Educational and reflective resource. You can use this resource independently or discuss it with a practitioner. It does not provide an individual assessment or establish a therapy relationship.
- For
- Personal assistants and support workers; disabled people who employ or direct them; therapists
- Time
- About 25 minutes to read; the worksheet takes 20–30 minutes
- Format
- Guide, with a two-part working agreement
- Prints
- Yes
- Evidence
- Disability studies and care research; the worksheet is this site’s own
When support is someone’s job.
Personal assistants, support workers and home support staff work in the most private parts of a disabled person’s life: their body, their home, their relationships, sometimes their therapy. This guide is for the people doing that work, for the disabled people (or people living with a disability) who employ or direct them, and for therapists who meet them.
The key idea: the disabled person directs their own support. The worker’s needs, limits and wellbeing are real too, and they are not in competition with that.
What’s here: how paid support differs from family care; the body, boundaries, choice and privacy; power on both sides; what to do when therapy is involved; the worker’s own needs; endings; and a working agreement to fill in together.
A note on words: many personal assistants, and many disabled people, don’t use the word “carer”. Independent living services in Ireland often say plainly that a personal assistant role is not a caring role. This page lives in the Carer Guide so people can find it, not because the word fits everyone.
Where are you right now?
I work as a PA or support worker
I employ or direct my support
How paid support is different
A family member who helps out, an agency support worker and a personal assistant can do exactly the same tasks: help with a shower, cook a meal, drive to an appointment. What differs is the relationship around the task: who decides, what the relationship rests on, and how it can end.
| What differs | Family or unpaid supporter | Support worker through a service or agency | Personal assistant directed by the disabled person |
|---|---|---|---|
| Who decides how support is given | Often negotiated, and often unclear | A care plan and the service’s procedures, ideally shaped by the person | The disabled person, within the hours and funding available |
| What the relationship rests on | Love, history, duty, obligation | Employment by the service | Employment, sometimes by the disabled person themselves |
| Who the worker answers to | No one, formally | A manager or coordinator | The disabled person, and sometimes a coordinating organisation |
| How it ends | Rarely cleanly | Rota changes, a new job, a service decision | Resignation or dismissal, like any job |
| A common tension | Help turning into control; exhaustion | Rushed visits; tasks set by someone else | Closeness blurring the job; who holds power when things go wrong |
Real life is messier than any table. A personal assistant may be a cousin. An agency worker may be someone a person has trusted for ten years. A family member may be paid. The useful question is not which box someone is in, but who is directing the support, and whether everyone knows that.
Personal assistance and independent living
Personal assistance grew out of the independent living movement, led by disabled people. Its central claim is simple: independence doesn’t mean doing everything yourself. It means having choice and control over your life, including over the support you need to live it. A personal assistant is one of the ways that control becomes real. The disabled person decides what is done, when, and how.
This is why some disabled writers and activists have been wary of the word “care”. In a lot of disability history, being “cared for” meant other people deciding: what you ate, when you got up, whether you could go out. Personal assistance was meant to turn that around.
If you direct your own support: you are allowed to want things done your way, even if it’s slower, or not how the worker would do it. You are allowed to change your mind. You are also allowed to find managing staff tiring, or not to want to be an employer at all. Some people prefer an agency or a coordinated service, and that is a legitimate choice too.
Directing support is skilled work, and it is rarely recognised as such. It can involve recruiting, training each new person in your body and your routines, planning rotas, and handling conflict, all while relying on the same people for intimate daily help. If this is you, it is reasonable to bring the strain of it to therapy.
The body as a workplace, and as a home
Personal care is intimate work. Washing, dressing, toileting and positioning bring a worker into contact with parts of someone’s body and life that most adults share with very few people. The care researcher Julia Twigg describes how this work happens at the boundary between the body, the home and paid employment, and how much depends on the small ways it is done.
What dignity looks like in practice
- Ask before touching, even when the routine is familiar
- Explain what you’re about to do
- Talk to the person, not over them
- Cover, close doors, knock
- Never discuss someone’s body in front of them as if they weren’t there
- Follow the person’s way of doing things
What the worker needs too
- Training for lifting, moving and any equipment
- Enough time to do the task safely
- Working equipment, and a way to report when it isn’t
- Clear agreement about tasks outside their competence
- Safety when working alone in someone’s home
The home is both things at once. For the disabled person, it’s their private space. For the worker, it’s a workplace, often an isolated one. Both are true, and both shape what’s reasonable.
