Actions speak louder than words: counselling clients with communication difficulties
University and College Counselling, March 2024

People always interrupt me and think I don’t understand’ is something I hear from many young people with verbal communication difficulties. I reflect on the enormous daily challenges and how exhausting it can be for them. Clients describe how people make assumptions about what they want to say, or hurry conversation along to hide their own embarrassment, leaving them feeling patronised and dismissed on a daily basis by others thinking that their physical difficulties reflect mental capacity. Clients tell me how they do not want to be changed to ‘fit in’ to society, and yet they often feel that they have to.

Each client comes with their own story and individual ways of expressing it, but all seem to have something in common: feeling repeatedly misunderstood, silenced and excluded by society. Detailed accounts express how the deep pain of not belonging drenches them with a deeper ongoing isolation. Upon leaving the education environment and going out into the world for the first time, many disabled young people find it impossible to find a counsellor, not because the availability isn’t there, but they are being told that practitioners do not feel able to meet their needs. This prevents those managing complex health challenges from accessing much needed mental health support; potentially compounding an already existing feeling of being a burden on society.  

Societal influences 

The past has failed to accurately capture much of the disabled experience as it was ignored and silenced for centuries. In the mid-1800s, the medical model of disability began to replace the moralistic and religious model, but the world of psychology still regarded disability as something to fix or cure, influencing the views of leading scholars, politicians and researchers.¹ The social model of disability created by disabled people describes how we socially create disadvantage, and widespread oppression experienced by those having (or who are perceived as having) impairments.² Literature claims society moved away from the medical model of disability in the 1980s, replacing it with the social model of disability,³ thus abandoning assumptions that a person’s primary problem is their disability. 

In consideration of this, together with witnessing how technology has progressed and, in knowing how hard clients have worked to use a communication method that works for them, why then do those with communication difficulties still experience such a huge disadvantage when seeking support? In 2001, Vic Finkelstein criticised the social model of disability on the following basis, which I wholeheartedly agree with: ‘(i) the social interpretation of disability does not provide an ‘explanation’ of disability, and (ii) disabled people are not the subject matter of the social interpretation of disability’.⁴ 

It is easy to see the detrimental flaws of relying upon such socially manufactured ideas, which are then considered pillars of truth, generalising and minimalising disabled people’s experiences. Isn’t therapy supposed to be about the subjective experience? 

Therapy or invisibility? 

Treloar’s School and College offers around 170 students, aged four to 25 years, a specialist environment where learning takes place alongside therapy and care. Our students are physically disabled with complex needs. Mainstream schools and colleges cannot provide the support they need to achieve their goals. 

Since before COVID-19, high numbers of individuals contact Treloar’s each year seeking private arrangements for therapy, due to not being able to find a counsellor locally. People who hadn’t given up searching for support after being rejected over and over again. This problem is also evidenced in Birmingham, by Catherine Jackson in her article in the May 2023 edition of Therapy Today, describing how a client finally found a therapist, having been turned down by 160 individual therapists!⁵ People are trying to tell us there’s a problem, so we can begin to imagine how far reaching this could be. Listening to so many disabled young people, I am left wondering about the impact of my own profession and possible contributions to the continued invisible stigma and disablement of young adults. How might our profession be preventing people from accessing an ordinary therapeutic relationship?  

Working with communication barriers 

Over the past 15 years working as a school and college counsellor primarily in mainstream education, I have had the privilege of working with many young people who face a vast range of language, cognitive and/or communication challenges. These include clients who have stammers, or where English is not their first language and those who have acute or chronic medical conditions impacting vocal cords and restricting bodily movement. Individuals have found creative ways of communication using signals or hand gestures such as waving, pointing and giving a ‘thumbs up’ or ‘high fives’. Some clients come to counselling using a variety of different machines and software called augmentative and alternative communication (AAC) devices, using their eyes or limited available movement to select words and phrases on a digital screen. Some very clever and bespoke tech! I remember feeling extremely intimidated when I first came across it.

Core training teaches us the importance of non-verbal body language nuances, and managing the basic practical elements of a session, but what if a client requests a variable session slot, due to their attendance being dependent on their communication facilitator being available? Having a third-party present during sessions could be considered unethical, as we have learnt from our training. Also, what happens when the counsellor struggles to use everyday technology and the client turns up with an AAC? What happens when the session regularly takes longer than the generic 50 minutes due to their disability or personal needs? These are all questions I wish I knew to ask when I was in training. Of course, we work these things out as we go, but perhaps discussing potential barriers with disabled clients earlier on in initial training, would increase confidence, and positively impact those early sessions for the client.  

Visibility in the therapy space

I remember how I first felt working with a client I couldn’t understand and panic set in! I would say to myself, ‘What if I make things worse for them?’ and, ‘What if I can NEVER understand them?’ I realised through clinical supervision that some of this was coming from the client; their fear of not being understood, feeling like a burden on the counsellor. I also became aware of my own underlying expectations and not feeling skilled enough, which was causing potential blocks to the already challenging communication process. Examining previously unexplored biases, assumptions and fears with my supervisor meant I could put all this aside, and focus on the person in front of me in the room. The realisation then came… this is fundamentally no different from other client work, I just needed to remain flexible, non-judgmental and willing to learn.  

At Treloar’s, these are some of the things considered:

• it’s OK to be scared of technology and asking the client is OK; many enjoy sharing how they use it
• feeling afraid of getting it wrong is normal. Talking openly with the client in session conveys vulnerability
• time goes really fast and it generally takes longer for the communication process, so allowing extra time when assessing, planning and reviewing helps take the pressure off both parties
• having communication difficulties can be utterly physically and emotionally draining. Some days may be better than others. Attendance may be impacted and breaks may be needed
• taking ownership of learning more about a client’s disability out of session can save the client time and/or energy in session, and help them to feel valued
• you don’t need to be an expert – have patience with yourself, feeling helpless is commonplace
• when a third party needs to attend (either a translator, interpreter or communication facilitator), it’s useful (if not essential) to draw up a boundaries contract before therapy starts
• room space is a common issue, especially in older buildings, and you may need to get creative! I have two fold-up chairs in my office, which can be stowed away to allow for wheelchair space when needed
• inclusivity is deemed the priority, where our counsellors look to accommodate in every way possible before declining a referral. 

We know working within an educational environment doesn’t necessarily come with the same pressures as private practice; there may be financial implications for things like needing extra time when working with a disabled client. Mel Halacre states that ‘before offering or starting therapy, these valid concerns should be brought to supervision. Finances are an issue for many disabled clients too. Some therapists offer reduced rate slots for lower income clients, and perhaps additional time could be similarly accommodated.^’6 

Consideration of inclusivity (and its importance) early on helps preserve the therapy space, so that potential clients are not weighed down thinking about these things during the work. However, if accommodating a person’s needs feels too challenging, I find it useful to talk about it in supervision for problem solving. Sometimes, when I feel I am going above and beyond to accommodate a disabled client, I remind myself that they have likely had to work double-fold to make contact and get here – it is not a level playing field. 

We know counsellors are legally required to provide any reasonable adjustments necessary, which enable disabled individuals access to counselling. Increasing discussion around what these practical changes might look like, and what the potential implications of making such changes could be, seem vital. Including these conversations, and also disability equality training as part of the initial qualification route, might make it less taboo and help open up better access to psychological support services for our disabled community.