Tom sat opposite me. He’d come for counselling because his GP had said it might help him deal with depression and anxiety following a redundancy and bereavement. He looked uncomfortable: ‘So what happens then? Do we just talk?’

I soon established that Tom didn’t know anyone who’d had counselling and had no idea what to expect. Although he’d chosen to come, he really didn’t know what counselling was about. We also discovered, as we worked together, that he’d never really learned to notice or share what was happening inside him and had a pretty limited vocabulary to describe how he was feeling. For quite a while, he’d tell me ‘I feel right thingy’ – and we’d spend time working out what kind of ‘thingy’ he felt.

I enjoyed working with Tom; he was one of my early clients in my first placement at a local Mind, and it seemed to me that he came to, and stayed with, counselling ‘against the odds’. During that placement, I became increasingly aware of feeling – and sometimes being – different with certain clients who, like Tom, just seemed far less prepared for therapy. In group supervision, colleagues talked of clients with ‘no idea’ how counselling worked, who struggled to articulate their thoughts and feelings, and who often dropped out. I wondered then whether different ways of working could have made a difference.

I was so curious about this that I decided to embark on a Research master’s to see if I could discover more about what I’ve called ‘unprepared clients’.

What do I mean by 'unprepared' clients?

I needed a definition for my research and this is what I settled on:

‘Unprepared’ clients come with no real understanding of therapy and also tend to struggle with the very processes therapy depends on.

They are not used to noticing or sharing their inner worlds and often lack the emotional vocabulary to do so.

They are not reluctant or involuntary; they have chosen to come and want the therapy to work but they do not know what they have chosen or how therapy works.

And they often need help to engage effectively with the process.

Research focus

As many of you will know, when you begin a Research master’s, you need to review existing research and literature on your topic. For me, this proved to be a challenge because it simply wasn’t there. The only relevant research that existed focused on clients with specific backgrounds, such as working class or low income, and on what helps these ‘unprepared’ clients to access counselling and whether it’s effective – the beginning and end of the process.

What was missing was a focus on what happens when ‘unprepared’ clients actually become clients – how the experience feels for both counsellor and client, and what’s been learned about how to do this work effectively. That’s what my research focused on, and it turned out to be the start of a fascinating journey.

I interviewed six experienced therapists working in community-based counselling agencies across east London. All the agencies actively targeted ‘unprepared’ clients, and most of the counsellors thought the people they saw would be unlikely to access counselling in traditional, mainstream settings, although I suspect many could be referred by GPs to IAPT services.

My focus was how it felt to counsel ‘unprepared’ clients and what these counsellors had learned about how to do it well. I discovered considerable untapped expertise and knowledge about working with this client group, and a remarkable degree of consensus.

How 'unprepared' clients feel different to work with

There was a lot of agreement about how ‘unprepared’ clients feel different to work with.

For ‘unprepared’ clients, counselling is usually ‘culturally strange’; two counsellors used the phrase ‘a strange land’. This phrase sums up for me how difficult it can be for some clients to reach a counselling room in the first place, and how much further they have to travel once they’re there to engage effectively with the process.

Not understanding therapy

Everyone talked about ‘unprepared’ clients not understanding therapy when they arrive; and this lack of understanding was experienced as a significant challenge:

‘I think that probably would be the biggest challenge, them trying to get their head around “What is this thing? What is this person and what is she offering me?”’

Understanding what therapy is not is also important. For example, clients sometimes expect counsellors to offer advice:

‘…they’re going to come and tell you their problems and then you’re going to tell them what to do… so a lot of the work at the beginning can be about dealing with the disappointment about that.’

There can be scepticism about whether counselling can help at all:

‘I’ve had clients say to me, “How’s talking going to make a difference?”’

And this scepticism is not always verbalised:

‘I think that’s often a question that you can pick up but that’s not actually said outright; the question of “Does counselling really work? Is this going to make any difference?”’

This scepticism can remain until the client feels change beginning to happen. Of course, many ‘prepared’ clients can be sceptical, but the difference is in the starting point – trying to establish a relationship with someone who doesn’t understand or trust the process at all.

The specific rules and boundaries of therapy can be particularly challenging for clients to understand:

‘We understand it’s all about the relationship and trust, but they, why would they? They don’t know the rules.’

