Accessibility
& therapy.
What would it actually take for a session to work with a body, rather than against it?
Access shouldn’t require proof.
This page is an educational resource about access in any therapy. Communication, processing time, fatigue, sensory needs and the shape of a session can all be adapted around how a body and mind actually work. No diagnosis, letter or fully worked-out list of accommodations should be needed first. Sometimes the right adjustment is already known. Sometimes all that’s clear is: something about the usual way of doing therapy is making this harder than it needs to be. That’s enough to begin.
What has access
already cost you?
Maybe there’s a familiar exhaustion in working out whether participation is even possible before arriving. Maybe there’s a rehearsed explanation ready for why the camera needs to be off. Why more time is needed to answer. Why moving is necessary. Why the body has changed between one week and the next. Why cancelling because of illness isn’t the same as not valuing therapy.
Often the adjustment itself is simple. The exhausting part is having to keep proving why it’s needed.
What if the starting point was simply asking, rather than requiring proof first?
If this sounds
familiar.
I’m exhausted before therapy even starts
Fatigue, travel, preparation, masking or the effort of getting through a full session can sometimes take more energy than the therapy itself.
Explore pacing & fatigue →I need more time to find my words
You may think slowly, communicate differently, use AAC, need silence, or know what you mean before you know how to say it.
Explore communication & processing →Video makes things harder
Camera use, eye contact and seeing yourself on screen can add sensory, physical or emotional effort that is unnecessary for some people.
Explore camera & sensory access →My body changes from week to week
Pain, fatigue, chronic illness, medication, capacity and concentration do not always follow a predictable timetable.
Explore fluctuating access →I need to move, stim or look away
Movement does not automatically mean disengagement. Eye contact is not the same thing as attention.
Explore movement & presence →I’m tired of explaining why I need things
You should not need to make a convincing case before an adjustment becomes legitimate.
Explore access without proof →I don’t actually know what I need yet
That is completely workable too. Sometimes access is something worked out along the way.
Explore figuring it out →I’m older, and some of this is new to me
Disability that arrives or changes in later life deserves the same adjustments, without being written off as “just age”.
Explore access in later life →Access when you’re
older.
Some people have been disabled all their lives and are now growing older with it. Others become disabled later: hearing or sight loss, arthritis, a stroke, Parkinson’s, or memory changes. Either way, you’re entitled to the same adjustments as anyone else.
- Hearing: ask for captions on video calls, or a phone session if it works better with your hearing aids. A quiet room matters.
- Sight: large print, or information read aloud or sent in a format your phone or tablet can read out.
- Technology: you don’t need to be good with video calls. Phone sessions, or help setting up the first call, are reasonable to ask for.
- Memory and pace: a written note of what was agreed, a reminder before sessions, and time to think.
- Getting there: transport, stairs and seating that is easy to get out of.
Watch for ageism dressed up as kindness: being talked down to, spoken about instead of to, or told your feelings are “just your age”. Grief about what has changed is real, and so is the rest of your life. Therapy can be about either.
See an example: sight loss in later life.
Is access really
just one thing?
Access is not only whether someone can enter therapy. It is whether they can participate, belong in the relationship, and have their experience understood accurately once they are there.
When people ask whether therapy is accessible, they often mean: can I get through the door? That matters enormously. But a service can get that right and still fail badly at the other three layers.
Can I get into the room?
Step-free access. Wheelchair space. Appropriate seating. Accessible toilets. Room for equipment, assistance or whatever someone needs to physically occupy the space. This is the most visible form of accessibility. It is essential. It is also only the beginning.
Can I actually participate?
Pacing, communication, processing time, sensory environment, written information, technology, scheduling, fatigue, and session structure. Being physically present does not necessarily mean the therapy itself is usable.
Can I bring my disabled self into this relationship?
Without having to constantly educate, minimise, perform, reassure, justify, or defend it.
A staircase can communicate: your body was not expected here. A therapist who never acknowledges disability can communicate: this is not something we talk about. A therapist who sees nothing but disability can communicate: this is all I can see when I look at you. Accessible therapy needs somewhere between those extremes.
Can my experience be understood without everything becoming pathology?
