease, being bullied) may develop a tendency toward anxiety.

Children want to play and have fun, but anxiety takes away their ability to play uninhibited and enjoy life, says Pitman, who treats children and adolescents with anxiety disorders. “Normal levels of worry and stress impact us, but not in a way that they make our daily lives overly difficult,” she explains. “When anxiety starts to impact a child’s ability to function and enjoy life, that’s when it’s time to make a change.”

Assessing for anxiety

Parents play a pivotal role when assessing children for anxiety. Elsaesser recommends counselors have parents participate in the intake process because they know their children best and can be helpful in answering questions about the child’s emotions and behavior.

“Clinicians will perform a detailed intake evaluation with the parents to discuss symptoms, severity and functioning of the child,” says Elsaesser, who specializes in treating children struggling with anxiety and phobias. “We ask for physical symptoms, anxious thought patterns, behaviors indicating anxiety and how it is affecting functioning in different areas of the [child’s life].”

Elsaesser recommends counselors use the Screen for Child Anxiety Related Emotional Disorders Assessment with both parents and children during intake. This self-report assessment screens for general anxiety disorder, separation anxiety disorder, panic disorder and social phobia in youths aged 8 to 18. The assessment statements for children (e.g., “When I feel frightened, it is hard to breathe,” “I don’t like to be with people I don’t know well”) and parents (e.g., “My child worries about other people liking him/her,” “When my child gets frightened, he/she feels like passing out”) are rated on a scale of 0 (not true or hardly true) to 2 (very true or often true).”

Elsaesser says the assessment gives her insight into a child’s understanding of their own anxiety and what parents may notice but the child does not recognize. The information from these assessments helps her formulate a treatment plan, but she notes that screening is not the sole determining factor for diagnosis.

Pitman often asks her clients’ parents if they have noticed any changes in their child’s behavior or if it is affecting the child’s daily functioning. To determine this, she tells parents to ask themselves the following:

  • Is my child having trouble going to school every day?
  • Is my child unable to enjoy fun events?
  • Is my child obsessing over something or someone?
  • Is my child feeling afraid more often?
  • Is my child irritable every day and unable to control their emotions?

For example, if a child refuses to attend school, has trouble concentrating in school, avoids sleepovers and parties or doesn’t try new things or if their physical symptoms (such as stomachaches or headaches) cause them to be impaired, then the parents should consider having their child assessed for anxiety.

Jena Jozwicki, a licensed associate counselor at Elevate Counseling in Glendale, Arizona, says she uses her own checklist of questions to screen children for generalized anxiety disorder. These questions include:

  • How long have you been feeling this way?
  • How often do these anxiety attacks occur?
  • When do you notice the symptoms most?
  • How do you know you are experiencing anxiety?

These questions allow Jozwicki to understand the severity and frequency of the child’s anxiety symptoms so she can best classify and make a diagnosis.

Determining an effective treatment plan

The counselors interviewed for this article agree that cognitive behavior therapy (CBT) is an effective treatment for anxiety disorders because it helps children become familiar with their distressing thoughts and learn how to replace them with healthy thinking patterns. It can also help them learn to become more aware of their emotions and how they influence their behavior.

Counselors should also consider working with parents during therapy because family members can be helpful in teaching children how to recognize anxiety and implement the coping skills and behaviors they learn in treatment.

Pitman devotes the first few sessions of therapy to helping children build emotional and relational skills and determining what modality will work best for the child and their family. She often finds CBT, trauma-focused CBT, eye movement desensitization and reprocessing, internal family systems and trust-based relational intervention work well for her clients. She also uses the information she gleans from these first few sessions to help her later assess if the child is progressing or regressing.

During the first therapy session, Pitman meets only with the parents to establish rapport and learn more about what the child is struggling with, without having to use age-appropriate words or timing. Pitman asks parents, “What are you hoping I can help you with?” and “What have you tried already?”

Pitman wants to know if the parents have a good understanding of anxiety or if this is their first time encountering it. This helps her determine how much psychoeducation about anxiety is needed at the start of therapy. She also discusses the importance of parents spending quality time to connect with their child and to be empathetic to validate the child’s experience and let them know the parent is there to help them manage their anxiety.

Pitman devotes the second session to helping the child and parent(s) build rapport for the work they will do together in session. She says she usually begins this session by asking the child and parent(s) to play a trust-based relational intervention connection game to increase co-regulation between the child and parent and build communication to disarm shame and confusion around anxiety in the home.

“When a child’s home is an open place to talk about their needs, they are better able to manage their anxiety,” Pitman adds.

One connection game she often has her clients play involves the use of Band-Aids. Pitman asks the parents and child to share a happy and a sad thing that happened to them during the week. Then the parents put a Band-Aid on the child for their sad thing, which shows empathy and care, and the child puts a Band-Aid on the parent for their sad thing. This activity is one of Pitman’s favorite games because it helps children build emotional and communication skills, allows parents to model how to talk about positive and negative feelings, and lets parents and children practice giving and receiving care. Even the simple act of asking where the person would like them to place the Band-Aid helps build the skill of asking permission and negotiating emotional needs.

After playing the game, Pitman works with the child alone, if they are comfortable, to build rapport, and she incorporates psychoeducation to teach them about the purpose of therapy and normalize their experience with anxiety. For example, she may ask, “What do you know about counseling?” and “Sometimes kids worry and feel like they can’t stop. Have you ever felt that way? Did you know that a lot of other kids often feel that way?”

Pitman continues to meet with both the parents and child during the third and fourth sessions and keeps her focus on building rapport and introducing the child to breathing exercises, which can be fully implemented in later sessions.

“These [early] sessions give you time to build rapport and determine the severity of the child’s anxiety,” Pitman explains. “Once you have seen that, you are able to see if there is something deeper the child needs to process, like trauma, or if it is general anxiety.”

