Psychotherapy With Non-Verbal Clients: Blending Empathy and Flexibility By Tom Medlar, LMHC on 7/18/23 - 12:46 PM

Psychotherapy with Non-Verbal Clients

Hello, Jane.

My name is Tom.

Can you hear me? Blink once if yes, or blink twice if no.

One blink.

Is your name Jane?

One blink.

Is my name Tom?

One blink.

Is my name George?

Two blinks.

Is your name George?

Two blinks.

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Jane is fully paralyzed, and can only communicate by use of eye blinks — one for yes, and two for no. Her yes/no responses had been tested by the speech therapist and were deemed to be reliable. By responding to a series of my comments and questions, she could indicate her answers, and gradually build up a conversation about her thoughts, feelings, and concerns.

Consequent to a brain stem stroke, Rachel became paralyzed from the neck down. Her brain functions are intact, and she makes facial expressions, but cannot speak or move her body or limbs. Rachel communicates with a clear plastic board with black alphabet letters and numerical digits. I hold it up and watch her eyes carefully and methodically scan the board, and then say aloud each letter she selects by looking at it, as she builds words and sentences. Rachel can have thoughtful and meaningful conversations in psychotherapy, or with others — if someone is willing to make the effort to use her method of communication. In our first conversation Rachel communicated, “We should do staff in-service training, Tom, because they don’t always use my letterboard.”

Roger sustained a severe brain injury, and he was only able to move his right thumb, yet he would lift his thumb once for yes, and twice for no, and with that method, Roger could generate basic communications.

Doris was deaf for most of her life and was a skilled signer and reader of lips. She came to the nursing facility after a stroke. I don’t know how to sign, and I wear a mask at the facility, so I would write my questions and comments, and Doris would read them and give verbal responses.

Mark had been in a persistent vegetative state after a brain injury. He eventually made a surprising recovery, regained his speech, and moved about in a wheelchair. Mark explained to me that during the period when he was outwardly unresponsive, he had been aware of others speaking around him, yet he could not let them know. During that period, he also experienced an exact recurring sequence of twelve dreams, which he was glad to now be able to share with me.

Combining Empathy, Creativity, and Flexibility in Psychotherapy

In psychotherapy, I commonly attend to the specific content of what a client is saying, as well as what may be left out or avoided, what might be hinted at or signaled indirectly. I listen to the tone and pace of a client’s speech, and to gestures and body postures that also communicate meanings. I follow the attention of the client, how one establishes or breaks contact, and if the client is speaking directly to me as they search for new understanding or might be repeating comments they have made to others, or even if they might be speaking to an internal audience more than to me. I pay attention to what the client inwardly attends to and ask questions or make comments to guide their attention to what they might overlook, minimize, or avoid. This approach becomes more critical when working with clients like these with medical or disabling conditions that affect their ability to communicate verbally.

While practicing psychotherapy in nursing facilities, I might work with a client with intact cognitive and language skills, or sometimes with someone with a brain injury or a neurological condition. The individual might even be a non-verbal communicator, which as I have learned, does not preclude meaningful, empathic communication.

Some of my clients use non-verbal methods of communicating such as gestures, or a letter board, or an electronic device for spelling or voicing their typed comments. I may need to extend my patience and concentration when working with a non-verbal client. If an individual can only offer yes/no responses, it is important to clarify and confirm the accuracy of their responses. When documenting the conversations, I might state that I said or asked this, and the client indicated or selected that to limit assumptions or misunderstandings about precise communication with the client.

When working with a non-verbal client it is, ironically, the non-verbal communication that is lessened, as the client and I are focused more on the concrete words or meanings being generated than on the manner of communicating.

Social communications are an essential human need. A reduced ability to communicate or the loss of speech can be profound, and when added to an acquired disability condition, communication can be that much more difficult, especially between therapist and client. When a person most needs to talk about their situation, they might be unable to speak, or quite limited in their ability to communicate — if others do not effectively assist their abilities with some augmentative type of communication method. A person might lose the ability to verbalize speech, yet they do not thereby lose their need to communicate. Psychotherapy with a non-verbal client is possible yet may require adaptation of methods, therapeutic approach, and attitude.


I have been especially moved by the challenges faced by people with one or another barrier to ordinary human communications. I feel proud of the courage these individuals display as they grapple with enormous communication problems — those that others might overlook.

Some clinicians and health care providers might think it is not effective to attempt psychotherapy with significantly disabled persons or clients with an absence or impairment of speech. But my clients have many times expressed their appreciation for being helped to develop and refine methods of communication through speech therapy and psychotherapy.

It has been important to help my clients think about and prepare ways they might more successfully communicate with others, and not only with their therapist. For example, Rachel could have a card posted in her room or attached to her wheelchair that explains her need for help to communicate, and brief instructions for how to help. Or I might coach a client to practice sharpening the point of their messages so they more quickly convey their needs or requests before a listener might lose patience and end an interaction.

Psychotherapy can still be a dialog even when it is not a typical verbal conversation. A client can still be helped to find and use their personal “voice” even if it is not a spoken one.  

File under: The Art of Psychotherapy, A Day in the Life of a Therapist