Tag Archives: stress & anxiety

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.

LinaDes/Shutterstock.com

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.

Nithid/Shutterstock.com

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.

Reintegrating into a changed world amid an ongoing pandemic

By Katie Bascuas January 12, 2022

Samuel Bearer, a licensed professional counselor in St. Louis, remembers hearing a podcast interview back in fall 2020 with sociologist and author Brené Brown in which she described how the initial shock of the COVID-19 pandemic and its effects on people’s day-to-day lives had helped many individuals push through the early stages of the crisis, but after several months of pandemic living, people were starting to wear down. 

“When there’s a sense of ‘I’ve been dealing with the unknowns for so long,’ there’s more and more energy it takes to maintain that level of hypervigilance,” Bearer says. “That comes at a high cost.” 

At that point in the pandemic, many counselors began witnessing an increase in anxiety and depression among their clients. Some providers shifted their practice from one that had focused on supporting clients with self-actualization to one that supported clients with learning survival skills. 

“You can’t self-actualize if you don’t have your basic needs met,” says Ashleigh Jackson, a licensed mental health counselor in Melbourne, Florida. “So, if there was a job loss or a partner’s job loss, money and paying bills became the priority.”

Fast-forward 12 months, and the levels of exhaustion and stress felt by many were even higher. The need for further decision-making and risk assessment turned a new corner as people started returning to work and school amid a surge in COVID-19 cases resulting from the delta variant.

As breakthrough cases mounted, dampening some of the initial excitement about the vaccine’s promise to significantly slow the virus’ spread, many people were left to wonder when or if the pandemic would end. Add to that the heated political debates around mask wearing and vaccine mandates, as well as a deluge of negative media coverage, and you get a recipe for increased levels of anxiety, depression and fatigue. 

Counselors were faced with supporting clients as they navigated even more change, with added layers of uncertainty, during this reentry phase. Despite the challenges and the continued strain on many individuals — including counselors themselves — some providers began to identify opportunities for growth, both for clients and the profession.  

Reassessing values around work and home

For some people, the initial reentry phase was an exciting time — a chance to return to old activities and familiar ways of life. But for others, it presented added stress for any number of reasons, including individual health concerns, the complexity of navigating a “new normal” and, for some, the realization that they were now very different from the person they had been 18 months earlier when the pandemic began.

To help clients manage some of the uncertainty around the reentry phase, Bearer says he tried to help clients see the opportunities in the transition. “The reentering is also about ‘Do I want to go back to doing what I was doing, or do I want to make a switch?’” Bearer says. “Anytime we face a crisis like that or we lose a piece of our identity, which might have been part of the work that we did — and all of that might have gone up in the air — there’s a sense of ‘Has this fundamentally changed me or not?’”

Some of those changes might include minor adjustments, such as changes in appearance or office attire. “I’ve seen several clients transition back to work and wonder, ‘Do I have to do my hair again?’” Jackson says. “But you don’t have to do these things. Those were all things that we thought that we had to do, and now we learned that we don’t.”

Some shifts that people were experiencing were more significant, however, such as deciding whether they wanted to return to working in an office setting or whether they even wanted to keep their jobs. Both Jackson and Bearer say that being a sounding board for clients to explore alternative work or employment scenarios became an important part of their work. Bearer also used the opportunity to help clients assess their values around work. 

For example, Bearer found that for various clients, 18 months of teleworking had different effects on their work-life balance. Whereas some found the extra time valuable to devote to personal or family needs, others struggled with delineating their work and home lives and subsequently felt overwhelmed. 

“To whatever degree that we have been affected by the pandemic, there may be moments that we come to where we can clarify for ourselves, to say, ‘Hey, if I’m feeling the tension between the value of work and the value of home, how do I clarify that for myself?’” Bearer says. “It’s normal that we fluctuate through life, but now we are learning more how to recognize which stage we’re in and what we need to prioritize.” 

Bearer hopes that as more people reenter the workplace or return to pre-pandemic commitments, they get the opportunity to identify a new balance among all of their responsibilities, whether that’s at work, school, home or with family. He encourages people, where possible, to recognize this as an opportunity not to default to the broader culture, but rather to make individual choices that better resonate with their unique goals and lifestyles.

Halfpoint/Shutterstock.com

More people taking risks

In addition to decisions around work and how to return to an office or workplace, Jackson says she has noticed more clients taking large leaps of faith and making significant life changes as things began to open up more. “People are learning that life is short and everything can be gone in a moment,” she says, “so some are taking drastic risks, moving across the country, ending relationships, ending careers.”

The combination of those life changes with the physical reentry process can be a lot to manage at one time, adds Jackson, who compared the reentry phase during COVID-19 to reentering the world post-divorce or after the loss of a loved one. “We’re not the same,” she says. “But we have to figure out ‘Who am I now?’ integrating everything that’s happened, and then determine ‘How do I show up?’” 

Jackson says that encouraging clients to reintegrate slowly and giving clients “permission” to not be awesome at reintegrating right away was helpful in her work with individuals feeling tension around the reentry process. She also helped to normalize clients’ fears and concerns, taught grounding and mindfulness strategies, and recommended that clients take advantage of collective resources, such as meditation and breathing apps. 