Pitman says a counselor can also learn where the family stands in terms of the child’s treatment. Are the parents able to complete the assigned activities at home? Can the parents help the child manage their anxiety or are they dealing with their own anxiety and are not able to help? The answers to these questions help counselors determine a treatment plan for the client, she notes.

Learning to handle distress

Elsaesser recommends teaching clients distress tolerance skills because they can use these skills throughout their lifetime whenever they encounter stress. She provides a hypothetical example to illustrate how counselors can help children struggling with anxiety learn to manage physical symptoms and de-escalate anxious thoughts by evaluating and reframing them.

Eric is 9 years old and has been struggling with separation anxiety for several years. His parents are not aware of any specific incident that caused his anxiety, but his mother’s side of the family has a history of anxiety disorders. When Eric begins counseling, he presents with several anxiety symptoms, including worrying that something bad might happen to his parents. He becomes nervous and stressed if his parents are not near him. He calls his parents multiple times throughout the day to check on them. Every time they leave, even when he knows where they are and when they will be home, he asks repetitive questions for reassurance, such as “Where are you?” “When will you be home?” “Are you going out tonight?” “Who will put me to bed?”

He tells the counselor he is experiencing stomachaches, a rapid heartbeat, fast breathing, shakiness and muscle tension, and he has a difficult time concentrating when he is worried or nervous about his parents’ whereabouts.

In therapy, Elsaesser says she would teach this client relaxation and coping techniques to handle his physical symptoms. She would first ask him to draw a picture of his body and to point out all the places where he experiences physical symptoms. Then she would normalize his experience by telling Eric that the symptoms are common in people who struggle with anxiety.

Once Eric knows what anxiety looks and feels like in his body, Elsaesser would encourage him to name these bodily symptoms when they arise. For example, he may say, “My stomach hurts because I am worried about being alone.” She would also have him practice relaxation techniques, such as deep breathing and tensing and releasing his body through progressive muscle relaxation.

Elsaesser would use CBT techniques to help him get control of his thoughts. She would discuss thoughts versus facts and helpful/useful worries versus unhelpful/useless worries. “I would explain that helpful worries keep us safe, like how worrying about getting injured by a car makes us look both ways, but unhelpful worries keep us from living joyfully or doing the things we want to do,” she explains.

Elsaesser says she would then ask Eric to imagine the worst-case scenario for his parents. He may say that his parents could fall and get hurt when they are walking the dog, and if no one knows, they would be stuck there alone. She would also ask him how likely it is that would happen. He may admit that it is not likely but insist that it could still happen.

Elsaesser says she would then shift the focus to how he would handle the situation by asking, “OK, so it’s not very likely, but would you be able to handle it if that happened?” Eric may respond by saying, “No, because they’d be hurt, and I’d be so worried and sad.” She would validate that Eric is probably right that he would feel that way, but she would also ask him what he means when he says he couldn’t handle it.

“Usually when kids say they can’t handle it, they just mean that it would be difficult to deal with,” she explains. “But they will get through it because they have to and they have gotten through difficult things before.”

To help Eric put his fear and anxiety into perspective, Elsaesser would also use Socratic questioning and ask him, “If your parents did fall, then what would happen?” or “If others helped you, what would happen?” By taking this approach, Eric may respond to the scenario by saying, “Yeah, it has never happened before, but they always walk on the sidewalk in our neighborhood so a neighbor could see them.”

“Lots of times worries feel very big and overwhelming, but once we say them out loud and question them, we see they are not likely to occur or are that difficult to manage,” Elsaesser says.

Setting children up for success

With treatment, children can learn to feel more at ease with themselves and the world around them. Helping clients build a strong social network outside their family and school is pivotal in helping them learn how to better manage anxious thoughts and emotions, Jozwicki says.

“For those presenting with anxiety disorders, a strong social network may also serve as another outlet for them to share their concerns with their peers,” she explains. “Social networks, such as friendships, allow children to feel safe, which is the opposite of feeling anxiety.”

Elsaesser says when children learn what anxiety is, how it shows up in their bodies and what skills they can use to manage their anxious thoughts and behaviors, it sets them up for success in handling anxiety throughout their lifetime.

Pitman agrees. “When children can recognize what is happening in their body and build new neural pathways that take them to deep breathing, calm problem-solving skills and regulated ability to think, they can become adults who are no longer consumed with anxiety,” she says. “And instead, they can live peacefully and enjoy their life, no matter what comes their way.”


Lisa R. Rhodes is a senior writer at Counseling Today. Contact her at lrhodes@counseling.org.

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.

Treatment strategies for race-based traumatic stress

By Portia Allie-Turco July 18, 2023

A close-up of a Black person staring off to the side


Black Americans often face increased risk of health and mental health conditions because of systemic and structural racism. For example, they are more likely to face discrimination in employment, schooling, housing and health care or to be exposed to and die from preventable or manageable illnesses (such as the COVID-19 virus) because of medical neglect. Exposure to life stressors exacerbated by oppression and chronic socioeconomic disparities leads to higher rates of illness and death. In fact, across most health metrics, Black Americans have increased chances of physical deterioration and early death.

These physical experiences compound Black Americans’ risk for emotional and mental health challenges because they all contribute to the suffering and complications of trauma. In addition, these experiences with discrimination and oppression can result in race-based traumatic stress, a term used to describe the stress Black Americans experience because of cultural, individual and institutional encounters with racism.

Although Black Americans experience mental illness at rates similar to or higher than other populations, research shows that they face multiple barriers to effective mental health treatment. For instance, Black Americans are more likely to terminate counseling prematurely when they do initiate counseling services because of prohibitive cost, limited health insurance, limited numbers of facilities in stressed neighborhoods and transportation issues, among many others. Often, inadequate care is associated with mental health providers’ lack of cultural competence, which exacerbates these mental health inequities.

