Tag Archives: stress & anxiety

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.


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.

Past, present or future: Where do you usually live?

By Madhuri Govindu June 10, 2022

Your monkey mind wants to live in either the painful past or the anxious future. It doesn’t like to stay in or savor the present moment.

This mental habit of ruminating over what has happened or what will happen can make life a miserable journey. Many people are unable to control their mental chatter and continue to suffer. But there’s hope if you can learn to tame your mind to stay in the present moment.

Life happens here and now

Life exists in this present moment. Not in the past or future as most of us are accustomed to. As a mental health counseling student, living in the present moment has been my anchor in a life filled with unexpected ups and downs. Undoubtedly, living in the “now” has served as a saving grace for me as we all continue to battle the darkest days of our current realities.

When I was younger, I couldn’t understand why “the past” would be a crucial part of someone’s life. I constantly pondered why adults ruminated about things that happened decades ago. This quest to understand people’s mindsets led me to quit my corporate job as a training and development manager with Accenture, a multinational company in India. Thereafter, I pursued my passion for counseling psychology, which brought me to the United States in 2018. Currently, I am a graduate student at Penn West University (Edinboro University of Pennsylvania) and will graduate with a mental health counseling degree in 2023.

Early on, I wanted to build a platform that would help those struggling with issues such as depression, anger, fear, past trauma, bullying and an inability to find a solid direction in life. Soulful Conversations, an in-person platform, allowed people to have heart-to-heart discussions and helped thousands of individuals cope with past traumas and future anxieties. This journey taught me that living in or thinking too much about the past is nothing but a disease — one that afflicts millions of people today.

Ruminating over what happened, why it happened and “how could it happen to me?” has become an irresistible habit for many individuals. Through the Soulful Conversations community, I started to understand better the workings of the human mind. For the first time, I questioned my audience: “Ask your mind, what is its next thought?” Interestingly, the moment you ask your mind this question, it goes blank, as if it has been put under a spotlight and its auto-running mode has been caught.

After trying this technique, my audience found a sense of relief to experience a much-needed pause in their uninterrupted mental activities. As people created even a 10-second gap between their reckless past and future thoughts, they found immense respite in their inner stillness. They discovered deep peace within that emanated from shutting the endless chatter of their untamed monkey minds.

Are you in the present moment?

As a counselor, it is vital to be aware that living in the present moment can help us reduce stress, stay more focused and better understand the repetitive patterns in our lives caused by our compulsive habits. When you are in the present moment, you are not waiting for the next moment to be fulfilling or happy. This is because you are not unhappy in the “now,” subject to unpleasant clingy thoughts from the past, empathy fatigue or any other distraction.

You are now more present with your family and friends. You are livelier, content and stress-free because you refuse to entertain past experiences or future anxieties related to health, money, family, work, etc. It may be helpful to have a phone wallpaper featuring the NOW clock or a gemstone that reminds you that everything you are experiencing exists only in the present. Don’t forget: Memories are just thoughts in your mind, quite similar to your thoughts about the future.

Gratitude changes everything

Many times, we carry stressful work situations or unsatisfactory client encounters with us in our minds. We repeatedly replay them in our minds to analyze and dissect how that meeting could have been better. Often, this stress spills into our personal space as well. We carry these feelings of resentment while we are spending time with family members and friends.

We forget that we have the right to “choose and appreciate” whatever the present moment brings to us. So instead of ruminating about past and future worries, we can choose to drop all fears and swim in the magic of the present moment. With practice, the ability to stay in the present moment can be mastered.

The present moment brings an opportunity to offer gratitude, which makes life more livable and joyful. Gratia, the Latin word for gratitude, means grace or gratefulness, and even a small act of thanking the present moment — appreciating what you see, feel, hear and sense around you — deepens that awareness. This helps you leave the perennial stream of unconscious mental chatter, which is eventually the root cause of myriad problems.

Tame the monkey mind 

The monkey mind can hop in and hop off from one branch to another within seconds. It can scuba dive into the ocean of sorrow and bring you back into the sky of happiness in a matter of

Stephen Tafra/Unsplash.com

seconds. As counselors, we must try to bring ourselves to the present moment and erode the old conditioning by doing simple things consciously.

These activities can retrain our monkey minds to see the beauty in the present moment. The racing mind is like a galloping horse without any direction. It feels as if the mind is unstoppable, and you are helpless because you simply have no idea how to tame the unruly mind. In such situations, the easiest way to bring your mind to the present moment is to bring your attention back to your breath. Ask yourself, “Am I breathing consciously?” This question helps you to step outside the compulsiveness of identifying yourself with your thoughts.