Managing added stimuli

Those techniques are also helpful when dealing with the overstimulation that can come with reentry, says Emily McNeil, an LPC who owns the Mariposa Center for Infant, Child and Family Enrichment in Denver.

“Meeting all the demands of work and family and extracurriculars … it’s a trigger for a lot of depression and anxiety because people went from very low stimulation, in a lot of ways, to incredible stress and more demands, on top of the fact that we’re not out of the pandemic,” McNeil says. She incorporated a healthy dose of mindfulness, breathing and somatic techniques to help clients focus on the present moment and encourage them to take one day at a time. 

McNeil and other clinicians in her practice also began referring clients to other providers, including acupuncturists, psychiatrists, massage therapists and craniosacral therapists. Given that she primarily works with children, McNeil and her colleagues also found themselves reaching out to schools more frequently. “We’ve been creating community with schools to make sure that the schools and the family and the community-based providers are all on the same page with how to support children who might be struggling,” she says. “So, our amount of case management at this time is really high.”

Not only are people being barraged with added stimuli from the physical reentry process, but many are also feeling overwhelmed with the noise coming from the media.

“It seems like we’re constantly being bombarded with breaking news and information and opinions right and left, and this can often take us out of the present space and into a pseudo reality,” says Kristin Prichard, an LPC in Houston. “Then you compound that with a novel worldwide pandemic and the restrictions and lockdowns, and it can cause our brains to go into survival mode and trigger a recurrent fight-or-flight response.”

Prichard also noticed that some clients began to create rigid opinions or reactions to try and compensate for and feel safer amid the influx of information and differing opinions. “They want to go to an extreme and say, ‘I’ve weighed it, this is my decision, and I’m not going to waiver from it,’” Prichard observes. “It’s like a protection mechanism.” 

To help clients manage this type of fixed thinking, Prichard says she tries to meet clients where they are and model flexibility. “Something that I’ve tried to help individuals navigate in therapy is being more open-minded and taking in that information, but finding a way to process it before just automatically going to an answer,” she says. “[It’s about] exploring options.” 

Encouraging flexibility was helpful when supporting clients as they navigated interpersonal relationships at a time when more people were gathering but not everyone was on the same page about risk and safety precautions. Prichard urged clients to have an open dialogue, as much as possible, with those they were involved with. “The best thing to move forward is to recognize that nothing is set in stone, and you really need to have open communication with others and have patience and a general level of respect,” she says.

Recognizing resilience

Despite the increase in mental health disorders and the challenges centered on navigating a new normal, another theme that many counselors noticed as the pandemic wore on was a rise in demand for therapy services. This can be interpreted as a sign of resilience, according to some providers.

“While at times it is difficult to navigate, and there are lots of challenges and setbacks as we progress and then take a step back and then progress forward, overall I’ve recognized that more people are reaching out for help,” Prichard says. “You’re seeing the resiliency of individuals and people wanting to reach out for support.”

The reentry phase provided yet another pivot point — or opportunity, depending on how you look at it — to help reframe people’s mindsets from one of discouragement and frustration to one of strength and adaptability.

“There are so many times when I’ve felt, and when I’ve heard from colleagues, clients and supervisees, that I can’t take one more thing, and then there is [one more thing], and people keep going,” McNeil says. “They figure it out.” 

McNeil began using examples of people’s resilience to help validate their strengths. “A lot of people who are coming to counseling say things like ‘I’m broken,’ and I never agree with that, but this has been an opportunity for people to look within themselves and see all the things that they continued to do over the last year and a half and hold the mirror up and say, ‘Actually, you’re not broken. Look at how resilient you are even as hard as this has been. You’ve gotten through it, or at least to this point.’”

While counselors were helping clients recognize their personal resilience in the face of one more hurdle, many professionals were also recognizing their own limits and fatigue. Thus, a potential side effect, or benefit, of the pandemic’s longevity was the realization among some counselors of the need for greater personal and professional well-being to ensure effective and sustained practice.

“I’m a huge proponent and advocate for therapists having their own therapy,” says Jackson, who realized a greater need to engage in personal therapy during the pandemic. “Everyone was in crisis, as opposed to a few [clients] every week, so I had to enlist my own support to process how this was all affecting me.”

In addition to therapy, some counselors found themselves reaching out more to colleagues and others in the field who were facing similar experiences. 

“I think it is really helpful to build a community of support,” McNeil says. “So, having colleagues who have your back, whether you work with them or whether they’re peers who you get coffee with or connect over Zoom with. [Having] other people who really get what you do and can share notes with you about what it’s like to work in a virtual world when we’re a relational profession.”

A new balance?

The reentry phase also presented an opportunity to assess the value of teletherapy, which became a necessity in the early stages of the pandemic but less imperative once the vaccine became widely available.

“At first I, as well as some of my colleagues, were leery of telehealth,” Prichard says. She explains that the fear of losing a sense of physical presence and connection with her clients, as well as the potential difficulty of picking up on clients’ nonverbal cues, initially made her question the effectiveness of teletherapy. However, after several months of providing virtual services to clients, Prichard says she came to respect the benefits that telehealth provides. 