As the ACA Code of Ethics stipulates, counselors have the ethical obligation to develop the awareness, knowledge and skills related to cultural competence to eliminate barriers effectively for Black Americans. For mental health professionals, that means understanding how to treat Black American clients who are affected by racial trauma. Counselors have a role to play in dismantling racism and its complicated, corrosive effects within our society.

Creating a safe environment

To address race-based traumatic stress, counselors first need to prepare to broach issues of race in session. When counselors are comfortable discussing racial issues in counseling, they reduce the likelihood that Black American clients will water down their racialized experiences to make them palatable to the counselor. It is also important for counselors to emphasize to clients that the responsibility for inclusive counseling rests solely on the counselor. A counselor could approach this by saying, “I know that it’s not your job to educate me about race and racism, and I want you to know that I’m doing my part to keep learning and growing in this area.”

Counselors can acknowledge the difficult issues that are present due to systemic racism and broach the topic in session by saying, for example, “Do I have your permission to point out and talk about what seems to be a racially based survival strategy in the discussion we are having right now?” or “I’m wondering if you are feeling like I get it when you are sharing your experiences with microaggressions at work.”

Black American clients have developed several strategies to deal with racial trauma and stress, including double consciousness and code-switching. Double consciousness, a term coined by W.E.B. Du Bois, describes how Black Americans face pressure to embrace their Black American identity to distance themselves from the presumption that Black people are culturally inferior, while also being aware of the need to internalize a Eurocentric identity and value system to gain respectability. Thus, Black Americans constantly scan and make decisions about whether their Black American identity can be acceptable in white spaces. Living with this double consciousness results in increased stress and hypervigilance.

Code-switching, or alternating between two or more languages or varieties of language in conversation, is a protective strategy that Black Americans use when responding to environmental stress associated with being Black in white spaces. In therapy, a Black American client might change their vernacular when expressing themselves to a non-Black clinician. For example, a client might not use the phrase “do you feel me,” which is a phrase commonly used in the Black community to establish relatability and check for cognitive and emotional connection and understanding, with a racially different counselor. Instead, they may say, “Do you understand what I mean?” to ensure that the clinician understands them. But this change in phrasing causes the counselor to lose the richness of the client’s desire for connection and relatability.

Code-switching also applies to appearance. A Black American client, for example, might feel pressure to conform to white norms of beauty or dress rather than embracing an Afrocentric aesthetic in how they style their hair or what clothes they wear. This constant switching is mentally and emotionally exhausting and prevents Black American clients from fully engaging in therapy as their authentic selves.

It is the counselor’s responsibility to unburden the Black American client from having to code-switch for the counselor’s benefit. Clinicians should develop awareness and address the pressure their clients feel to code-switch by saying, for example, “I wanted to let you know that I’m familiar with the phenomenon of code-switching and why it may have been necessary. In this space, I would like to support you in feeling safe to be fully yourself without fear of encountering microaggressions or being stereotyped.”

Treating race-based traumatic stress

Individuals with race-based traumatic stress can experience psychological and physiological symptoms similar to posttraumatic stress disorder, including avoidance, hypervigilance, flashbacks, nightmares and physical pains. They may also experience grief, loss, anger, shame and self-blame. Counselors who do not understand race-based trauma symptomatology, however, may overlook signs of this type of trauma, which further limits Black Americans’ ability to receive adequate treatment. (For more on assessing racial trauma, read the online exclusive “Conceptualizing and assessing race-based traumatic stress.”)

After assessing for race-based traumatic stress, counselors can use the following treatment approaches to ensure they are addressing the underlying mental health issues related to racial stress.

Disenfranchised grief. Effective trauma treatment universally requires acknowledging and addressing losses that have occurred as a result of the trauma. The treatment considerations are similar when the trauma is caused by racism. Living as a Black American means dealing with pervasive impacts of systemic and structural racism stemming from slavery. It is no wonder then that Black Americans suffer from a profound sense of grief that often manifests as a loss of trust and safety on every level in both social and personal life. Furthermore, this type of grief is disenfranchised, meaning that it is not openly acknowledged, mourned or publicly supported as being legitimate.

To address the profound grief of racial trauma, counselors must recognize that single-incident racist experiences are compounded by collective racial trauma. This larger narrative of disempowerment, which is part of a whole history of trauma inflicted on people of African descent, needs to be recognized and validated as part of the process of healing.

When a Black client expresses grief related to their own racialized experience, or the cultural grief they carry, a counselor can ask the client to name the specific grief, and they may also need to situate the grief in the context of historical losses, such as the long-lasting impacts of slavery. It may be helpful to offer a validating comment such as “What you are experiencing is called disenfranchised grief because the grief that you feel is not always acknowledged or recognized by others.” In addition, the counselor can facilitate a grief ritual, or suggest that the client develop one that will have meaning and healing potential for them, such as sharing with other Black clients in group therapy.

Emotional processing and regulation. Clients who have survived racially charged incidents often present to counseling with complex emotions surrounding these experiences, which require processing in therapy. Several emotions that can be challenging for counselors to work through with Black American clients are anger, shame, humiliation, and internalization of stigma and racist attitudes that stereotype Black Americans as threatening, explosive, dangerous or impervious to pain.

Counselors need to acknowledge that Black people spend a lot of time managing their emotions in white spaces to protect against potential backlash resulting from stereotypes of aggression and violence. Part of this protection is to self-silence and push down emotional responses, such as anger. Dealing with anger and underlying hurt, however, is necessary for the recovery process. Therefore, counselors must work to elicit truthful expressions of anger that may be suppressed by the clients. For example, a counselor might broach this topic by saying, “I’m noticing that you seem agitated when we talk about this certain topic. I’m wondering how it feels to express your emotions in this space. I’d like you to know there is no need to self-silence here.” The counselor can also encourage the client to identify and deal with the underlying emotions, including hurt, injustice, and generational pain and oppression, and they can validate that these emotional expressions are justified considering the historical and ongoing racial issues.