So how do we build awareness? How do we become aware of our mindless mental chatter? Some of the simple ways such as chewing food slowly, washing hands consciously, taking occasional deep breaths, and setting alarms for present-moment reminders can be very helpful. Furthermore, the regular practice of meditation can help counselors in de-weeding the garden of their minds.

Even 20 minutes of meditation can help us observe everything the mind holds on to and help us see the workings of the mind more clearly. We can then navigate through the mind’s workings and ensure that we do not attach to any of the weeds that slowly creep into the subconscious mind. Hence, a regular practice of de-weeding through meditation is important.

Suffering and counselors

No one is immune to suffering in this world, not even counselors. Like all humans, they have their own professional and personal challenges to deal with. Also, navigating from one client to another, counselors often help others deal with afflictions such as addictions, trauma, posttraumatic stress disorder and so much more. Counselors try their best to help their clients, but this leaves them with very little time for their own recovery and self-care.

However, the good aspect is that counselors are well equipped to understand the unnecessary problems and conflicts created by the mind. So if we can leave the client stories behind, meditate for five minutes before each session, and then step into the next one, a lot of our projections will disappear. It is important to note that the moment you realize that you are not living in the present moment, you are immediately transported back to the present moment. Isn’t that wonderful?

We must understand that the countless voices in our heads will never be silent. At times, it even annoys us, and this inner dialogue makes us miss most of life’s present moments because we are never in the NOW. So, realize that you are not the voice in your head — you are the conscious being who has the power to observe this voice and still not believe in it.

Mind full or mindfulness?

One mindful step at a time can help us embrace inner peace. I personally have trained my mind over the last two years to consciously bring it back to the present moment. As counselors, our work involves welcoming clients from diverse cultural backgrounds and helping them hold their inner peace. This doesn’t leave us with a lot of buffer time to recover, rejuvenate and refocus on the next client.

Hence, it is extremely important for counselors to focus on their mental movements and understand if there is an underlying stillness. A simple practice of five-minute meditation can help counselors embrace the present moment between sessions. The art of practicing self-observation to identify your intrinsic motivations, projections and deflections can help counselors go into tiny mindful retreats and hold their inner peace.

Judgment detox

If counselors can continue to observe their own minds in a nonjudgmental way, then they will be more effective in their profession. The present-moment awareness practice can help in increasing focus and alertness, having a relaxed state of mind, being more mindful with clients and not getting distracted easily.

Being fully aware of the counselor-client relationship can lead to building deeper connections, being more efficient as a counselor, embracing self-compassion and living a fulfilling professional life. What’s more? It will be easier for counselors to bounce back from intense sessions as they continue to deepen their present-moment practice. Random mind wandering is common, and being aware of how often your mind wanders and leaves the present moment is a great indicator of your happiness and mental well-being.

How often have you found yourself unhappy while having sex, exercising, watching your favorite show on Netflix or taking a warm shower? It is the presence of thoughts, drifting mind and past woes or future anxieties that jeopardize your present-moment happiness. A moment of pause, deep breathing in that pause, and being aware of the pause can soothe your nervous system immensely.

With consistent practice, there will be a significant reduction in your thoughts and a more focused approach at work, and an absence of worry and rumination can help you become happier. Another interesting creative approach is using mandalas, which are visual diagrams that can help one become more mindful of the present moment. These intricate patterns allow one to dive deeper into the drawing and deepen one’s relationship with the present moment.


I hope counselors will feel more conscious of their mental chatter and be more confident in helping themselves with some of the present-moment techniques that I have shared. It is fulfilling to know that we deserve to take mental breaks, focus on self-care and refuse to succumb to the cessation of endless mental activities.

In one of my Soulful Conversation sessions, I had mentioned, “Don’t take the time, effort, patience and mental health of counselors for granted. We sacrifice a lot to maintain a peaceful and positive demeanor while underplaying some of our inner challenges. We believe in our own ability to impact the lives of others in a positive way and create a culture of wellness by touching the lives of others mindfully, one day at a time.”



Madhuri Govindu is a counseling psychology graduate student at Edinboro University of Pennsylvania. Her work was featured in The New Indian Express in 2018 when she began to invite individuals from all walks of life to embrace the present moment through her open social change platform titled Soulful Conversations. Contact her at madhurigovindu23@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.