Boundaries: close, but not the same as family
Closeness is normal in this work and often good. Many disabled people and their personal assistants like each other, laugh together, and know each other well. The question isn’t whether you’re close. It’s whether the closeness still serves the disabled person’s choices, and whether it can last.
Some common ways boundaries drift:
- Unpaid extra time that slowly becomes expected, and then resented.
- Becoming the only one who knows how, so the person can’t take a break from you, and you can’t take a break from them.
- Speaking for the person to doctors, family or shop staff, because it’s quicker.
- Photos and social media: the person’s home, body or story appearing online without their clear choice.
- Money and gifts: loans, presents or shopping arrangements that nobody has agreed openly.
- Your own life spilling in: the person ending up supporting you through your problems.
- Being treated as a servant: dignity runs both ways. A worker doing what they are directed to do still deserves respect.
Questions to check a boundary
- Would we both be comfortable if this were written in our agreement?
- Does this make the person more in control of their life, or less?
- Could someone else step in if I couldn’t come tomorrow?
- Am I doing this because it’s wanted, or because I find it hard to say no?
Choice, risk and disagreement
Support workers often see choices they wouldn’t make themselves: staying up late, eating differently, going out alone, refusing an aid, spending money on something that seems unwise. Supporting choice doesn’t mean pretending you have no view. It means the decision stays with the person.
- Say your concern once, clearly, and then respect the answer.
- Offer information and options, not pressure.
- Record and report in line with your employer’s procedures where that’s required.
- Remember the law starts from capacity. In Ireland the Assisted Decision-Making (Capacity) Act 2015, and in England and Wales the Mental Capacity Act 2005, both presume a person can make their own decisions. An unwise decision is not, on its own, a sign that someone lacks capacity.
- Serious, immediate danger is different. If someone is at real risk of serious harm, follow your organisation’s safeguarding procedure or contact emergency services.
For a structured way to work through disagreements about help, see Support Without Taking Over.
What you see and hear
Personal assistants often know more about a person’s daily life than almost anyone: their health, finances, relationships, arguments, and what happens in their appointments. That knowledge comes with responsibility.
- What you see and hear at work is private. Don’t share it with friends, family or other people you support, even without names, if it could identify the person.
- Don’t post about the person, their home or your work with them without their clear agreement.
- If you are worried that someone else is harming or neglecting the person, follow your employer’s safeguarding procedure, or contact your local adult safeguarding service. Where you can, involve the person in what happens next.
Power runs both ways
Paid support relationships hold power in both directions, and it helps to name it.
The disabled person may depend on the worker
for getting up, eating, washing and going out. This can make it very hard to raise a problem: if you complain today, who helps you shower tomorrow? Disabled people can experience neglect, control or abuse from the people paid to support them, and dependence can make it harder to speak up.
The worker may depend on the job
which is often low-paid, insecure and done alone. Workers can experience disrespect, unsafe conditions, unreasonable demands or harassment, and may worry that raising it will cost them their income, or the relationship.
Both people deserve a way to raise a problem that doesn’t leave one of them without support or the other without work. That usually means agreeing in advance how problems will be raised, and knowing who else can help: a coordinator, a service manager, an advocate, or a peer network.
When something keeps going wrong, it can help to sort it the way this site’s Mine, Yours, Ours, System framework does:
A lot of conflict between disabled people and their workers is really a system problem, such as too few hours to do the job well, landing on the two people in the room.
When therapy enters the picture
Personal assistants and support workers are part of many disabled people’s lives, so they are often part of their therapy too: driving to sessions, helping with transfers, supporting communication, or simply being in the house during an online session. Each person involved has a different job.
If you’re the disabled person
- It’s your choice whether your PA knows you’re in therapy, whether they come, and where they wait.
- For online sessions at home, privacy can be hard. Options include booking sessions when no support worker is present, asking them to be in another room, headphones, or using the chat function for things you don’t want overheard.
- You can talk about your support in therapy. Bringing frustration, gratitude, conflict or grief about the people who support you is legitimate. It isn’t disloyal.
- Your therapist shouldn’t treat your PA as an informant. Any contact between them should happen only with your agreement, and you can ask what was said.
If you’re a PA coming to a session
- Before: agree with the person what you’re there for. That might be transport, a transfer, communication support, or nothing at all beyond the journey.