“What it does offer is a sense of calmness or peace for the client to know that at any time, they can check in for a therapy session from wherever they are, and they can do it in their own space, feeling comfortable, and they don’t have to deal with all the stressors and ins and outs of going into a session like traffic and parking,” Prichard says. “From that standpoint, I think it’s been a unique but rewarding thing to realize that we can provide good service care in different forms than we first recognized.”

While there are very real benefits to teletherapy, in-person therapy continues to have its benefits as well. So, what will the future delivery model for professional counselors look like? Maybe a mix of both. 

“You can move forward with the new technology and a new way of doing things while still respecting other ways that you’ve done things before and finding a balance between the two,” Prichard says. 

This balanced approach may also present the opportunity to serve more clients, especially if licensure portability can keep track with the technology, Jackson adds. (To learn more about the Counseling Compact effort that the American Counseling Association is supporting, visit counselingcompact.org.)

“I am encouraged that the pandemic has brought a lot of counselors to virtual,” Jackson says. “It has increased accessibility for so many people who otherwise would not get therapy, and I’m really hopeful that this will carry over into more portability for us so that we can see people in different places. We will be dealing with the effects of this for a really long time, so we need to be able to help as many people as we can in the ways that are ethical.”

 

****

Katie Bascuas is a licensed graduate professional counselor and a writer in Washington, D.C. She has written for news outlets, universities and associations.

****

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.

Crisis counseling: A blend of safety and compassion

By Bethany Bray July 27, 2021

When crisis strikes, clients need a counselor who can listen and share their heartbreak without inserting themselves into the situation, says Amanda DiLorenzo-Garcia, an American Counseling Association member and mobile response coordinator for the Alachua County Crisis Center in Gainesville, Florida. She describes crisis counseling as a short-term intervention to an acute situation with a singular purpose: ensuring that the client is safe and feels seen and heard.

Clients need someone who is “willing to be there, be present and be uncomfortable,” she explains. “We can’t help to fix the situation; all we can do is help the client to withstand it, to survive it — and often that’s heartbreaking. It challenges our humanity. … We have to stretch ourselves to be able to hold space for the immense emotions of despair, grief, hopelessness and helplessness, and that can be really uncomfortable to do.”

Part of life

Crisis counseling is a specialty within the counseling profession, but it’s also a skill that all counselors need to master because crises will pop up in everyday life for clients in all settings. 

Thelma Duffey and Shane Haberstroh, in the ACA-published book Introduction to Crisis and Trauma Counseling, explain that crisis “is often an immediate, unpredictable event that occurs in people’s lives — such as receiving a threatening medical diagnosis, experiencing a miscarriage or undergoing a divorce — that can overwhelm the ways that they naturally cope.” 

Crisis can also occur when multiple stressors are present simultaneously in a client’s life and a seemingly small incident, such as losing their keys and getting locked out of the house, pushes them to “the end of their rope” and sends them into a tailspin, says Ruth Ouzts Moore, an associate professor in the Counselor Education Department at the Chicago School of Professional Psychology.

Shock, denial and disbelief are often the first emotions that clients experience in crisis situations, along with hopelessness and helplessness, says DiLorenzo-Garcia, who co-presented on “Breaking Through Barriers to Provide Effective Crisis Support” at ACA’s Virtual Conference Experience this past spring with Jessica L. Tinstman Jones and Amber Haley. A vast range of physical, mental, emotional and behavioral symptoms can indicate that a client is in crisis, she notes. (See list below.) 

Moore defines crisis as the presence of a “risk of foreseeable harm” in a client’s life, either immediately or in the short term. The client may not automatically disclose this risk factor in counseling, however. Instead, their presenting concern can often be a “Band-Aid” or something more benign, she says, and it’s up to the counselor to “peel away the layers” to assess for risk. This can especially be the case with children, who may be referred to counseling for behavioral issues or because they’re falling behind at school. Sometimes, a crisis — such as abuse at home — may be the root cause of these struggles, notes Moore, an ACA member who specializes in working with children and adolescents who have experienced crisis and trauma.

Ali Martinez is a licensed marriage and family therapist and director of the Alachua County Crisis Center (where DiLorenzo-Garcia also works). In addition to mobile crisis response and in-person counseling services, the center operates a local 24/7 crisis hotline and responds to calls from their area of Florida to the National Suicide Prevention Lifeline. Most of the more than 45,000 calls the agency answers each year are from people who are feeling utterly alone as they face something that feels threatening to them, Martinez says. This includes losses that involve the death of a loved one as well as relational, financial and other losses.

“Most [callers] are not suicidal but are in some level of pain — experiencing something big that hasn’t been fully expressed, and they’re seeking space to do that,” Martinez explains. “They either are truly alone in what they are facing or feel alone in what they’re facing. They’re desperate for some sense of connection. They often know we can’t fix what’s happening — and that’s not usually what they’re seeking. …The struggle with crisis, what creates the danger and the true pain around a crisis, is the sense of how it disconnects us from people. The chaos, lack of control and strong emotions can make us feel alone. On the hotline, so often it’s trying to manage that chaos and find validation and connection — that what they’re feeling is a normal response to an abnormal situation. People often need someone outside their own world to let them know that what they’re feeling is OK and give them permission to express it.”