Mental gymnastics: Navigating challenging relationships

By Grace Hipona May 13, 2022

“I am not sure how they are feeling and what they are thinking. I am confused. I feel like I am going crazy. I question everything, and I don’t know if I can trust what I am feeling and thinking.”

Relationship issues are one of the more difficult problems to help clients manage. When clients make any of the statements above, especially in relation to someone else, I talk with them about what I have coined as “mental gymnastics.” Mental gymnastics can start with unsettling statements and questions but also can lead to impacting other areas of a person’s life. In this article, I discuss how clients can be affected and strategies professional counselors can use to help them navigate these challenges.

Direct communication

When a client is experiencing mental gymnastics, they may commonly ask, “Why is this so hard? Why can’t I make this work? Why is this so exhausting?”

Direct communication, including asking questions, is the best strategy for clients to navigate mental gymnastics. However, if direct questions are asked and the other party does not respond with an honest or genuine answer, then it becomes more complicated. Sometimes, there is a discrepancy between what a person says and how they act. Sometimes, they may not even have this awareness, especially if they are confused themselves.

Unfortunately, it may feel purposeful or malicious when others do not communicate directly, lie through omission or engage in other forms of dishonesty. A classic example is when a person asks, “How are you?” and the other person responds with “I am fine.” However, their body language and tone of voice indicate that they are not actually “fine” but are instead upset or angry. Another common exchange is one person asking, “Do you need anything?” and the other person responding with “no,” even though they need help.

When discrepancies between what clients say and how they act arise, it is natural for clients to question their own inclinations. “Can I trust how I feel or what I think?”

Adding to the internal conflict, the other person can potentially invalidate how the client feels or completely deny their reality. Therefore, as professional counselors, it is important to specifically ask clients their feelings about the relationship in question. This clarity can increase clients’ self-awareness. Clients will find it easier to navigate relationships when they are aware of their reality and have confidence in it.

Good vs. bad anxiety and needs vs. wants

One common example of mental gymnastics that I’ve encountered is when a client has begun getting to know someone (whether a budding friendship or a romantic relationship) and they experience anxiety that is more constant and intense than typically associated with relationship building. This is when clients may begin having unsettling questions and statements: “Why can’t I tell if they like me? I can’t seem to get a straightforward answer. I don’t know what they want.”

When this occurs, I help clients differentiate “good” versus “bad” anxiety. In other words, I provide a space for them to process how they perceive the adrenaline associated with their experiences. A person should experience levels of anxiety when meeting someone new and getting to know them. This could be perceived as “good” anxiety or excitement. Clients may feel butterflies in their stomach, brighter in their affect, and hopeful. With good anxiety, clients may have thoughts and questions such as, “Do they like me?”; “Did I make a good impression?”; and “I can’t wait to see them again.”

If clients experience “bad” anxiety, such as excessive worry, irritability, dread and the triggering of the “fight, flight or freeze” response, this may be a red flag. They may have thoughts such as, “I don’t know what to do”; “I can’t seem to say anything right”; and “What can I say or do so that they will like me more?”

In helping clients assess whether they are experiencing “good” versus “bad” anxiety, I ask them if in general they feel more positive emotions than negative ones. For example, “Do you feel happier more than 50 percent of the time?”

I also help clients determine their needs and wants. I describe needs as things that are non-negotiable to them, such as respect, trust, honesty, marriage, children, and religious or spiritual beliefs. Hard boundaries need to be set around these needs.

Wants are negotiable or flexible. Examples include physical appearance, financial status, educational background and geographic origin. When it comes to positive and healthy relationships, clients should have their needs met, and the relationship should feel like it is a “want” or a choice.


Minimizing and denying

The answers to the assessment questions in the previous section can be interrelated and could lead to more confusion. For example, clients could determine that they feel happy most of the time with their relationship but that most of their needs are not being met. This discrepancy can cause clients to question their feelings, and this could lead to an increase in anxiety.

Another potential cause of internal conflict is receiving information from the other person that minimizes or denies the client’s experience. For example, the client may be questioning their own reality because the other person is directly challenging it: “Oh, you shouldn’t feel that way. Are you sure?”

The other person could be completely denying the client’s reality: “That didn’t happen. I know what you’re feeling. You’re not really mad.”

Some may even define this as “gaslighting” (questioning their internal reality or “sanity” based on external pressure and manipulation).