When a counselor can sit with and hear the client’s anger, it creates a safe space for the expression of painful emotions. Thus, the ability to remain grounded when a Black American client expresses anger is an important skill for counselors to have when working with this population and requires an inner posture of non-defensiveness, particularly for white counselors who may experience their own discomfort with the interaction. Counselors need to practice being grounded before entering sessions with clients experiencing racial trauma. This may mean taking time to regulate their own breathing, thoughts or body tension; cultivating a curious and open mind; and seeking supervision with mentors to explore biases and process emotionally charged sessions.

Counselors can also support Black American clients in expressing anger in healthy ways, such as through journaling, music, dance, art and social justice activism.

Internalized racism. Trauma undermines the sense of self and the belief in one’s worthiness, so in racial trauma treatment, counselors must also directly address shame and self-blame. The humiliation that is associated with experiences of trauma often results in a sense of shame that leaves the person feeling intrinsically unworthy. These feelings are related to self-blame where a client might internalize a violator’s view of them and believe that aspects of themselves are responsible for the racial trauma they have experienced, rather than holding the violator alone responsible. Black American clients who internalize racism might speak derogatorily about themselves as a member of the Black American community.

Clinicians can address internalized racism with clients by using culturally adapted cognitive behavioral approaches that focus on restructuring the cognitive distortions that result from trauma and false beliefs. By holding those who violated them accountable, Black American clients can begin to heal and move toward healthy trauma integration.

Focusing on cultural strengths

Counselors must also challenge the notion that Black Americans live in communities that are riddled with problems that can only be solved by adopting Eurocentric solutions. That approach is based on deficit models, in which systemic and structural challenges due to oppression are assigned to Black people and their responses are pathologized. Instead of applying a Eurocentric lens to try to understand an Afrocentric culture, counselors should incorporate an Afrocentric worldview as an antiracist and culturally responsive approach to the treatment of Black American clients. Although largely ignored in counselor training, professional development and even scholarship, an Afrocentric worldview supports the development and maintenance of cultural pride, which research has found increases resilience as a buffer in the continued struggle against oppression. An Afrocentric worldview includes an awareness that Black Americans have retained elements of the ancestral wisdom of Africa, passed down generationally. This ancestral wisdom is reflected in many aspects of their cultural worldview, including:

  • An understanding that spirituality is central to many Black American clients
  • A focus on community connection, as opposed to individualism
  • A holistic view of life experiences that includes natural rhythms and cycles
  • A circular thought pattern that goes beyond a linear approach to include broader contexts
  • An understanding of the importance of relational storytelling

Counselors can become knowledgeable about Black American culture through social justice initiatives such as Nikole Hannah-Jones’ The 1619 Project, which highlights the legacy of slavery in the United States. Counselors must be willing and able to listen to their clients’ stories and be mindful that storytelling may be fuller and more detailed and does not immediately “get to the point” in a way that they are used to. In addition, counselors must be comfortable exploring spirituality with clients and encourage them to use their cultural identity to care for themselves, their families and their communities as a part of healing.

Cultural beliefs and practices are protective for people who have experienced historical trauma. Counselors can use narrative counseling approaches to help Black clients facilitate a strong connection with Black American culture, which can help buffer them against racial harm, as noted in the literature. Viewing Black American culture as a rich source of strength and power can promote wellness by leveraging existing resources within the culture that have endured despite overwhelming and systemic oppression. Researchers have identified six primary cultural resources that operate as forms of wealth or capital for communities of color:

  • Aspirational capital: the ability to pursue hopes and dreams even in the face of barriers
  • Linguistic capital: the language and communication skills that a person has acquired throughout their life, including core expressive concepts such as virtuosity, originality, creativity and beauty, which are reflected in dance, music, poetry, theater and art
  • Social capital: the ability to develop and maintain supportive relationships and networks
  • Navigational capital: the ability to adaptively negotiate social institutions that are unwelcoming and exclusionary
  • Familial capital: using kinship connection to build on generational knowledge and intuition
  • Resistance capital: the endurance, perseverance and skill to stand firm in one’s cultural identity and engage in actions that protect and promote equality

Counselors can tap into all these expressions of cultural strengths when working with Black American clients to support them in healing and in using cultural buffers to shield against the ongoing onslaught of racial trauma. Working from this framework and accessing each empowering aspect require counselors to identify, affirm and incorporate them in treatment planning. This is crucial because cultural strengths have provided the bedrock for Black Americans’ survival and enable their ongoing ability to persevere.

Promoting healthy coping strategies

Trauma recovery involves learning effective coping strategies. In counseling sessions, counselors can teach emotional regulation and stress tolerance skills, such as breathing techniques, somatic therapies and other trauma-responsive care, all with the understanding that these efforts are necessary to address the unique and ever-present racial stressors. Other coping strategies include inviting Black American clients to create a space for rest and restoration, exercise, movement and dance, self-expression and spiritual practice.

Counselors can also explore how Black American clients have coped in the past, including engaging with community support. Research shows the benefits that communal healing has for Black Americans, so group counseling can improve the well-being of survivors of racial trauma. Racial healing circles, for example, offer a supportive healing environment for processing racial wounds. Similarly, sister circles — a sacred space that Black women create to accompany one another as sisters on their healing journeys — is another example of communal healing that also draws from ancient African wisdom. Counselors can facilitate similar types of support through traditional group counseling that is modeled after healing circles or by referring clients to locally run racial healing circles within their community.

Another mental health strategy is to empower and support Black American clients’ need to self-advocate for social justice. Research shows that Black American clients benefit from resistance strategies that encompass activism, such as non-violent confrontation with racism, lobbying for anti-racist policies and other actions that support the client.

