Working with Complex Clients: Advanced Formulation and Relational Skills
Written by the ICPS College Academic Team · Reviewed by ICPS College faculty · Last reviewed: September 2026
Every practitioner meets clients whose difficulties do not fit neatly into one category. Multiple overlapping problems, long histories of trauma or loss, relational patterns that repeat in the therapy room, and fluctuating risk can all leave a counsellor feeling uncertain about where to begin. These are often described as complex presentations.
What makes a presentation complex
Several co-occurring difficulties, such as trauma, addiction, anxiety and relationship problems.
Long-standing patterns in how the person relates to themselves and others.
Difficulty trusting helpers, often rooted in earlier experiences of being let down.
Periods of crisis or elevated risk.
Involvement of multiple services with different priorities.
Formulation as a compass
A good formulation is a shared, evolving map that links a person's history, current difficulties and the patterns that maintain them. It helps practitioner and client decide what to focus on, in what order, and why. Formulation also protects against drift, where sessions become reactive and the therapeutic direction is lost.
The therapeutic relationship under strain
With complex clients the relationship itself often becomes the site of the work. Ruptures, such as missed sessions, anger or withdrawal, are not failures; handled well, they can become opportunities for repair and learning. This requires the practitioner to notice their own responses, including countertransference, and to use supervision to think clearly under pressure.
Risk, boundaries and collaboration
Working safely with complexity means knowing the limits of your role, contracting clearly, assessing and reviewing risk, and collaborating with other services where appropriate.
Develop advanced skills with ICPS College
The Professional Diploma in Advanced Therapeutic Skills for Complex Clients is a live-online specialist programme carrying 60 CPD credits. It focuses on complex presentations, advanced formulation and relational practice. Visit the course page for modules and enrolment.
Related ICPS College courses
Important information
This article is educational content for practitioners and learners. It is not a substitute for professional advice, counselling or therapy.
If you are struggling or in distress in Ireland, you can call Samaritans free on 116 123 or text HELLO to 50808 at any time. In an emergency, call 112 or 999.
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