Another example that can cause internal conflict is when the client brings a concern or stressor to the other person, and that person minimizes the client’s experience. The other person might respond with, “You’re making a big deal out of nothing, and you shouldn’t feel that way.” The other person may shift the focus to themselves while minimizing the client’s experience, “You think you’re upset? I’ve felt so much worse. You don’t know what suffering is really like.”

In any of these scenarios, the attention has turned toward the other person, and the client’s thoughts and feelings have been dismissed. In other words, the client is then reactively directing their energy toward the other person, and the client has lost sight of their inner experience. The client could be more likely to “lose themselves” in the relationship and, therefore, not get their needs and wants met.

Like the sport, mental gymnastics requires a person to use energy and effort. However, unlike the sport, mental gymnastics unnecessarily uses a person’s energy. One indicator that clients are engaging in mental gymnastics is that they feel tired and their mood is generally lower than usual. Clients may describe feeling “drained” even though they are not actively and purposefully using their energy. They may feel the need to use certain strategies or efforts to engage with a particular person. Clients may feel the need to “perform” a certain way; otherwise, they may feel judged, criticized and denied any love, support, care or validation from the other person. Clients may feel dueling inclinations of needing to spend time with the other person but also wanting to avoid that person.

Another reason clients may unnecessarily use energy to engage with another person is that even when trying to support this person, clients feel like they “can’t win.” In other words, the intention and effort may be there, but the other person still feels “it is not good enough.” Even if conditions are met, the other person may find something wrong with what has happened. That person may say, “That was a nice try, but I would have liked this instead.”

Aside from helping my clients gain clarity over their needs versus their wants and insight into their internal experience in general, I believe it is important to help clients reality test. Writing a “pro/con” list or something similar can be useful, especially for clients who tend to be visual in nature. Asking the following questions can support development of this list:

  • How do you benefit from this relationship?
  • How does this person meet your needs and wants?
  • How do you feel about them?
  • How do you feel about the relationship?
  • How is your life impacted by this person?
  • How do they challenge you to be the best version of yourself?
  • What do you like about this person?
  • What do you dislike about this person?
  • What do your friends and family think about this person. 

Active and reactive decision-making

After time, effort and space have been given to the questions mentioned in the previous sections and clients continue to move forward in a relationship where mental gymnastics is present, I encourage clients to think about the consequences of this choice. At this point, clients can take ownership and feel empowered by their decision-making.

When I work with clients, I focus on strategies to help them make ACTIVE decisions rather than reactive ones. Once there is a level of insight into decision-making, they can make informed decisions. This awareness can lead to active decisions where the clients feel they have a choice. Without any awareness, clients may not feel like they have a choice. They may feel compelled to do something but not know why.

An example of a reactive decision is when a client chooses not to end a relationship even though there is evidence that the relationship is unhealthy. A client may say, “I don’t want to break up with him because I love him.”

As the client’s counselor, I would ask, “Why do you love him?”

The client may respond with, “I just do” or “I am not sure, but this is how I feel.”

If clients continue making reactive or passive decisions, this can perpetuate or exacerbate negative anxiety. Counselors can assist in exploring the client’s decision-making process so the client can answer the question “why?”

I believe when clients experience anxiety, it is not just their fear of the unknown and the byproduct of internal conflict, but also a result of them not feeling empowered in their own lives. For clients to feel empowered, they need to be an active participant in their own decision-making process. Counselors can help clients manage this anxiety by helping them focus on their locus of control.

Clients can examine what they say and how they act toward the other person. They can focus on their self-care and on other important aspects of their identity. Clients can also concentrate on purposefully coping with their anxiety in healthy ways. These strategies can lead to feeling confident in navigating potential mental gymnastics.



Grace Hipona is a licensed professional counselor for NeuroPsych Wellness Center PC and holds a doctorate in counselor Education and supervision. Her dissertation focus was on disaster mental health, specifically sheltering-in-place. She is also a certified substance abuse counselor and approved clinical supervisor. Her experiences over the past 15 years include working in private practice, managing behavioral health programs, teaching graduate students, and providing supervision for master’s-level counseling students and counselors-in-residence. Contact her at ghipona@hotmail.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.

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

By Lindsey Phillips January 26, 2022

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

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

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

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

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

Is it stress?

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

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

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

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

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

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

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

Is it anxiety? 

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

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

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

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

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

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

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

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

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

Is it burnout? 

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

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

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

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

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

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

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

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

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

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

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

Managing stress and anxiety

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

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

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

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

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

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


Emotion regulation

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

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

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

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

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

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

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

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

Building strong internal and external resources 

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

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

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

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

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

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

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

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

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



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