This is where accessibility becomes more than logistics. For example:
- “I need help” does not automatically mean unhealthy dependency.
- “I’m exhausted” does not automatically mean avoidance.
- “I don’t want to do that exercise” does not automatically mean resistance.
- “I’m angry about this” does not automatically mean the problem is how I regulate anger.
Psychology may still matter. The question is whether the psychological explanation actually fits what is happening.
What can actually
be adapted?
These are practical things that can genuinely change, session to session.
Session length & pacing
Some people work better in shorter sessions. Some need longer sessions with pauses. Some need more processing time before answering. What’s realistically sustainable can be discussed directly, rather than assuming one standard pace works for everybody.
Camera & video
Camera on. Camera off. Part of the session on and part off. Looking away. Changing position. Whatever makes it easier to actually participate. Eye contact or visual engagement doesn’t need to be performed to demonstrate presence.
Communication
Speaking. Writing. Text chat. Notes. AAC. Pauses. Or a combination of ways of communicating. The aim isn’t the most conventional way of communicating. It’s the best chance of saying what’s actually meant.
Processing time
Silence is not automatically resistance. Neither is difficulty finding words. What’s happening might be processing, fatigue, overwhelm, searching for language, deciding whether to speak at all, or simply a different pace. Not every quiet moment needs filling. And difficulty speaking isn’t automatically avoidance either.
Written information
Some people remember a conversation easily. Others do much better when something is written down. Where appropriate, key ideas, reflections or agreements can be captured in writing rather than relying entirely on memory.
Sensory environment
Lighting. Background noise. Visual clutter. Volume. Screen positioning. Anything on the therapist’s side of an online session that makes participation unnecessarily difficult can be discussed and changed where possible.
Movement, stimming & eye contact
Rocking. Fidgeting. Shifting position. Lying down. Looking away. Moving hands. Stimming. Resting. A behaviour can be noticed without deciding in advance what it means. Behaviour is not meaning. If something helps someone stay present, it doesn’t need to look conventionally attentive.
Fatigue & cancellations
Bodies are not always predictable. A fluctuating condition does not always fit neatly into a fixed weekly schedule. This can be discussed clearly at the outset, and a workable approach agreed that recognises genuine fluctuation while keeping the therapeutic frame (glossary) sustainable. A cancellation policy should create reliability without pretending every body is predictable.
What adaptations can look like
for different conditions.
These are starting points, not rules. Two people with the same diagnosis can need completely different things, so always ask the person. More detail: Hidden and Fluctuating Conditions and Psychosocial Disability.
| Condition | What might help in therapy |
|---|---|
| Parkinson’s | Sessions timed for “on” periods, soon after a dose. More time to speak. Not reading a still face as lack of feeling. A chair that’s easy to get out of. |
| Dementia | The same time, place and person each week. A reminder the day before. A short written note to keep. Talking about feelings even when facts are muddled. The person decides who else is involved. |
| Stammering | Time to finish without being hurried or helped. Don’t finish words. Video lag can make blocks feel longer, so a phone or text option can help. Some people prefer the word “stammer”, others “stutter”. |
| Selective mutism | Being able to type in the chat, write, or use cards, with no pressure to speak. Speech may come later, or not at all, and therapy can still work. |
| Down syndrome | Easy Read information, short sentences and checking understanding without testing it. Speak to the person, not their supporter. Distress can be missed if it’s put down to the diagnosis. |
| Fragile X syndrome | Not expecting eye contact. Predictable routines, a quiet room, and warning before changes. Anxiety is common and is worth taking seriously in its own right. |
| Osteogenesis imperfecta | No touch or movement exercises without clear agreement, because of fracture risk. Seating and getting in and out need planning, not improvising. |
| Larger bodies | Sturdy chairs without arms, and no comments on weight unless the person raises it. Weight stigma in healthcare is common and can be part of what someone brings. |
| Cystic fibrosis | Online sessions or a ventilated room with no shared waiting area. Times that fit around treatment, and a place kept during hospital stays. |
| POTS | Lying down, reclining or feet up, on camera if needed. Water to hand. A racing heart isn’t automatically panic. |
| Crohn’s and colitis | A toilet nearby and permission to leave without explaining. Switching to video during flares. |
| Diabetes | Checking glucose or eating during the session without comment. Pausing for a hypo. |
| Cancer treatment | Online sessions when immunity is low, notes if concentration is affected, and no pressure to “make progress”. |
| Bipolar, psychosis, long-term depression | Session times that work around medication effects, a plan made while well for what happens if unwell, and flexibility during difficult periods. |
What if it isn’t
clear yet what’s needed?
