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Tom sat opposite me. He鈥檇 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: 鈥楽o what happens then? Do we just talk?鈥�

I soon established that Tom didn鈥檛 know anyone who鈥檇 had counselling and had no idea what to expect. Although he鈥檇 chosen to come, he really didn鈥檛 know what counselling was about. We also discovered, as we worked together, that he鈥檇 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鈥檇 tell me 鈥業 feel right thingy鈥� 鈥� and we鈥檇 spend time working out what kind of 鈥榯hingy鈥� 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 鈥榓gainst the odds鈥�. During that placement, I became increasingly aware of feeling 鈥� and sometimes being 鈥� different with certain clients who, like Tom, just seemed far less prepared for therapy. In group supervision, colleagues talked of clients with 鈥榥o idea鈥� 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鈥檚 to see if I could discover more about what I鈥檝e called 鈥榰nprepared clients鈥�.

What do I mean by 'unprepared' clients?

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

鈥楿nprepared鈥� 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鈥檚, you need to review existing research and literature on your topic. For me, this proved to be a challenge because it simply wasn鈥檛 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 鈥榰nprepared鈥� clients to access counselling and whether it鈥檚 effective 鈥� the beginning and end of the process.

What was missing was a focus on what happens when 鈥榰nprepared鈥� clients actually become clients 鈥� how the experience feels for both counsellor and client, and what鈥檚 been learned about how to do this work effectively. That鈥檚 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 鈥榰nprepared鈥� 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 鈥榰nprepared鈥� 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 鈥榰nprepared鈥� clients feel different to work with.

For 鈥榰nprepared鈥� clients, counselling is usually 鈥榗ulturally strange鈥�; two counsellors used the phrase 鈥榓 strange land鈥�. 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鈥檙e there to engage effectively with the process.

Not understanding therapy

Everyone talked about 鈥榰nprepared鈥� clients not understanding therapy when they arrive; and this lack of understanding was experienced as a significant challenge:

鈥業 think that probably would be the biggest challenge, them trying to get their head around 鈥淲hat is this thing? What is this person and what is she offering me?鈥濃��

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

鈥樷��they鈥檙e going to come and tell you their problems and then you鈥檙e going to tell them what to do鈥� so a lot of the work at the beginning can be about dealing with the disappointment about that.鈥�

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

鈥業鈥檝e had clients say to me, 鈥淗ow鈥檚 talking going to make a difference?鈥濃��

And this scepticism is not always verbalised:

鈥業 think that鈥檚 often a question that you can pick up but that鈥檚 not actually said outright; the question of 鈥淒oes counselling really work? Is this going to make any difference?鈥濃��

This scepticism can remain until the client feels change beginning to happen. Of course, many 鈥榩repared鈥� clients can be sceptical, but the difference is in the starting point 鈥� trying to establish a relationship with someone who doesn鈥檛 understand or trust the process at all.

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

鈥榃e understand it鈥檚 all about the relationship and trust, but they, why would they? They don鈥檛 know the rules.鈥�

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

鈥樷��some people don鈥檛 understand that you meet at the same time every week for the same period of time.鈥�

Unhelpful beliefs

The research identified a number of unhelpful beliefs commonly held by 鈥榰nprepared鈥� clients:

Counselling is not for people like me: 鈥業t鈥檚 one of those sort of alternative things that people do, you know, the whole 鈥渙ther people do it鈥�.鈥�

Talking won鈥檛 help, or will make things worse: 鈥楾he biggest example of difference between prepared and unprepared clients is 鈥渢alking makes it worse鈥�.鈥�

Having counselling means you鈥檙e weak, or mad: 鈥楾here was a terror of being seen as weak, or even more sort of old-fashionedly, if you like, just mad!鈥�

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

鈥樷��a lot of them would say 鈥淚鈥檝e never talked like this before. Nobody ever talks like this in my family鈥�.鈥�

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 鈥榰nprepared鈥� clients. Language needed to be accessible and 鈥榚veryday鈥�, and some counsellors were aware of changing their use of language with 鈥榰nprepared鈥� 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 鈥榰npreparedness鈥�:

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

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:

鈥業 think the challenge that comes to people who wouldn鈥檛 normally access counselling is the relationship. That鈥檚 the part they find really difficult.鈥�

鈥業 find that with the clients who鈥檝e not had any experience at all, it seems to take longer to build up that trust in the relationship.鈥�

Material brought

鈥楿nprepared鈥� 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 鈥榰nprepared鈥� clients.

Previous experience

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

鈥業 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.鈥�

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:

鈥業 think people come with a context. You can鈥檛 counsel people in a vacuum.鈥�

Learning by doing

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

鈥業 don鈥檛 think you can really be taught this until it faces you.鈥�

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 鈥� demystifying therapy. This client group needs clear, straightforward explanations that assume no prior knowledge:

鈥業 think you need to be very prepared to expose what a counselling relationship is, and your understanding of counselling, how it might work.鈥�

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

鈥業 would talk about why one-to-one talking for an hour鈥� might be helpful. I鈥檝e had clients before saying things like, 鈥淵ou know I wish you could meet me for coffee鈥�; and trying to unpack that with them, what does it mean?鈥�

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鈥� emotional literacy is also central; strategies included talking more factually, explaining about feelings, using countertransference as an indicator of clients鈥� 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:

鈥楾hey would need you to be open to working in different ways from what you might narrowly have experienced if you鈥檝e only worked with private clients.鈥�

And a willingness to learn:

鈥樷��as far as you are able, go in with an open mind, expecting to learn a lot from the person you鈥檙e going to work with.鈥�

And to be surprised:

鈥榊ou don鈥檛 make assumptions, but you hold a whole load of possibilities in your head; and be prepared to be surprised a lot.鈥�

What happened next?

My research confirmed that the 鈥榰nprepared鈥� client is a concept that means something to others. It also confirmed that it is absolutely possible for 鈥榰nprepared鈥� clients to engage with, and benefit hugely, from therapy; I interviewed counsellors with many years鈥� 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鈥檇 stumbled upon something important, and when my master鈥檚 was completed, I was determined to do what I could to get therapists thinking and talking about the concept of 鈥榰nprepared鈥� clients. I wrote an article called 鈥楽trangers in a Strange Land鈥�, 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 鈥榰nprepared鈥� client but had never read anything about the subject before:

鈥楾he notion of 鈥榰nprepared clients鈥� is not something I鈥檝e seen articulated before and now that you鈥檝e coined it, it鈥檚 like a sigh of relief.鈥�

鈥業t 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.鈥�

鈥業 have a new confidence that I feel from realising that these issues are not just in my mind.鈥�

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 香港六合彩精准资料 Making Connections event in October 2013. 香港六合彩精准资料 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 香港六合彩精准资料 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鈥檚1 香港六合彩精准资料 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 鈥榰nprepared鈥� clients. Workshop participants actively explore how to work more effectively with 鈥榰nprepared鈥� 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鈥檚 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 鈥榰nprepared鈥� clients is clearly very relevant, and who have appreciated opportunities to explore it.

My initial focus was on disadvantaged clients, but I鈥檓 becoming aware that clients can be unprepared for lots of other reasons 鈥� groups suggested to me so far (largely by workshop participants) include academics, migrants from places where counselling doesn鈥檛 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 鈥榰nprepared鈥� 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 鈥榰nprepared鈥� 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.

Reference

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

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