Crisis is self-defined

People can express their feeling of being in crisis very differently, but one common way that it manifests is tunnel vision, according to Martinez. In counseling, practitioners may hear a client who is experiencing a crisis speak with a narrowed scope or train of thought, returning to a singular experience or feeling over and over again.

Clients in crisis may feel like they’re drowning in emotions and that the issue that sent them into crisis is all-encompassing. Counselors may get the sense that their words are not getting through to the client because the client’s anger or despair is “filling the room,” Martinez says. Attending to the pain a client experiences during a crisis forces counselors to slow down their approach.

If counselors are “trying to get [the client] to look at the long term or take a bigger perspective and they can’t seem to do that and they keep coming back to that one painful thing, then we must change our approach and realize that this is the most important thing for them right now — and we have to listen for that,” Martinez says.

Above all, counselors must remember that “a crisis is defined by the person in it,” Martinez stresses. “For them, if it’s a crisis, it’s a crisis, and we have to honor that. Be aware that in that moment, we might have a much broader perspective on the possibilities [in the client’s life] and we might have good ideas about what could happen, but they may not be ready to hear it.” One of the most powerful things a counselor can say to a client in crisis is “tell me what this means to you,” she adds.

Martinez gives an example of a 12-year-old adolescent who is devastated after their first romantic relationship ends in heartbreak. As an adult, it would be easy for a counselor to tell the preteen client that this is the first of many heartbreaks life will bring. However, the client won’t be ready to focus on larger lessons about relationships and self until the counselor has helped them attend to their initial pain and despair over the breakup.

“For them, this is everything — feeling rejection and shame, sadness and despair. It doesn’t make it any less of a crisis experience for them,” Martinez says. “We [counselors] have to go in understanding it from their thinking.”

Josh Larson, a licensed professional counselor (LPC) in private practice in Denver, agrees that crisis must be self-defined by the client. He previously worked as a crisis clinician and operations and quality assurance specialist at Rocky Mountain Crisis Partners, a nonprofit organization that answers calls around the clock for several crisis hotlines, including the National Suicide Prevention Lifeline.

“We would always assure the caller that what they feel is a crisis, is a crisis. For one person, it could be that their cat got outside and they haven’t seen [the cat] for two hours and they’re feeling suicidal. For someone else, it’s something much bigger or more layered,” says Larson, an ACA member. “As a practitioner, even if what the client is telling us wouldn’t be a crisis for us, if they identify it as a crisis, then we need to treat it as such.”

Freedom to speak authentically

There is no shortage of crisis counseling models and assessment tools in the professional literature for practitioners to draw from in their work with clients. The counselors interviewed for this article did not recommend any one particular model or framework over another. They instead encouraged practitioners to research and select the counseling approach that works best for their style and client population.

No matter the model — or even if no model is used at all — a competent crisis counselor should shape a session into an arc that begins with rapport building and ends with connecting the person with resources. This last step ensures that the client has a safety plan (if needed) and is aware of options for follow-up care, such as local counseling services, walk-in crisis clinics and emergency hotline numbers. In the middle of this arc, at the core and heart of the therapeutic interaction, counselors create a nonjudgmental and empathetic space for the client to talk about their situation and share their burden.

The client does most of the talking in crisis counseling sessions, with the majority of the time spent simply “letting them tell their story,” DiLorenzo-Garcia explains.

Given that some clients may experience suicidal ideation during a crisis, an important part of this work is becoming well-versed in suicide assessment. DiLorenzo-Garcia and the other counselors interviewed for this article recommend that practitioners weave questions about a client’s safety, including those focused on suicide assessment benchmarks and protective factors, throughout the conversation.

In some situations, crisis counseling can offer clients the much-needed freedom to make strong statements without feeling judged or censored, Moore notes. This includes the freedom to talk about feelings such as anger or thoughts of harming oneself that can have shame or stigma attached to them.

This was the case for a 15-year-old client Moore once counseled who had turned to drinking, taking drugs and other risky behaviors to deal with turmoil at home, including feeling powerless when his father was abusive toward his mother. In session, the teen, referring back to an invective his father had directed at him, asserted, “I want to be an asshole.” Moore didn’t flinch at the client’s use of profanity. Instead, she responded, “You’re not an asshole.” When she repeated her statement, the teen began to cry, releasing emotions that had been pent-up. 

“He had a deep, deep level of anger, resentment and betrayal that we needed to talk through. He found freedom in being able to say those things in a safe environment,” Moore recalls. “It was freeing that he could speak so strongly and hear his counselor repeat it back.”

Many of the crisis calls DiLorenzo-Garcia’s team responds to are in the public schools. Sometimes they respond because a student has called the county hotline themselves, but most often it’s because a school staff member (a school counselor, principal, school resource officer or administrator) has called to request their help.

