A reflexive thematic analysis study to explore what contributes to initial engagement in therapy from the perspectives of clients and their therapists

When clients first start therapy, the initial sessions set the scene for how the therapy might unfold. Existing research suggests that if the client and their therapist are able to engage with each other early in the process, then this can lead to better outcomes and a reduced likelihood of clients ending therapy prematurely. This study aimed to explore what contributes to initial engagement in therapy from the perspectives of clients and their therapists. To date, research in this area has been predominantly quantitative in design, and has largely focussed on the development of the therapeutic alliance or reasons why clients may prematurely end therapy from either the client’s or the therapist’s perspective. This study brought these domains of engagement and non-engagement together and, through taking a qualitative approach, presented a unique in-depth perspective on both clients’ and therapists’ experiences of initial engagement in therapy.

The research took place at a low-cost counselling service in which clients are offered the option to transfer to a new therapist if they feel unable to work with their current therapist. Participants were clients who had transferred from one therapist to another along with one, or both, of their therapists. All of the therapist-participants were trainees and, in total, six clients, four first-therapists and five second-therapists took part. Data were collected through semi-structured interviews and analysed using reflexive thematic analysis, situated within a constructivist paradigm. From this, four themes were developed: (1) ‘forming a personal connection with the therapist’, (2) ‘the therapist’s responsiveness to the client’, (3) ‘is the client in good hands?’, and (4) ‘the client’s decision to change therapist’. Running through all of the themes was an emphasis on the importance of the therapeutic relationship, the therapist’s capacity for self-regulation, and the impact that the client and therapist had on each other. The findings highlight the importance of therapists attending to difficulties in their relationship with their clients, and the utility of offering clients the option to transfer to a different therapist. They also draw attention to key areas that impact engagement which could be a focus for training providers and individual therapists.