When counselors adopt an anti-racist stance and communicate it consistently, they join the client in actively challenging the status quo. In learning about culturally inclusive care and applying strategies for treating race-based traumatic stress, counselors can fulfill their ethical responsibility and make significant advances in addressing the existing mental health inequities for Black Americans.


Learn how to access for race-based traumatic stress in the companion article “Conceptualizing and assessing race-based traumatic stress.”


headshot of Portia Allie-Turco

Portia Allie-Turco is an assistant professor, clinic director and program coordinator in the Counselor Education Department at the State University of New York at Plattsburgh. She is also a licensed mental health counselor who specializes in healing racial, generational and complex trauma. Contact her at p.allieturco@gmail.com.

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.

Conceptualizing and assessing race-based traumatic stress

By Portia Allie-Turco July 6, 2023

A silhouette profile group of men and women of diverse cultures


Counselors have a responsibility to promote and provide equitable care and treatment as outlined in the ACA Advocacy Competencies and the Multicultural and Social Justice Counseling Competencies. To do so, counselors require awareness, knowledge and skills to work effectively with Black American clients. Clinicians seeking to treat Black American clients must understand that racial trauma is deeply rooted in historical, generational and ongoing systemic oppression and has a pervasive impact on the well-being of Black individuals and communities. The toll of racism is implicated in health and mental health disparities that can be addressed only through knowledge, awareness and a commitment to culturally responsive care. Culturally competent counseling requires specialized conceptualization, assessment and treatment of racial trauma.

A foundational understanding is that racism is embedded in all aspects of daily life and is a common and frequent experience for Black Americans. Racial inequity has profound economic, health and mental health impacts. Racial disparities contribute to unequal access to employment, education, housing and other material resources. Black families are more likely to live in dangerous neighborhoods and areas of concentrated poverty, have limited employment and poor access to quality health care, and experience food deserts, all of which exacerbate the effects of poverty and impede access to opportunity. Racism contributes to mental health issues such as anxiety, depression and posttraumatic stress. Racism is implicated in the phenomenon of weathering — a trauma response related to repeated exposure to chronic stress and adversity — resulting in myriad chronic health issues including hypertension, obesity, heart disease and early death.

The effects of racism extend to the counseling realm. Historically, racial trauma in Black American slaves was attributed to mental health conditions not believed to exist in other people. In 1851, Dr. Samuel Cartwright, who had apprenticed under Dr. Benjamin Rush, the “father of American psychiatry,” diagnosed two slave disorders he labeled “drapetomania” and “dysaesthesia aethiopica” (or “rascality”). Supposedly, drapetomania caused slaves to escape plantations; rascality was understood as an inherent trait of laziness and carelessness. Unfortunately, the idea of rascality continues to permeate views of Black Americans in relation to poor work ethic and criminality. The recommended treatment for both drapetomania and dysaesthesia aethiopica was physical torture. Today, these false diagnoses are associated with justifying police brutality and the harsh treatment of Black Americans facing legal authorities.

In counseling, Black Americans face an increased risk of retraumatization because of inappropriate assessment, misdiagnosis and poor treatment. Given this reality, and the resulting cultural mistrust of health care professionals, it is not surprising that rates of unilateral termination in counseling are much higher among Black American clients.

Conceptualizing historical trauma and slavery’s lasting effects

Historical racial trauma reflects the unresolved collective grief and cultural wounding that are passed down generationally. The field of epigenetics highlights that negative environmental conditions and stressors affect human beings down to the cellular level. For Black Americans, the racial trauma of slavery underpins a soul injury of unresolved grief that affects the whole being. In this context, the social-cultural wound is a collective experience of an internalized racial injury so pervasive that it impacts Black American culture in distinct racialized ways.

Anti-Black racism is rooted in the belief that people of darker skin tones are uncivilized, savage and prone to violence, regardless of how much status, achievement and standing a Black person may attain. This manifests in the phenomenon of colorism — the preference for lighter skin tone and Eurocentric features. Counselors need to know that colorism affects all aspects of a Black person’s life and influences their life chances, both within and outside of the Black American community. Black Americans face greater likelihood of poverty, more restricted access to education, and higher rates of imprisonment, underemployment and health inequity the further removed they are from the white ideal.

Posttraumatic slave syndrome (PTSS) is a theory of historical trauma that highlights the multifaceted impact of the violence of slavery, institutionalized segregation and oppression, and ongoing struggles for racial justice on the lives of Black Americans who are descendants of enslaved Africans. Counselors need to know the theory of PTSS, which was developed by researcher and educator Joy DeGruy-Leary to describe the survival strategies that were necessary for enduring the hostile conditions of slavery. PTSS accounts for both negative responses and positive adaptations and can explain some of the behavioral patterns of present-day Black Americans.

Controlling images and stereotypes

When Black American clients come to therapy, counselors should be aware of the controlling images and racial stereotypes these clients face.

The labeling starts early. In school, Black children are disciplined at higher rates than other children, with severe consequences that can include out-of-school suspensions, law enforcement involvement and, ultimately, even imprisonment for some Black children. Black boys are disciplined for being too “aggressive.” Black girls are disciplined for being “too loud” or dressing in a sexually provocative way. This reflects “adultification bias,” wherein school authorities hold Black girls to excruciatingly high standards because the girls are perceived to be more developed than they actually are. These responses stem from broader toxic stereotypes against Black Americans, deriving from slavery.

Controlling images underlie many of the mental health and stress-related concerns among Black women. One controlling image, the “Jezebel,” originated during slavery to justify the raping of Black women by white slave owners. It continues to have repercussions today in the increased risk of violent sexual assault against Black women due to the perception that they possess voracious sexual appetites and welcome aggression. The media also exploits the Jezebel trope and reinforces it in music videos, social media, television and movies, where Black women are often hypersexualized projections.