Sometimes there’s a very clear access plan already. Sometimes all that’s clear is: “I don’t know, I just know this usually doesn’t work for me.” Both are valid starting points.
What helps thinking? What helps communication? What causes tiredness? What makes someone disappear from a conversation? What gives more room? What makes therapy easier to use? These can be noticed together, rather than worked out alone in advance.
Becoming an expert in one’s own accessibility isn’t a prerequisite for asking for it.
Are access needs
allowed to change?
What works now may not work six months from now. What works during a well period may not work during a flare. An adjustment expected to help may turn out not to. Something useful may only become clear halfway through therapy, in a way that couldn’t have been known at the beginning.
Changing an access arrangement doesn’t mean the original one was wrong. It means something was learned.
What stands out,
if anything?
None of these need answering fully. Just notice whether one lands.
- What usually makes conversations tiring?
- What helps communication feel clearer?
- What happens when more time is needed?
- What makes online conversations easier or harder?
- What does a body usually need halfway through something demanding?
- What would be hard to ask a therapist for?
That last question can be particularly telling. Sometimes what someone hesitates to ask for says as much about past experiences of access as the adjustment itself would.
Can accessibility itself become psychological work?
Sometimes, yes. Patterns can form: not asking, not wanting to inconvenience anyone, not needing too much, apologising before requesting something, having to prove real need, appearing capable even when the effort is enormous, or accepting help in ways that leave very little control.
Those patterns are worth exploring. Not because needing access is the problem, but because repeatedly having to negotiate it can leave a psychological history behind.
Can therapy fix everything on its own?
No. A working lift. Accessible transport. Adequate personal assistance. Communication access. Appropriate healthcare. Income. A safe home. An accessible workplace. A reasonable accommodation (glossary). None of these come from insight.
Therapy can help with the emotional weight of not having these things. But it shouldn’t quietly convert an external failure into an internal one. Psychological flexibility cannot make an inaccessible environment accessible.
What if something
gets misunderstood?
Accessible therapy doesn’t mean nothing will ever be misunderstood. An assumption might get made. Language might not fit. Something might be interpreted in a way that doesn’t match lived experience. Something important might simply be missed. What matters is what happens next.
It should be possible to say: “No, that isn’t what this means for me.” “I think something physical is being psychologised.” “That exercise doesn’t work with my body.” “I need something different.”
And for that disagreement to become information, rather than automatically being read as resistance.
Why ask about
access early?
Accessibility doesn’t have to be something added on after the “real work” begins. How someone gets into a session, communicates, rests, processes and uses their body is already part of the therapeutic environment.
Asking early, and continuing to ask as things change, keeps access from depending on repeatedly explaining or justifying it.
What should happen
at the start?
At the beginning of any therapy, there should be space to name what would make sessions easier to use. No diagnosis, doctor’s letter, proof, or polished explanation should be required.
If something stops working later, it can change. If something goes wrong, it can be talked about. If something gets misunderstood, that can be named. And if the real difficulty turns out to be something psychotherapy can’t solve, that’s worth naming too.
Access should make therapy more usable, not another test to pass.
Accessibility is not only a checklist of ramps, captions and accommodations. Worth asking: can this client participate in the way therapy is structured? What gets interpreted as resistance? What assumptions get made about eye contact, movement, silence or dependency? Can someone disagree with an interpretation safely? Is it clear when the problem requires psychological work, and when the environment needs to change instead?
Access shouldn’t require you to prove that you need it.
Asking is allowed. Not knowing yet is allowed. Changing your mind is allowed. And therapy is allowed to change with you.
What helped when looking for a therapist
For me, an important quality in therapy is a willingness to understand the person rather than make assumptions about disability. I value an approach where practical needs can be discussed openly, questions are welcomed and the therapeutic relationship develops collaboratively.
