One night, whilst working as a newly qualified therapist for a non-profit counselling service, I was reminded of the stark importance of the ‘core conditions’. To explain, in person-centred therapy the core conditions are six ‘necessary and sufficient’ conditions that must be present for therapy to be effective. Condition 4 is that the therapist is congruent – meaning they possess the ability to convey helpful aspects of what it is like to be in a relationship with their client. Unconditional positive regard (condition 5) is the therapist’s attitude of absolute respect and acceptance towards their client. Empathy (condition 6) is the therapist’s ability to understand how their client experiences their world and to covey this understanding so that the client feels heard and understood. These three conditions are often emphasised but there are three lesser known conditions.

Condition 1 states the client and the therapist must be in psychological contact – simply put, client and therapist must enter into a therapeutic relationship with one another. Condition 2 states that the client is in a state of incongruence which easily translates as presenting with a problem or difficulty. And finally, condition 3 requires that the client is able to receive the congruence, unconditional positive regard and empathy offered by the therapist. During my training these first three conditions seemed obvious and hardly worth stating. However, experience tells me that access to therapy is by no means universal. On this particular evening as counsellor fresh from training, my trio of clients were Pauline, Alison and Kerry (names have been changed to preserve anonymity). Pauline is my success story while Alison exemplifies the challenge of condition 1, and Kerry the precariousness of conditions 1-3.

For thirteen months I had supported Pauline through a series of events arising from her ending an abusive relationship. She had had to make numerous court appearances which had kept her in a protracted state of anxiety and depression. She was taking medication to manage the symptoms of low mood while at the same time our therapy sessions were helping her to tolerate the emotional rollercoaster that threatened to derail her. In our safe confidential space she had been able to cry, to express doubt, to tremble with fear, to feel lost in a fog. There were times when she clung to our sessions so as not to feel entirely alone. But with each corner she turned I sensed her growing stronger, watched her confidence unfurling, her spark returning. In recent weeks we had been making preparations for our ending, and the time had come when she was ready to let go. I was experiencing an incredible, vibrant, strong woman. During our final therapeutic hour she demonstrated her steely determination, her hard-won resilience and, notwithstanding, her precious vulnerability. She conveyed hope and positivity. She had fought for her life and she had won. That evening, at her invitation, we embraced as we said our goodbyes. I was gratified to have played my part well, to know I had been instrumental in her recovery. Between us we had achieved all six necessary and sufficient conditions.

Alison did not come. In stark contrast to my earlier elation, I felt bereft. This client, whom I had seen sporadically over several months, was also courageous and had fought hard to overcome multiple barriers just to be able to ask for help. I wondered if something unexpected had happened or whether the additional challenge of her physical ill-health had made the emotional demands of counselling too overwhelming. Unable to reach her by phone, and this not being her first or even second ‘no-show’, we reluctantly moved her to our ‘no longer active’ file. Condition 1 had failed us, we were not in a therapeutic relationship, and the lack of this simple condition makes all other conditions null and void. Except of course condition 2, for I had no doubt that she was still in a great deal of emotional pain. I feared this ultimately unsuccessful experience might make it harder for her to reach out in the future. I reflected on the brutality of her life experiences and the damage it has done to her self-esteem and how, without the right kind of support, her mental health would continue to worsen over time. Her case was instrumental in the evolution of my private practice policy to provide an inclusive tailored-practice in the service of people with disabilities and long-term health conditions. Some people need help to break down the socially-constructed barriers to therapy that will help them turn their lives around. Existing is not the same as truly living.

When I welcomed Kerry that evening I once again had cause for celebration. She wasted no time in triumphantly announcing it was her fourth session. A month prior she had presented as an anxious woman confused as to why she had ever agreed to face me across a windowless therapy room. That first time, she had arrived complete with her social mask for all occasions which served to protect her from emotional vulnerability. In assessing how we could begin to build a trusting therapeutic relationship I appealed to her obvious grit and adventurous spirit by suggesting she give counselling four weeks before deciding whether to stop or continue. That day she was glorious in victory. And I had a convert to counselling. We joined forces to traverse the mire and I felt sure that in 2 months, or 4 or 7, we would embrace as Pauline and I had done, to say our goodbyes.

So do you want the good or the bad news? There can be no effective therapy without psychological contact. In other words, participation is key. That is the good AND the bad news. By putting yourself forward for counselling, you can begin, continue, and eventually gain closure. But if you don’t participate, or you are prevented from participating, you cannot achieve all six conditions for effective therapy. In my humble opinion, providing an inclusive range of accessible and effective therapeutic services is vital for the health of UK society. And I would go further. For me, it’s a human rights issue – because when I think about Alison and the struggles she faces on a daily basis because of the awful things that have happened to her, I don’t believe that anyone should be consigned to merely existing, but that everyone should have the opportunity to truly live.