When counselors buy into the Jezebel myth, they risk misdiagnosing and mistreating sexually related concerns in therapy. Therefore, it is important to explore healthy sexual identity development and to challenge traumatic internalization of this controlling image. To further support and advocate for Black clients effectively, counselors need to be aware of these controlling images that discourage women from reporting sexual crimes and make it less likely they will be believed or find justice in court.

Another trope is the “Angry Black Woman.” This is routinely applied to Black women who are assertive and stand up in defiance of expectations of being demure and submissive. When they challenge injustice, they are labeled as domineering, masculine and emasculating. This combines racialized and gendered oppression and encourages the self-silencing of Black American women.

In response to these damaging stereotypes, Black American culture sought to reclaim the dignity of Black femininity. This was done in part by cultivating virtues of a Black matriarch who embodied strength, self-reliance, care of others and emotional containment while being a pillar of the community. In internalizing this “Strong Black Woman” schema, however, Black women are under enormous pressure to achieve excellence, block their emotions and care for others to the exclusion of their own needs. If counselors are unaware of this schema, they may not recognize the self-silencing, emotional dysregulation and fatigue that are the result of an endless demand on Black women for strength and voiceless endurance. Counselors should know that Black women who internalize this schema are most at risk for pain-numbing behaviors such as binge eating disorder, which is not about image or dieting, but rather an emotional regulation strategy.

Microaggressions and racial trauma in daily life

Psychiatrist and Harvard University professor Chester M. Pierce first proposed the term “racial microaggressions” to describe brief, commonplace verbal or behavioral racial slights, whether intentional or unintentional, that communicate hostile, derogatory or negative insults toward Black Americans. Microaggressions are often veiled and ambiguous; for example, complimenting a Black person about how well-spoken they are. The implication is that the listener is surprised because they did not expect the Black person to be articulate.

The subtle nature of microaggressions makes them especially frustrating for victims, who may be unsure of the intention behind the slight and unclear about whether or how to respond. This distress is damaging to a person’s well-being, especially when accumulated over time. Microaggressions result in increased stress, anxiety, depression and other trauma-related conditions. They can also lead to anger, voicelessness, internalized self-devaluation and an assaulted sense of self. 

Race-based traumatic stress

Experiences with discrimination and oppression can result in race-based traumatic stress (RBTS), a term coined by researcher Robert Carter and colleagues to describe the significant stress Black Americans experience because of cultural, individual and institutional encounters with racism. Much like posttraumatic stress disorder (PTSD), RBTS carries psychological and physiological effects such as avoidance, hypervigilance, flashbacks, nightmares and somatic expressions (e.g., headaches, stomachaches, heart palpitations). At the same time, racial trauma differs from PTSD in significant ways. For instance, racial trauma involves ongoing cumulative injuries due to exposure, both direct (such as physical assault) and indirect (such as vicarious injury when other Black people are racially harmed or when witnessing racist incidents in person or in the media).

RBTS also includes reexposure to race-based stressors. Criteria include exposure to a racist event that is experienced as painful and uncontrollable. The traumatic reaction of avoidance, intrusion or arousal can manifest in several ways, including emotionally, cognitively, behaviorally and physiologically. Unfortunately, most of these wounds are easily overlooked if counselors do not understand race-based trauma symptomatology. Black American clients may need help in understanding and managing their strong reactions to these events. It is incumbent on counselors to have this awareness because Black American clients may not know that these exposures are considered traumatic.

The fact that racism is a stressor that can harm or injure its targets is still not recognized as an official diagnosis in the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This decreases the chances that counselors can identify, assess and treat RBTS, even though researchers have reported higher rates of traumatic experiences among Black Americans when compared with the general population.

Although the current diagnostic criteria for PTSD in the DSM-5-TR is more expansive with respect to trauma generally, it does not account for the symptoms of RBTS due to its limiting of the types of experiences that lead to trauma. For instance, Criterion A specifies “exposure to actual or threatened death, serious injury or sexual violence” as the main diagnostic criteria, even though other types of stressful experiences, such as racism, have been linked to negative mental health outcomes.

Criterion A also contains a specific notification, under Criterion A4, that explicitly states “experiencing repeated or extreme exposure to aversive details of the traumatic event(s) does not apply to exposure through electronic media, television, movies or pictures, unless this exposure is work-related.” This is concerning because advancements in technology and the ubiquitous reach of media have increased the exposure of Black Americans to heightened images of racial injustice and trauma, such as the gruesome images, in real time, of the murder of George Floyd.

Similarly, newer forms of hate crimes have emerged in social media networks as a convenient means of transmitting hate. All of this can have the effect of retriggering and retraumatizing previous racialized experiences. Black American clients might present to counseling with trauma stirred up by these media exposures to racism, but it may not be apparent because of the everyday nature of these incidences. In addition, diagnosis is difficult because of the electronic media exclusion note in Criterion A4.

The current definition of PTSD in the DSM-5-TR is problematic. It contributes to potential misdiagnosis and the pathologizing of racial stress symptoms, and it limits the ability of Black American clients to receive adequate racial trauma treatment. Additionally, without an official diagnosis, health care insurance coverage and reimbursement can be restricted.

RBTS assessment measures

Despite the limitations of the DSM-5-TR diagnostic criteria, counselors can still offer an appropriate assessment of RBTS, if they have the necessary knowledge and awareness and the proper tools. Experts in the racial trauma field have developed several scientifically validated instruments that accurately assess trauma symptomatology. Counselors can choose any of these instruments during a scheduled intake or following a session when a client presents with symptoms that may be indicative of racial trauma. These tools can help counselors assess Black American clients and develop treatment strategies for healing their traumatic experiences.