What I’d look for in a therapist
When I think about what makes a therapist approachable, I don’t necessarily need someone who knows everything about cerebral palsy or disability.
Actually, I’d probably be a little suspicious if someone told me they did!
What matters much more to me is curiosity.
I’d appreciate someone who is comfortable asking questions, listening to my answers and recognising that I might experience something differently from what they expected.
I wouldn’t want my disability ignored, but equally, I wouldn’t want every conversation to come back to it.
Sometimes I might want to explore something connected to disability. Other times, I might want to talk about work, relationships, everyday frustrations or something completely unrelated.
And that’s important. Disabled people have wonderfully ordinary, complicated and interesting lives, just like everyone else.
For me, a good therapeutic relationship begins with being interested in the whole person, rather than assuming you already understand them because you know their diagnosis.
A little curiosity, some flexibility and a willingness to figure things out together can go a very long way.
Casey Donaghey is the psychotherapist behind this site and lives with cerebral palsy.
What disabled people have said
Getting to therapy at all
Disabled adults interviewed about therapy named cost, insurance, office layout, scheduling and transport as frequent barriers. Some also described therapists who made real adjustments, and how much that mattered.
Mia Mingus, on access intimacy
Mingus, a disabled writer and organiser, named a kind of closeness that comes when access is understood without a fight: “Access intimacy is that elusive, hard to describe feeling when someone else ‘gets’ your access needs.” Good access in therapy is more than a ramp or a link. It is not having to explain or prove what you need.
Sources
- Conner, K. J., Acosta, V. M., Nouri, R., Tyler von Wrangel, M., Gramillo, E., & Conner, A. (2023). Psychotherapy experiences of U.S. adults with physical disabilities: Recommendations for affirmative practice. The Counseling Psychologist, 51(7), 970–1004. doi:10.1177/00110000231186824
- Mingus, M. (2011, May 5). Access intimacy: The missing link. Leaving Evidence. leavingevidence.wordpress.com
Summaries are this site’s own wording. Please read the originals.
- In interviews with 24 US adults with physical disabilities, about a third said therapists had attributed their physical symptoms to psychological causes, and over half described having their disability experiences invalidated. Conner, K. J., Acosta, V. M., Nouri, R., Tyler von Wrangel, M., Gramillo, E., & Conner, A. (2023). Psychotherapy experiences of U.S. adults with physical disabilities: Recommendations for affirmative practice. The Counseling Psychologist, 51(7), 970–1004. doi:10.1177/00110000231186824
- Clients whose preferences about therapy were accommodated were less likely to drop out. Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta-analysis. Journal of Clinical Psychology, 74(11), 1924–1937.
- A foundational guide to disability-affirmative therapy, including adapting the setting and frame. Olkin, R. (1999). What Psychotherapists Should Know About Disability. Guilford Press.
More: What visibly disabled people report about therapy · Sources and Bibliography
Which evidence supports which part of this page
- “What can actually be adapted?” and “We agree how sessions will work for you”: clients whose preferences about therapy are accommodated are less likely to drop out and do a little better (Swift et al., 2018). Olkin (1999) describes adapting the setting and frame for disabled clients.
- “Fatigue & cancellations” and “Are access needs allowed to change?”: NICE guidance on ME/CFS (2021) says services should adapt appointment timing, length and format, and not discharge people for missing appointments because of their symptoms.
- “Psychological accessibility” (being understood without everything becoming pathology): about a third of disabled adults in one study said therapists had put physical symptoms down to psychological causes (Conner et al., 2023).
- “What if something gets misunderstood?”: research on repairing ruptures in the therapy relationship suggests that repair is linked with better outcomes (Safran, Muran & Eubanks-Carter, 2011).
- “No proof required”: equality law in Ireland and the UK does not make access to adjustments depend on a formal diagnosis.
- “The four layers of accessible therapy”: this is the site’s own framework, not a tested model.
Additional sources
- NICE (2021). ME/CFS: diagnosis and management (NG206). nice.org.uk/guidance/ng206
- Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48(1), 80–87.
Conner et al. (2023), Swift et al. (2018) and Olkin (1999) are referenced in full in the box above.
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