- During: wait outside unless the person asks you in. If you are supporting communication, relay their words exactly. Don’t summarise, improve or soften them, and don’t answer for them.
- After: don’t ask what was said. Anything you overheard stays private.
- If you are asked for your view by the therapist, check first that the person you support agrees.
If you’re the therapist
- Agree the PA’s role with the client alone, before the PA is involved.
- Speak to the client, not the PA, including when the PA is supporting communication.
- Include support arrangements in your contract: who may be present, where they wait, and what happens if there’s an emergency.
- Don’t seek information from the PA without the client’s consent.
- Notice your own reactions. A common one is treating the non-disabled worker as the competent adult in the room.
- When a client brings conflict with a PA, avoid taking a side too quickly. Hold the client’s experience, and keep the wider system in view: hours, funding, staffing.
For a worked guide to a third person in the therapy room, see When a Carer Joins a Session.
Your needs as a PA or support worker
The work can be meaningful, skilled and rewarding. Many personal assistants describe real respect and connection with the people they work for. It can also be hard, often in ways nobody asks about.
- Emotional labour. The sociologist Arlie Hochschild used this term for the work of managing your own feelings as part of a job. Staying calm, cheerful and patient through long shifts, often alone, is work.
- Physical strain from lifting, moving and long hours on your feet.
- Isolation. Lone working can mean no colleagues to debrief with.
- Moral distress when hours are cut or a visit is too short to do what you know is needed, and you can’t fix it.
- Being invisible. The work is often unrecognised, and the worker’s own life, health and needs can drop out of view.
What can help
- A clear working agreement (see below) and an employment contract
- Training, especially in moving and handling, and in disability and independent living
- Someone to debrief with: a coordinator, a manager, or a peer network of other PAs
- An employee assistance programme, if your employer has one
- Your GP, if your own health is suffering
- Your own therapy
Bringing this work to your own therapy
Things personal assistants and support workers often bring to therapy: guilt about setting limits; anger that gets nowhere to go; grief when someone dies; worry about a person they support; feeling unseen; or the strain of doing intimate work for low pay.
You can talk about your experience without identifying the person you support. A therapist who understands disability won’t turn the person you support into a story about burden. Your feelings are real, and so is their right to direct their own life.
If you run a service that employs supporters
Agencies, disability services and employers of personal assistants shape how support feels, long before anyone arrives at a door. Things that make a difference:
- Training that covers choice, consent, privacy and communication, not only tasks and safety.
- Continuity: the same people where possible, and warning before changes.
- Accountability: a clear, accessible way for the disabled person to raise concerns or complaints, including about staff, that doesn’t go through the worker involved.
- Clear roles: written down, agreed with the person being supported, and reviewed when needs change.
- Therapy and privacy: staff go to therapy appointments only as the person asks, and never report on what was said.
- Support for staff: supervision and someone to talk to, so workers aren’t carrying difficult work alone.
Duties differ between employers, agencies and services, and between the Republic of Ireland, Great Britain and Northern Ireland. This section is general guidance. Check the rules that apply to your service and contract, and get advice where needed. Paid staff support decisions; they don’t make them for the person.
Endings
Personal assistants move on, contracts end, rotas change, and sometimes the person being supported dies. Endings in this work can be abrupt, and they are often not marked at all.
- For the disabled person, losing a PA can mean losing someone who knew their body and routines intimately, and starting again with a stranger. That’s a real loss, and a real workload.
- For the worker, the end of a long working relationship, or a death, can bring grief that others don’t recognise because “it was only a job”. Kenneth Doka called this disenfranchised grief: grief that isn’t openly acknowledged or supported.
- Where possible, plan endings: give notice, write a handover with the disabled person (in their words, about their preferences), and say goodbye.
Printable worksheet · Two parts and a shared section
Our working agreement
To fill in together, the disabled person and their PA or support worker. The disabled person’s part comes first, because they direct their support. The worker’s part matters too, because their limits are real.
Part A · The person being supported
How I like support to be given
What’s private to me
Appointments and therapy
If I’m unwell, or something goes wrong, I want you to
Part B · The PA or support worker
What I need to do this job safely and well
My limits: hours, tasks, and anything outside my training
What’s going well, or what I enjoy about this work
Together
What’s working well between us
How we’ll raise problems
When something keeps going wrong, we’ll sort it into four parts
This agreement is not an employment contract or a care plan, and it doesn’t replace either. If there is serious, immediate danger, or a real safeguarding concern, follow the relevant procedure. Respecting someone’s choices doesn’t mean ignoring real risk, and risk alone doesn’t take away their right to choose.