Examples of rules and boundaries not being understood included time keeping, meeting outside sessions, and the need for regular attendance:

‘…some people don’t understand that you meet at the same time every week for the same period of time.’

Unhelpful beliefs

The research identified a number of unhelpful beliefs commonly held by ‘unprepared’ clients:

Counselling is not for people like me: ‘It’s one of those sort of alternative things that people do, you know, the whole “other people do it”.’

Talking won’t help, or will make things worse: ‘The biggest example of difference between prepared and unprepared clients is “talking makes it worse”.’

Having counselling means you’re weak, or mad: ‘There was a terror of being seen as weak, or even more sort of old-fashionedly, if you like, just mad!’

Clients can struggle when counselling goes against cultural or family norms:

‘…a lot of them would say “I’ve never talked like this before. Nobody ever talks like this in my family”.’

These beliefs can create significant barriers and there was no mention of them during my training.

Communication and emotional literacy

Everyone described differences in language or communication when working with ‘unprepared’ clients. Language needed to be accessible and ‘everyday’, and some counsellors were aware of changing their use of language with ‘unprepared’ clients.

Every counsellor had experienced this client group struggling with the process of talking about their feelings, and there was a sense that emotional literacy is core to the ‘unpreparedness’:

‘It’s not just that counselling’s a first, it’s that any kind of conversation, even mentioning emotions, is a first, at all. So you’d have a very, very narrow language band in relation to feelings, so you’d only really know happy, sad, angry, jealous, and have never thought about maybe needing any more than that.’

Therapeutic relationship

The therapeutic relationship is key to connection, trust and the possibility of change. Some of the counsellors I spoke to felt this was a significant challenge:

‘I think the challenge that comes to people who wouldn’t normally access counselling is the relationship. That’s the part they find really difficult.’

‘I find that with the clients who’ve not had any experience at all, it seems to take longer to build up that trust in the relationship.’

Material brought

‘Unprepared’ clients living with disadvantage often present with one issue which turns out to be the tip of an iceberg. My experience is that people living with life-limiting disadvantage tend to experience a double bind: problems affecting several of the key pillars of life (health, money, work, relationships), and fewer choices or ways out. An important part of therapy can therefore be helping people to realise they do have choices, skills and resources.

Working effectively with 'unprepared' clients

There was a surprising degree of consensus about the ways of working that counsellors had developed and found to be helpful with ‘unprepared’ clients.

Previous experience

Every counsellor considered that their previous experience with this client group mattered, and they sometimes drew on this in their work:

‘I knew about this client group before I had them as clients. I certainly knew the language already and I kind of knew where they were coming from.’

Several described life experiences they thought gave them personal understanding of the journeys of their clients, like living on a very low income; counsellors need to understand the kind of backgrounds and the struggles that may contribute to what their clients bring:

‘I think people come with a context. You can’t counsel people in a vacuum.’

Learning by doing

Every counsellor talked of learning and adapting their practice through experience. There was a sense of trial and error – of refining and learning by doing:

‘I don’t think you can really be taught this until it faces you.’

Helping clients to understand what therapy is

Every counsellor talked about the importance of helping clients to understand what therapy is, and all had developed their own ways of doing this. A key theme was making things transparent – demystifying therapy. This client group needs clear, straightforward explanations that assume no prior knowledge:

‘I think you need to be very prepared to expose what a counselling relationship is, and your understanding of counselling, how it might work.’

This transparency extends to the rules of therapy and why they exist:

‘I would talk about why one-to-one talking for an hour… might be helpful. I’ve had clients before saying things like, “You know I wish you could meet me for coffee”; and trying to unpack that with them, what does it mean?’

Communicating effectively

Getting language or communication right was mentioned by every counsellor. Key themes were using everyday language (no jargon), finding creative, non-verbal alternatives, and slowing the pace of language.

Supporting emotional literacy

Supporting clients’ emotional literacy is also central; strategies included talking more factually, explaining about feelings, using countertransference as an indicator of clients’ feelings, and using creative techniques.

Therapeutic approach

Counsellors considered that they had learned to adapt their therapeutic approach over time. Common themes were working slowly and gently, being more real with clients, and that working integratively offers more possibility of tailoring and choice, both of which can be very important.