  • The University of Connecticut Racial/Ethnic Stress & Trauma Scale (UnRESTS) uses an interview format to facilitate communication regarding clients’ experiences with racism. UnRESTS uses a two-column format: one column with instructions for the counselor to prepare the interview and the other column describing questions to ask the client. This measure is helpful for counselors who are inexperienced in identifying racial trauma or those who are hesitant to broach racially charged topics in counseling. It provides clinicians with a structure to conduct the interview, starting with identifying racial or ethnic identity development and moving through experiences of covert and overt racism, including vicarious racism. This provides counselors with the confidence that they have elicited the greatest input from their clients on these issues and can make a treatment plan based on this comprehensive review.
  • The Race-Based Traumatic Stress Symptom Scale (RBTSSS) evaluates a client’s exposure to racist experiences and the symptoms that can result, including emotional and physiological reactivity. The measure includes 52 items in seven categories that explore self-esteem, physical reactions, anger, avoidance, depression, intrusion and hypervigilance or arousal, all associated with racial trauma. When using the RBTSSS, the clinician begins with open-ended questions to obtain information from the client about racist experiences. This is followed by closed-ended questions about the client’s reactions. A clinician can assist in administering this assessment, or it can be administered as a self-report measure.
  • The General Ethnic Discrimination Scale (GEDS) is an instrument specially designed for measuring clients’ frequency of exposure to racism. It is appropriate to use with most ethnic groups affected by racial trauma. GEDS consists of 18 self-reported items that measure the client’s personal perception of racial discrimination. This tool is similarly structured to other existing stress inventories currently in use. Because this is a self-reporting tool, instructions have been simplified for participants whose first language is not English. It is also specifically useful when faced with time constraints because it is a relatively quick measure for assessing racial trauma.
  • The Racial Microaggressions Scale (RMAS) is a tool measuring racial slights and the resulting distress of microaggressions. It specifically explores six types of microaggressions using a 32-item questionnaire in a Likert scale format. The distress subscales include criminality distress, low achieving/undesirable culture distress, sexualization distress, invisibility distress, foreigner distress and environmental distress. Counselors might choose this assessment when Black American clients report experiencing insults and invalidations that undermine their sense of self.

Because racial trauma is so deeply rooted in historical and generational oppression going back to slavery, Black Americans continue to experience the devastating toll. Counselors who work with Black Americans must understand the conceptualization of this experience and be competent in evaluating its impact on their clients.


Learn how to treat race-based traumatic stress in July’s Knowledge Share article “Treatment strategies for race-based traumatic stress.”


headshot of Portia Allie-Turco

Portia Allie-Turco is an assistant professor, clinic director and program coordinator in the Counselor Education Department at the State University of New York at Plattsburgh. She is also a licensed mental health counselor who specializes in healing racial, generational and complex trauma. Contact her at p.allieturco@gmail.com.

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 bimhoff@liberty.edu.

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.

Regulating the autonomic nervous system via sensory stimulation

By Samantha A. Hindman July 6, 2022

It is estimated that around 70% of the global population has been exposed to a traumatic event at some point during their lifetime. This is a staggering approximation when we consider that beginning counselors are often woefully unprepared to support clients from a trauma-informed perspective. Although the annual rates of diagnosable posttraumatic stress disorder (PTSD) are comparably low, symptoms such as hyperarousal, a frequently negative emotional state, and negative mood alterations can be far more common than clinicians may recognize when initially assessing clients.

A significant number of my very first clients were survivors of trauma or clients who had moderate to severe symptom presentations, which is not uncommon for a community mental health agency. As I waded my way through the tide of intakes and assessments and diagnoses as a green counselor, I naturally defaulted to a top-down approach to treatment. I confidently stepped into the field thinking that if I focused on coping skills, faulty thinking patterns and behavior modification, then I would help clients get to a place where they could choose to embrace a new way of living.

This was occasionally reinforced, but for maybe about 10% of my caseload. Regularly, clients would say that the skills didn’t work. They couldn’t find the words to journal or untwist their thoughts. Going on a walk only made them think about their distress more. Squeezing a stress ball when they were angry was fine, but it didn’t really do much to change their emotional state. In some cases, they couldn’t even remember that the skills existed until far after their distress had passed.

What I began to see was that most clients had significant difficulty getting to a place where their logical brain could be accessed. Clearly, there was something else going on. The more I explored different approaches for answers as to why these skills weren’t working, the more I realized that this top-down approach wasn’t meeting my clients where they had control.

Ignoring the body experience and the nervous system were almost certainly the barriers I had inadvertently fortified for these initial clients. What if regulating the nervous system could help clients quickly regain control and resolve distress? The possibilities were endless.

The autonomic nervous system

The autonomic nervous system (ANS) consists of two main processes: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). These processes typically work in tandem, cyclically activating the SNS and the PNS as the usual up and down experiences of life occur.

The SNS is the mobilization system often referred to as the fight-or-flight response. Activation of the SNS in the wake of perceived danger typically results in an increased heart rate, increased blood flow, increased body temperature and increased respiration rate. The PNS is the homeostasis system often referred to as the rest-and-digest response.

When stressors occur and danger is sensed, the body automatically moves from the rest-and-digest state into the fight-or-flight response of the SNS. Once the threat passes, the PNS will reengage, but it can be helped along by distraction and self-soothing, such as grounding or sensory techniques.

Grounding techniques include activities such as:

  • Cuddling a soft blanket, stuffed toy or piece of fabric
  • Rubbing fingers across a textured surface
  • Using a weighted blanket
  • Drinking a warm or cold beverage
  • Mindfully eating an orange
  • Experiencing soothing or relaxation-inducing smells
  • Listening to enjoyable music
  • Looking around and naming all of the items of a specific color that are in the vicinity
  • Looking at a picture of someone or something that is important to you
  • Accessing religious/spiritual tokens
  • Accessing other items of sentimental value

Polyvagal theory and somatic experiencing

Considering that approximately 70% of the global population has experienced a traumatic event during their lifetime, difficulty regulating the nervous system would appear to be more common than we may have realized. Furthermore, what do we do when the typical grounding techniques fall short of said regulation?