A worked example
Aoife is 34 and uses a power wheelchair. She directs a small team of personal assistants through an independent living service. She has online therapy at home on Tuesday afternoons. Dami, one of her PAs, is usually in the kitchen during the session.
A few months in, her therapist notices that Aoife has stopped mentioning Dami, after several sessions where she had talked about feeling rushed in the mornings. When the therapist wonders about this aloud, Aoife types in the chat: “She can hear me.”
- Mine (Aoife): she doesn’t want to seem ungrateful, and she worries about losing a reliable PA.
- Yours (Dami): Dami is trying to fit morning tasks into too little time, and doesn’t know Aoife feels rushed.
- Ours: Dami speeds up, Aoife goes quiet, and both feel tense.
- System: morning hours were cut last year. Therapy is booked into the only slot Aoife has.
What changed: Aoife moves therapy to a time when no PA is in the house. She and Dami fill in the working agreement together, and Aoife writes “follow my way, even if yours is quicker”. Aoife raises the morning hours with her coordinator. The therapist reflects on how long it took to ask who else might be listening.
Ireland and the UK at a glance
How personal assistance is arranged depends a lot on where you live. A brief summary:
Ireland
- The HSE funds personal assistant and home support services. These are provided either by the HSE directly or by voluntary organisations.
- Some independent living organisations support the disabled person (sometimes called the “Leader”) to recruit and direct their own team of PAs.
- There is no single national policy defining the PA service. In 2023, the HSE said one was needed and set up a review group to develop a model of service and access criteria.
- A HSE personalised budgets pilot has been open to adults already receiving HSE-funded disability services.
United Kingdom
- In England, people eligible for council-funded social care can take some or all of it as direct payments, and use them to employ their own PAs.
- Employing a PA makes you an employer, with duties such as tax, National Insurance and employer’s liability insurance. Councils are expected to support people with this.
- Skills for Care publishes a free toolkit for people employing PAs.
- Arrangements in Scotland, Wales and Northern Ireland differ, so check locally.
Checked November 2026. This is a plain-language summary, not legal or employment advice. Funding schemes change, so check current information with your local service.
Evidence & sources
- Disability studiesMorris, J. (1993). Independent Lives? Community Care and Disabled People. Macmillan. On independence as choice and control over support.
- Disability studiesKelly, C. (2016). Disability Politics and Care: The Challenge of Direct Funding. UBC Press. On disabled people’s tensions with “care”, and on directing your own support.
- Disability studiesShakespeare, T. (2000). Help. Venture Press. On the relationships and ethics of giving and receiving help.
- Care researchTwigg, J. (2000). Bathing: The Body and Community Care. Routledge. On intimate care at the boundary of the body, the home and paid work.
- SociologyHochschild, A. R. (1983). The Managed Heart: Commercialization of Human Feeling. University of California Press. The origin of “emotional labour”.
- GriefDoka, K. J. (Ed.) (1989). Disenfranchised Grief: Recognizing Hidden Sorrow. Lexington Books.
- LawAssisted Decision-Making (Capacity) Act 2015 (Ireland); Mental Capacity Act 2005 (England and Wales), section 1.
- IrelandHealth Service Executive, parliamentary question responses on Personal Assistant services (2023), including the PA Review Group; HSE, Personalised Budgets for People with a Disability; Department of Health (2018), Towards Personalised Budgets for People with a Disability in Ireland.
- UKSkills for Care, Employing personal assistants toolkit; local authority guidance on direct payments and employer responsibilities.
- Our frameworkThe working agreement, the comparison table and the guidance for PAs in sessions are this site’s own. They haven’t been formally tested. Mine, Yours, Ours, System is this site’s own framework.
- Fictional exampleAoife and Dami are invented for teaching. They are not real people.
Summaries are this site’s own wording. For every source cited across the site, see Sources and Bibliography.
Last reviewed: November 2026.
How to cite this page: Donaghey, C. (2026). Paid Support and Personal Assistants. Disability in Psychotherapy. Available at: https://disabilityinpsychotherapy.online/carer-guide/paid-support-and-personal-assistants/ (Accessed: [date]).
Shared under CC BY-NC 4.0, with extra permissions for teaching, supervision and therapy. Credit the site. See Reusing This Material.