Counsellor attitudes

Counsellors felt that their attitudes and the way they approached this work mattered a lot. Everyone talked about the importance of having an openness to work effectively with this client group, including an ability and desire to work differently:

‘They would need you to be open to working in different ways from what you might narrowly have experienced if you’ve only worked with private clients.’

And a willingness to learn:

‘…as far as you are able, go in with an open mind, expecting to learn a lot from the person you’re going to work with.’

And to be surprised:

‘You don’t make assumptions, but you hold a whole load of possibilities in your head; and be prepared to be surprised a lot.’

What happened next?

My research confirmed that the ‘unprepared’ client is a concept that means something to others. It also confirmed that it is absolutely possible for ‘unprepared’ clients to engage with, and benefit hugely, from therapy; I interviewed counsellors with many years’ experience and countless examples of successful engagement. Significant knowledge and understanding exists among practitioners about how to do this work well, but it appeared this was not being shared. Often my participants were working out what they did or felt or thought as they spoke to me.

I felt I’d stumbled upon something important, and when my master’s was completed, I was determined to do what I could to get therapists thinking and talking about the concept of ‘unprepared’ clients. I wrote an article called ‘Strangers in a Strange Land’, which was published in Therapy Today.1 I had quite a bit of feedback from therapists around the UK, working in a range of settings, who recognised the ‘unprepared’ client but had never read anything about the subject before:

‘The notion of ‘unprepared clients’ is not something I’ve seen articulated before and now that you’ve coined it, it’s like a sigh of relief.’

‘It was so stimulating and reassuring to be engaging with issues which are so alive in the voluntary agency in which I have been counselling for the last six years.’

‘I have a new confidence that I feel from realising that these issues are not just in my mind.’

I was discovering that there are many counsellors out there doing this work, often in isolation, and with no reference points for good practice or support.

On the back of the article, I was invited to present my research at a BACP Making Connections event in October 2013. BACP then suggested we try a workshop.

Luckily, two of the counsellors who took part in the research are also experienced trainers, and agreed to do this with me. Trish Blundell and Marcia Haley have joined me to develop and deliver the training. We delivered our first BACP workshop in February 2015; it was very well received, and our workshop is now included in the Professional Development Days (PDD) programme.

We also delivered a short workshop at last year’s1 BACP Student Conference and have been approached by other agencies to deliver training on the subject. We have developed an interactive workshop, which draws on the research to consider practically how we apply the learning to our relationship and work with ‘unprepared’ clients. Workshop participants actively explore how to work more effectively with ‘unprepared’ clients and experiment with creative tools and ways to demystify therapy.

Trish and Marcia will now deliver most of the training and I intend to focus my energies on further research, this time from the client’s perspective. This research will feed into the training, which I hope will be ongoing.

When I wrote my article for Therapy Today, I never imagined it would create such interest. I have met many therapists for whom the concept of ‘unprepared’ clients is clearly very relevant, and who have appreciated opportunities to explore it.

My initial focus was on disadvantaged clients, but I’m becoming aware that clients can be unprepared for lots of other reasons – groups suggested to me so far (largely by workshop participants) include academics, migrants from places where counselling doesn’t exist, young people, and even men! These are clearly huge generalisations, but the point is that clients can be unprepared for a range of reasons, and we need to be ready for this as counsellors.

I believe that, if we are serious as therapists about making therapy meaningful and accessible for anyone who needs it, we must look more closely at what happens when people arrive in the therapy room unprepared for what greets them. If more therapists gained understanding about working with ‘unprepared’ clients, they would be better prepared to work effectively with clients for whom the concept and process of counselling can feel quite alien. Most therapists will, at some point, find themselves working with someone like Tom.

In case you were wondering, Tom worked with me for quite a while. Once he got his head around what therapy was and how he could use it, he engaged well and made some significant changes as a result. My work with Tom planted a seed that is growing and spreading.

If you recognise the ‘unprepared’ client and would like to find out more, watch out for our workshops or contact me to find out more about my research or to share your experience

Currently a community development worker with a small private counselling practice in east London, Anne Crisp completed her MA in Counselling and Psychotherapy at the University of East London in January 2012.

See also

More from Healthcare Counselling and Psychotherapy Journal

Reference

1 Crisp A. Strangers in a strange land. Therapy Today 2013; 24(1): 32–34.

Disclaimer and copyright