In such cases, DiLorenzo-Garcia often begins a one-on-one session with a student by explaining the context of why the school asked her to come and speak with them. She assures the student that they are not in trouble and that she’s there because people are concerned about them. For example, she may say, “This is what I’ve heard from your school counselor, but I’m curious what your perspective is. What’s going on for you?” 

“That’s the door opener. I reassure them, ‘I don’t want to make any assumptions about you. Your experience is your own, and I want to understand,’” says DiLorenzo-Garcia, a postdoctoral scholar at the University of Central Florida whose dissertation was on the loss and growth experience of mass shooting survivors and their families.

If the client’s experience includes thoughts of suicide, allowing them to talk through how they truly feel can help both the client and counselor realize how serious those thoughts are, DiLorenzo-Garcia adds. Sometimes a client has thoughts of suicide but doesn’t want to die, which can be accompanied by feelings of shame or isolation. If a client has a concrete plan to end their life, talking that through can help determine whether or how soon the client might act on that plan — and the necessity for follow-up care.

Assessing client needs

Larson notes that a majority of the callers during his time at Rocky Mountain Crisis Partners were not suicidal. However, some callers would say at the start of the call that they were not suicidal, but as the conversation went on and they began to unpack the depth of their emotions, it would become clear they were in fact experiencing suicidal ideation, he says.

This aspect of crisis counseling is why it’s imperative for counselors to be familiar with and proficient in suicide assessment. A counselor should be able to assess for preparatory behaviors, substance use problems, a client’s internal and external coping mechanisms, and other benchmarks to determine next steps, including safety planning or follow-up counseling, DiLorenzo-Garcia says.

Moore says it is important to be knowledgeable about assessing for not only suicidal ideation but also homicidal ideation when clients are in crisis. She acknowledges that asking questions about homicidal intent can be uncomfortable for practitioners. However, counselors must keep in mind that when in crisis, clients could have thoughts about harming others as well as themselves, she says.

“Be comfortable asking those difficult questions: ‘Are you having thoughts of killing yourself or harming anyone else?’ Don’t sugarcoat it,” says Moore, who presented the session “One Size Doesn’t Fit All: Creative Strategies for Counseling Diverse Families in Crisis” at ACA’s Virtual Conference Experience.

Larson points out that, along with active listening, validation of a client’s concerns and assurance of safety, de-escalation is a large part of crisis counseling. This can include mini versions of deep breathing and other grounding skills that clinicians might use in long-term counseling sessions with clients.

It can be helpful to match the person’s affect level, Larson says. For example, a counselor shouldn’t respond to a person who is hysterical with a flat, monotone voice. Instead, mirror them with a tone that is slightly calmer to gradually de-escalate the situation, he advises. Similarly, a crisis counselor shouldn’t respond to a client who is monotone or expressionless with a bright, bubbly demeanor. Instead, mirror their tone at a slightly more expressive level to gradually lift their affect, he says.

In crisis counseling, de-escalation and being presented with the opportunity to talk through what they are feeling will be enough for some clients, Larson continues. Others will be looking for help with problem-solving, such as conflict resolution or next steps to take after receiving a crushing health diagnosis. But Larson finds that clients in crisis are usually looking for one or the other, not both. Therefore, he advises counselors to be upfront and ask those in crisis, “What do you need? Do you want someone to listen or [someone to] help you problem-solve?” 

“If you offer solutions to someone who is not wanting them, it can escalate them further into crisis,” Larson adds. Instead, he may tell clients, “I’m listening, and I’m willing to offer solutions if that’s what you’re looking for.” 

In cases of suicidal ideation, DiLorenzo-Garcia finds it helpful to focus on the short term with clients. For example, she may say, “It’s a lot to ask you to live forever or live until next year, but right now, let’s talk about if you can live to tomorrow. What might that look like? Can you withstand the pain you’re going through just for tonight? What would it look like to survive and come back to school tomorrow?” 

The counselors interviewed for this article emphasize that it is critical to arrange for follow-up support after crisis sessions but say that involving law enforcement to conduct welfare checks on a person in crisis should be done only as a last resort.

Always follow up with a person who is in crisis, even if your session ends well and it sounds like things are going to work out,” DiLorenzo-Garcia stresses. Her agency contacts each client within three days after the initial crisis counseling session to make sure they are supported and doing well. In school settings, she also debriefs the adults involved in the student’s care (e.g., parents, school counselor) to ensure they are aware of the student’s needs and any next steps after a crisis counseling session.

Client safety

Meredith McNiel, an LPC who co-wrote the chapter “Crisis and Trauma Counseling With Couples and Families” in Introduction to Crisis and Trauma Counseling, notes that during crisis counseling, practitioners should focus on client safety through three lenses:

  • Feeling safe to express themselves fully in the crisis counseling session
  • Feeling safe at home and in the world outside of the counseling session
  • Feeling safe within their life, including protective factors and social connections

An important part of this focus, she says, is reminding clients (multiple times if needed) that the counseling session is a safe and confidential space to speak freely about what they are experiencing.

Clients may disclose dark and powerful thoughts, such as suicidal or homicidal ideation, during crisis counseling, and McNiel acknowledges that many counselors’ first instinct may be to refer these clients for more intensive care. However, practitioners need to push through this initial reaction to keep from breaking clients’ trust.

