Access is part
of the therapy.
By minute forty I wasn’t taking anything in.
Why communication, energy, environment, format and pace aren’t something to sort out before therapy, but part of it.
What this is: a guide to treating access as part of the therapeutic work.
Why it matters: if taking part uses up someone’s energy, less is left for the work.
The sharpest reframe: access needs are requirements, not preferences.
One thing to take away: raise access first, and keep revisiting it.
The short version
Access is often treated as something to sort out before therapy starts: a ramp, a caption setting, a booking form. In pluralistic therapy, it is better understood as part of the therapy itself. How someone communicates, how much energy they have, where and when sessions happen, and how fast the conversation moves all shape what therapy can do. Access needs are requirements, not preferences to be traded off. They also change, so they need revisiting like any other part of the work. And talking about access is one of the clearest ways to show that a client’s knowledge of themselves really counts.
You might recognise this
Illustrative statementsDrawn together from common experiences. They are not quotes from individual people.
Why access belongs inside the therapy
Our frameworkPluralistic therapy asks what will help this person, with these goals. Whether someone can take part fully is part of that question, not a step before it. If a person spends their energy getting to the room, following fast speech, or recovering afterwards, less is left for the work they came for.
Access also isn’t neutral. If it isn’t raised, the person often has to raise it themselves, again, as they do with every other service. A therapist who asks first, and keeps asking, is showing in practice that the client’s knowledge about themselves matters.
Five areas to talk about
Our frameworkCommunication
Speech, sign, writing, communication aids, captions, interpreters. Time to respond. Plain language. Written summaries.
Energy, pain and fatigue
Session length and time of day. Breaks. What happens on a bad day: audio only, a shorter session, or cancelling without penalty.
Environment
Getting there, the building, the room, seating, lighting, noise, smells. Or the person’s own space, if sessions are online.
Format
In person, video, phone, text or a mix. Each has costs and benefits, and the best one may change.
Pace and processing
How fast the conversation moves. Silence and waiting. Checking understanding without making it a test.
Conall is 61 and had a stroke last year. He has aphasia: he understands most of what is said, but finding words is slow and tiring. At his first session, his therapist spoke quickly and filled the silences. Conall left exhausted, having said very little of what he wanted to say.
At the second session, the therapist asked how he would like them to communicate. Conall said he’d like his wife to help him prepare a note, and the therapist checked with him, privately, that this was what he wanted. With her help, he had written a short note: speak slowly, one question at a time, wait, and write key words down. They agreed on 40-minute sessions, a notepad between them, and a written summary with key words afterwards. He asked for it in large print, because his eyesight had also changed: aphasia itself doesn’t mean someone needs large print. The therapist learned to wait, sometimes for a long time. By the fifth session, Conall was talking about what he had lost, and what he still wanted, in his own words.
Conall is a fictional teaching example, not a real person.
A requirement, not a preference
Our frameworkPluralistic therapy pays close attention to preferences. Access needs are different in kind. A preference, such as wanting more structure, can be explored, tried and reviewed. An access requirement, such as time to respond on a communication aid, makes taking part possible at all. The person shouldn’t have to bargain for whether it matters, or be treated as lucky to get it. How to meet it is still something to work out together. More on Preferences and Choice.
That doesn’t mean every request can be met. A therapist may not be able to offer home visits, or a particular language. When that happens, saying so honestly, and helping the person find somewhere that can, is part of good practice.
When needs compete, and when a service can’t meet them
Our frameworkAccess needs can pull against each other. Conall needed time to find words, which made conversations slower, and he also tired after 40 minutes. Longer sessions would give more time but more fatigue. They settled on two shorter sessions a week for the first month, then reviewed. Working this out took discussion, and it took a couple of tries.
Sometimes a service genuinely can’t meet a need. Conall’s therapist couldn’t offer home visits on days he couldn’t travel. They said so at the start, and agreed video sessions as the alternative, with Conall’s wife helping set up the laptop if he wanted.
So meeting access needs usually involves several steps:
- Recognising the requirement. The person shouldn’t have to argue that it matters.
- Agreeing how to meet it. This usually needs discussion.
- Checking whether it works. And changing it if it doesn’t.
- Being open about limits. What this service can and can’t offer.
- Helping find an alternative when a need can’t be met here.
Access changes
Our framework- Conditions fluctuate. What works in a good week may not work in a flare.
- The work changes. Talking about something painful may need a different pace, format or length.
- Relationships change. Someone may need more control at the start, and less later.
So access needs revisiting, as part of reviewing how therapy is working, not only at the first appointment.
What it might sound like
Before we start: last time, I talked too fast and didn’t give you time. I’m sorry. How would you like us to do this?
(points to his note) Slow. One question.
One question at a time, and I’ll wait. If I start filling silences, will you tell me?
(nods, smiles) Hand up.
A hand up means I’ve gone too fast. Good.
What changes: the therapist slows down, and Conall has a simple way to say when they haven’t.
What needs attention here?
The person struggles through without saying anything
Possible focus: asking about access first, and again later
Watch for: waiting for them to raise it
An access need is treated like a preference
Possible focus: meeting it as a requirement
Watch for: trading it off against other things
Access needs change mid-therapy
Possible focus: adjusting without fuss
Watch for: treating the change as a problem
A request can’t be met
Possible focus: saying so honestly, and helping find an alternative
Watch for: quietly doing less than was agreed
Possible starting points, agreed with the person, not rules.
How you’d know it helped
Two different questions: whether the work is going well, and whether it is actually helping.
Is the work collaborative and accessible?
- Access was raised by the therapist, not left to the client.
- Arrangements were agreed together, checked, and changed when needs changed.
- Limits were explained honestly.
Is it helping with what matters?
- The person has energy left for the work they came for.
- Progress on what they came for.
Words you can use
For clientsQuestions worth carrying, as a therapist
Therapist Reflection- Do I raise access first, or wait for the client to?
- Am I treating any access needs as preferences?
- When did I last check whether the arrangements still work?
- What do I fill silences with, and who does that serve?
Evidence & sources
Sources checked in October 2026, using targeted searches rather than a systematic review. “We have not located” means our searches did not find it.
Cooper, M. & McLeod, J. (2011), Pluralistic Counselling and Psychotherapy. London: Sage.
Treating access as part of the therapy, the five areas, and the distinction between access requirements and preferences are this site’s synthesis.
Conall and the dialogue are constructed for learning. He is not a real person.
In interviews with 24 US adults with physical disabilities, the most common barriers to therapy were cost and insurance, followed by inaccessible offices, scheduling difficulties, and transport or parking. Participants valued providers who asked about access needs and accommodated them, for example with flexible scheduling. Conner, K. J., Acosta, V. M., Nouri, R., Tyler von Wrangel, M., Gramillo, E. & Conner, A. (2023), “Experiences of U.S. adults with physical disabilities: Recommendations for affirmative practice”, The Counseling Psychologist, 51(7), 970–1004. doi:10.1177/00110000231186824.
Our targeted searches did not find studies of access arrangements in pluralistic therapy specifically.
Last reviewed: October 2026.
How to cite this page: Donaghey, C. (2026). Access Is Part of the Therapy. Disability in Psychotherapy. Available at: https://disabilityinpsychotherapy.online/what-is-psychotherapy/pluralistic-psychotherapy/access-is-part-of-the-therapy/ (Accessed: [date]).