Stephen Porges, the researcher who posited polyvagal theory, suggested that the vagus cranial nerve plays a significant role in how information is communicated to the systems of the ANS. Rather than having two systems, Porges indicated that the ANS actually involves a three-system hierarchy that divides the PNS into two branches: the ventral vagus complex responsible for sensing safety and social connectedness, and the dorsal vagus complex responsible for sensing danger.

Activation of the PNS typically results in decreased heart rate, increase in digestive function, decreased muscle tension, regulated body temperature and regulated rate of respiration. However, perception of extreme danger may further immobilize an individual beyond the rest-and-digest response to experience what is known as the freeze-or-collapse response.

Peter Levine conceptualized in his book Waking the Tiger: Healing Trauma that individuals who do not perceive having access to safety during hyperarousal will shut down, their SNS seemingly suspended in time as the dorsal branch of the PNS takes over. Levine indicated that individuals could wake from this freeze response by bringing mindful awareness to the bodily experience, thus bridging compartmentalized aspects of previous trauma stored in the body. This would allow individuals to detach from trauma reminders and move that suspended energy from one system to another. 

Sensory integration

The 1960s work of A. Jean Ayres with sensory processing issues theorized that such impairment would result in various functional problems. This theory was expanded by later researchers and referred to as sensory integration theory. Sensory integration theory refers to the processes of the brain that regulate the impact of sensory experiences on motor, behavior, emotion and attention responses. The research of Stacey Reynolds and colleagues published in The American Journal of Occupational Therapy in 2015 postulated that delivering alerting or calming sensations to an individual could change the function of the ANS. They hypothesized that sensations that were alerting would increase SNS activity, whereas activities that were considered calming would activate the PNS.

Although these theories have largely been applied to sensory disorders and trauma responses, it is reasonable to believe that even for individuals experiencing chronic stress or intense symptoms of anxiety and depression, engagement in sensations recognized as alerting would serve to arouse the SNS and decrease the activity of the dorsal vagus complex of the PNS, effectively rousing the individual from immobility or dissociation. Once the stressor passed and the individual recognized that they did have access to safety, they would have the ability to move from SNS activation to the social engagement state of the PNS.

Building a sensory kit

By incorporating the ideas of polyvagal theory and sensory integration theory, we can surmise that the use of intense sensory experiences could wake an individual from immobility and reset the suspension of energy being held by the ANS.

The old frozen orange trick is an excellent example of this sensory distraction skill in action. The idea is that the cold temperature of the orange will cause an immediate distraction, thus slowing down the release of cortisol and adrenaline and releasing endorphins that help the body cope with the sensation of pain. Unfortunately, most of us don’t have access to a frozen orange in the middle of a stressful meeting, at the courthouse or while driving on the highway, which happened to be some of the exact moments when clients I was working with mentioned needing such an intervention.

In search of an accessible way to actively distract clients from the overwhelming physiological and emotional shutdown, I considered how sensory tools might look if they were portable. After all, having immediate and reliable access to these alerting sensory tools when the PNS dorsal vagus complex response is engaged is key to habituating the idea that we can be in control of regulating our own ANS.

carole smile/Unsplash.com

I started making small to-go bags for my clients to take with them, which I now refer to as a trigger kit. The bags contained sour candy, a raw crystal that was jagged to the touch, and a sample of peppermint essential oil.

You might be wondering why those things? Although we do have five external senses (i.e., sight, smell, taste, touch, hear), building a kit that effectively arouses the SNS involves selecting accessible tools that quickly and powerfully activate taste, touch and smell. Intensely distracting sounds or sights are likely to intensify dysregulation and are not advised, but of course, the kit is completely customizable. Whatever works for the client, works for the client!

I introduced the kit by providing psychoeducation about the ANS. I would have clients experiment with the sensations during session so they could have a reasonable expectation of what they were trying to replicate on their own. Maintaining a small sensory kit that can be easily transferred between locations — in a purse, in a jacket pocket or in a backpack — allows for immediate access as needed. I initially used small sandwich bags but have since moved on to small drawstring bags that can both conceal and contain the items. My clients have consistently cited the trigger kit as one of the most effective grounding tools they have attempted to use in the midst of distress.

Suggested items include:

  • Sour candy
  • Candied ginger (or other spicy food)
  • Raw crystal (or other jagged, rough item)
  • Rubber bands (to snap against the wrist)
  • Mini instant cold pack
  • Peppermint essential oil (or other strongly scented oil)

To move from the PNS freeze-or-collapse response to the SNS response and back to the PNS social engagement process, including recovery items in the trigger kit similar to those intended for grounding tend to ease the intensity of the transition. Clients frequently include items in their trigger kit such as pictures of loved ones, spiritual and religious tokens, and soothing sensory items such as bubbles or soft fabric to be utilized after the SNS has been reengaged.



Grounding techniques are commonly used to create a mindful awareness of the present moment and can be quite effective for bringing the client back to their body. However, when clients experience intense dysregulation, it is likely that typical grounding techniques will not be enough to pull an individual from hyperarousal or immobility. A more intense grounding experience, such as a powerful, portable sensory experience, may be useful. Empowering individuals with psychoeducation surrounding the functions of the ANS and the use of a trigger kit can assist clients who might benefit from regulating from the bottom-up.



Samantha A. Hindman is a licensed mental health counselor, national certified counselor and certified clinical mental health counselor. She is an educator for the Community Care program for AdventHealth in the central Florida region. She has experience working as a trauma therapist for a community domestic and sexual violence agency and is a therapist in private practice. Samantha has taught mental health courses at the graduate level and enjoys providing in-person and virtual trainings on research methodology, program evaluation, basic and advanced counseling skills, neurobiology, and therapeutic considerations for working with survivors of trauma. She is currently in the dissertation phase of her Ph.D. journey in a counselor education and supervision program. Contact her through her LinkedIn page at linkedin.com/in/samanthahindman.


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