“If a counselor is worried or nervous or scared about handling a situation, the client will feel that,” McNiel says. “We need to be comfortable asking hard questions while keeping the client comfortable.” The counselor should allow the client to say what they need to in session and “hold that space” without trying to fix their situation, she stresses.

“In a suicide crisis session, many professionals might [automatically] think, ‘Where can we send you?’ and in my experience, that is an absolute last resort. If a client hears that they’re going to be hospitalized or referred out to someone they don’t know or trust, they can instantly lose trust with a counselor,” says McNiel, an ACA member with a private counseling practice in Austin, Texas. Instead, “allow the session to happen fully in the way the client needs to share or release and process, and go from there,” she advises. “I assure [the client] that if anything further needs to happen, we will decide that together. I will not take control of what’s going to happen. I remind them that they are in control of their circumstances.” (See more about the ethical guidelines regarding protecting clients from “serious and foreseeable harm” in Standard B.2.a. of the 2014 ACA Code of Ethics at counseling.org/ethics.)

Crisis counseling is “less clinical and more relational” than long-term counseling, explains McNiel, who was a crisis counselor at the University of Texas at San Antonio Academy for Crisis and Trauma Counseling during her LPC internship. Practitioners need to let clients share and talk through their experience “until it feels complete” — whatever that looks like for them. 

To ensure that a client’s safety and comfort are the primary focus in crisis counseling, practitioners must be so familiar with assessment tools that they don’t need to read the questions off a piece of paper or computer screen, says McNiel, whose doctoral research was on college counseling work with students who were suicidal. “[Instead of] saying, ‘Hold on, I’m going to grab this checklist and ask you some questions’ … ask questions in a relational way and fill out the assessment afterward rather than stopping the flow of a session,” she says. Counselors should be “getting answers [from the client] through conversation rather than interrogation.” 

For example, an assessment tool might prompt a counselor to ask the client, “Are you thinking about killing yourself?” Practitioners still need to ask direct questions about suicidal ideation, but couching those questions in a more conversational way aids in maintaining trust, McNiel notes. Alternatively, the counselor could say, “I can see and hear that you are really struggling with this situation. You’ve shared with me that you have thoughts about killing yourself, and that makes sense considering what you’ve been through. I’m wondering how close you are to doing that? How close are you to going home and following through [on those feelings]?” 

“The difference [in phrasing it this way] is the compassion in the language surrounding those really heavy questions,” she notes.

At the conclusion of a crisis session, counselors should talk through next steps with the client, including addressing what the client would do if things became worse and a crisis resurfaced after the session, McNiel says. If the individual is a long-term client, she advises scheduling their next session and letting them know how and when to reach the counselor during nonbusiness hours, as well as providing crisis hotline numbers.

Martinez agrees that in crisis counseling, practitioners should resist the urge to “fix” the situation the client is facing. In addition, counselors should avoid viewing it as a linear cause and effect. This includes thinking of suicidal ideation in binary terms of yes or no.

“We have to think of suicide in a much broader continuum, a range of pain and despair,” Martinez says. “[Society’s] fear and the stigma around suicidality makes us think about it as an on-or-off switch, but it’s more complicated than that.”

By definition, crisis is chaotic and messy, and the goal of a crisis counseling session is to de-escalate and share that burden, rather than organize or reorder it. Martinez illustrates this with a metaphor of a jumbled pile of sticks on the ground. A counselor’s instinct might be to gather the sticks and assemble a neat structure for the client, she says. Instead, crisis counseling involves allowing the client to pick up the sticks, one by one, and assemble them however they need to — even if it’s just into another pile on the ground that, to an outsider, looks equally as messy. “That’s much more powerful than us trying to figure out where the sticks belong,” Martinez says.

If a counselor approaches a crisis counseling session with the goal of tracking a client’s story in context, the counselor will miss the client’s full range of emotions — and the chance to connect and help the client bear that pain, Martinez says. “We can get caught up in [feeling that] ‘I need to make sense of the story.’ But that’s our need, our desire. The client may not need that or be ready for that. … When they talk and are listened to, they often begin to make sense of it themselves.”

Take Care of Yourself

The counselors interviewed for this article agree that it is imperative for practitioners who engage in crisis counseling to take steps to avoid burnout. In addition to regular self-care, this can include ongoing supervision or consultation with colleagues as well as other methods to combat feelings of isolation and empathy fatigue that can easily overwhelm practitioners whose clients share such heavy and troubling topics.

Moore suggests counselors take steps to maintain a balanced caseload and stay aware of how stress and burnout manifest for them personally. “Doing trauma and crisis work is heavy stuff. It can be super rewarding but super draining,” Moore says. “We carry [clients’] trauma with us, so it’s important to take care of ourselves. … Sadly, we need more and more counselors to do crisis work, and if you don’t take care of yourself, that’s one less counselor to help people who need it.”

It’s also important to remember that sharing the burden of crisis with clients is a gift, Larson says. A crisis counselor may be the only person the client feels they can talk to during their lowest moments. 

“It takes a lot of courage to pick up a phone and tell a stranger [a crisis counselor] that you want to die,” Larson says. “Always remember that it’s an honor and privilege to hear people’s hardest stuff — their deepest, darkest secrets.”

fran_kie/Shutterstock.com

****

Contact the counselors interviewed in this article: 

 

****

Crisis counseling via text message

People in distress send messages to the Crisis Text Line 24/7 looking for help and support. Its team of volunteers across the U.S. has had nearly six million chat conversations since the nonprofit organization was established in 2013.

How can aspects of crisis counseling be translated for use via text? Counseling Today talked with Ana Reyes, a licensed professional counselor and bilingual manager of clinical supervision at the Crisis Text Line, to find out more about the nuances of crisis counseling via text message. Read more in an online exclusive article here.

 

****

Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@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.

What discomfort can teach you

By Shari Gootter and Tejpal June 16, 2021

Comfort is something we all seek. The notion of “being comfortable” is highly prized (and promoted) in our society. It is considered a major selling point if you are in the market to buy a bed, clothes, a car, a pair of shoes — almost anything. But the overvaluing of comfort in our lives can come at great cost.

Fizkes/Shutterstock.com

Our relationship with comfort and discomfort is influenced by our culture, our personal history and our personality. If we are born in a tradition in which failure is not an option and social success is the norm, we may challenge ourselves with long hours of work or study to avoid the discomfort of failure. If we are born into a family where depression or anger was part of the daily landscape, we may want to avoid these emotions at any price and dissociate when these feelings arise. Taking a deeper look at our relationship with comfort and discomfort provides us insight on our path toward acceptance and happiness.

Discomfort exists at many levels:

  • At the physical level, it may manifest as a headache, a digestive issue or a skin irritation.
  • At the emotional level, it may manifest as anxiety, worry or depression.
  • At the mental level, it may manifest as constant agitation, an inability to focus or ambivalence in decision-making.
  • At the heart level, it may manifest while experiencing loss, change or separation.
  • At the spiritual level, it may manifest as existential angst, lack of purpose or a feeling of disconnection.

Certain life events can be challenging and unfamiliar. If we are clinging to any form of comfort, we will limit our ability to adapt and grow. Through the years, the overpromotion of comfort, happiness and pleasure has created tremendous distortions. There is no tolerance for any amount of discomfort and tremendous impatience for any kind of pain. When comfort is the only choice, resilience and the ability to overcome adversity are lost.

Running from discomfort

If you want to stay centered and at peace, you need to stop running away from discomfort (or always running toward pleasure). Running from discomfort prevents us from being able to see and feel what is present. It holds us in a false state of reality and never allows us to know our true selves. On the other hand, being uncomfortable teaches us to transcend pain and pleasure, thus allowing us to be true to ourselves. It also allows us to see clearly when challenges occur.

The constant promotion of pleasure and comfort has contributed to the emergence of addictive behaviors. For example, many individuals use food, medication or gaming as a way to soothe their pain or “escape” their stress. This starts with a tremendous obsession of the mind that makes us believe there is only one way. When our mind gets frantic about one thing, there is no room for anything else and our behavior becomes extremely reactive. As soon as we grasp for more comfort, we become intoxicated. Intoxication does not necessarily have to involve a substance such as alcohol. We can be intoxicated with power or greed. As soon as we are intoxicated, we lose our intelligence and our ability to be present.

When you experience discomfort, we suggest that you stay away from labeling it, contracting and wondering when the pain will go away. None of us came to Earth to suffer, but none of us came to earth to run away from suffering either. Every time that you hit your limitations, you have the opportunity to unfold and open.

Mara, one of our clients, was struggling with tremendous discomfort. She was never satisfied with herself and experienced ongoing anxiety about her future. She dealt with her pain by consuming alcohol. After several years of doing this, Mara was no longer able to follow through with much of anything, and she ended up getting fired from her job. This was a much-needed wake-up call for Mara to realize that she needed help. When she first came to see us, she had a strong motivation to rid herself of her discomfort. But as she learned to develop a sense of compassion for herself, she grew more able to embrace her discomfort. Mara came to understand that when she was trying to cover up her discomfort, she was actually opening the door to self-destruction.

Accepting discomfort

Accepting our discomfort is led not only by bravery but by our heart center. At that moment, we choose to accept who we are. Our will does not help to heal our pain; our heart does. For Mara, getting fired was the saving grace. Others may go deeper into negative coping mechanisms that further enhance patterns of self-sabotage before determining to change their relationship with discomfort.

Often, when we experience discomfort, we perceive it as a threat. We want to separate from our discomfort to protect ourselves. When we do this, we create the opposite of what we are looking for. The more we separate from our discomfort, the more we separate from ourselves, and the more pain we experience as a result.

Underneath any discomfort, there is a fear. For some it could be the fear of missing out. For others it may be the fear of not being in control, or the fear of being overwhelmed and losing sense of self.

The longer we numb our discomfort, the more stuck we may feel. The longer we reject our discomfort, the louder our ego becomes. The practice of allowing discomfort is the practice of integration. Integration occurs when we allow our behavioral patterns, traits, emotional states and experiences to come together in a more unified and organized state. Without integration there is separation, and with separation there is distortion.

The purpose of pain is to awaken the heart, not trigger the mind. It is not about overcoming pain; it is about recognizing and being willing to learn from it.

Some spiritual traditions will bring discomfort to the core of their practice. The intent is to teach the practitioner to stay whole while in pain and to prevent the mind, led by the ego, from directing the experience. The focus is not on overcoming pain but rather on surrendering and allowing the experience of pain to expand where it wants to be. It teaches the mind not to separate but to allow. It teaches the mind to go beyond subject-object relationship. At that moment, there is an alchemy happening in the body, and one may shift from pain to bliss because the mind is not locked into form.

The practice of being uncomfortable

Regardless of your spiritual tradition and belief system, meditation is a great way to learn to be still with discomfort. Many people express difficulties when trying to learn to meditate and often give up, believing they are not good at it. The purpose of meditation is not to add pleasure or pain but rather to develop a neutral mind that allows whatever arises. Consistency in a meditation practice paves the way for acceptance and humility, which are two beautiful qualities of the heart.

If you are able to stay still during pain, without hoping for pleasure to come, you are free. If instead of fighting against the pain, you welcome it fully, you will shift and heal. When this happens, you will realize that pain and pleasure are not opposites, but simply sensations; you are now living beyond polarities.

Being uncomfortable does not always relate to pain or pleasure; our own fears and limitations can create great discomfort. To avoid discomfort, we may prevent ourselves from taking risks and put our self-development on hold. Some may feel stuck and have pushed the pause button, whereas others might operate on autopilot by staying with their to-do list. For example, some people may stay in a relationship or job even though they know it is no longer serving them. Both are forms of avoidance.

As we learn to allow pain to be part of our experience, we need to notice other possible scenarios that prevent us from learning about our discomfort. The first scenario is to be attached to our pain, allowing it to become our identity. At that moment, our life revolves around our pain, and this limits our ability to heal and make positive changes. The second scenario is to be uncomfortable with others’ discomfort. This steers us toward being “people pleasers,” constantly focusing on others’ well-being and avoiding being in touch with ourselves. Related to this second scenario, it can also be challenging to be around someone we deeply care for who is experiencing a great deal of discomfort. We may want to “fix it” or change it as a sign of love.

The practice of being uncomfortable teaches us to stay connected with ourselves, to be curious and open. It teaches us to be relaxed and surrender into the discomfort. The more we want to control our discomfort, the more stuck we become.

Allow discomfort to be part of your experience. Welcome it fully from the heart center. At the core of your pain or fear, you will grow and you will learn.

Practices

To become comfortable with the uncomfortable, we invite you to try the following practices. As with every practice, consistency and repetition are key to gaining insights and creating change.

Practicing in itself can create discomfort. It is when you are the least inclined to practice that it may be the most beneficial. Practice teaches you to go beyond your emotional reactivity. As you keep showing up for yourself, it will get easier.

Meditation Tonglen

Tonglen is a meditation practice found in Tibetan Buddhism and used to awaken compassion. Through acknowledging our own and others’ suffering, we open our hearts.

  • Sit in a comfortable position. Lengthen your spine and draw your shoulders down your back. Soften your face and jaw. Close your eyes.
  • Connect to one part of you that is in pain at a physical, emotional, mental, heart or spiritual level.
  • Notice the quality of your pain.
  • Imagine all of the people with a similar experience and inhale their pain. Do not be afraid to “inhale” others’ pain. You will not get more pain. In fact, you may feel some relief.
  • Exhale; send relief.
  • Repeat the process for at least three minutes.

Journaling

Some of you may be really reluctant to start this practice and others may simply love it. The benefits of journaling are priceless. It helps you process emotions or situations with more awareness and clarity. It is a safe container to express your voice. Research on journal writing therapy indicates positive outcomes related to identifying emotions and feelings and reducing stress. It can be a catalyst for change and healing.

  • Think of something that makes you uncomfortable. Is this new or old? What are the main emotions you are experiencing? What behaviors or strategies have you implemented? What did you learn about yourself?

Take action

Taking action is where the true learning takes place. You get an opportunity to truly assess your relationship with discomfort and stretch yourself.

  • Do something outside of your comfort zone.

 

******

 

This article is based on a chapter from our book WAY TO BE – 40 Insights and Transformative Practices in The Heart of Being. For more information, go to www.40waystobe.com.

 

******

Shari Gootter is a licensed professional counselor and certified rehabilitation counselor with decades of experience in designing and leading workshops for diverse populations. Her focus has been on helping people shift while going through losses or adjustments. She has also created programs for counselors that assist them in developing a framework that supports lasting transformation. Shari is a therapist in private practice and has taught yoga for decades. Contact her at sharigootter@comcast.net.

Tejpal has over 30 years of experience supporting individuals on their journey toward healing, life purpose and real joy. Tejpal blends her intuition, energy healing, creative processes, life coaching and yoga into her work. Tejpal was born in France and moved to the U.S. 25 years ago. She has worked with people from many cultures and traditions.

****

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.