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Canadian Journal of Occupational
http://cjo.sagepub.com/content/62/5/250The online version of this article can be found at:
DOI: 10.1177/000841749506200504
1995 62: 250Canadian Journal of Occupational TherapyMary Law, Sue Baptiste and Jennifer Mills
Client-Centred Practice: What does it Mean and Does it Make a Difference?
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Mary Law, Ph.D., OT(C) is an Asso-
ciate Professor in the School of Occupa-
tional Therapy and Physiotherapy and the
Department of Clinical Epidemiology and
Biostatistics, McMaster University, and
Research Associate, Occupational
Therapy, Chedoke-McMaster Hospitals,
Bldg T-16, McMaster University, 1280
Main Street West, Hamilton, Ontario,
Canada L8N 4Z 1 .
Sue Baptiste, M.Hsc., OT(C) is Se-
nior Advisor for Professional Issues,
Chedoke-McMaster Hospitals, and Assis-
tant Clinical Professor, School of Occupa-
tional Therapy and Physiotherapy,
McMaster University.
Jennifer Mills, B.HSc., OT(C) is an
occupational therapist at the Belleville
General Hospital, Home Care Program,
Belleville, Ontario
CJOT • VOLUME 62 • NO 5
• MARY LAW • SUE BAPTISTE • JENNIFER MILLS
KEY WORDS
Client-centred practice, occupational therapy
Delivery of health care
Empowerment
Client-centred practice: What does it mean and does it make a difference?
ABSTRACT During the past 15 years, occupational therapists in Canada,
through the Canadian Association of Occupational Therapists, have worked to
develop and implement guidelines for practice of a client-centred approach to
occupational therapy. One of the difficulties with the current Guidelines for the
Client-Centred Practice of Occupational Therapy is the lack of a definition and
discussion of the concepts and issues fundamental to client-centred practice.
In this paper, key concepts of client-centred practice: individual autonomy and
choice, partnership, therapist and client responsibility, enablement, contextual
congruence, accessibility and respect for diversity are discussed. Two practice
examples are used to illustrate these ideas and raise issues about obstacles to
the practice of client-centred occupational therapy. Research evidence about
the effectiveness of client-centred concepts in enhancing client satisfaction,
functional outcomes and adherence to health service programmes is reviewed.
RÉSUMÉ Au cours des 15 dernières années, les ergothérapeutes au
Canada, par le biais de l'Association canadienne des ergothérapeutes, ont
travaillé au développement et à l'instauration de lignes directrices relatives
l'approche centrée sur le client en ergothérapie. Une des difficultés actuelles des
Lignes directrices relatives à la pratique de l'ergothérapie centrée sur le client
se trouve dans le manque de définition et de discussion sur les concepts et la
problématique fondamentale de la pratique centrée sur le client. Dans cet article,
les concepts clés de la pratique centrée sur le client sont présentés, ce sont :
l'autonomie individuelle et le choix, le partenariat, la responsabilité de
l'ergothérapeute et du client, la capacité d'action, la concordance contextuelle,
l'accessibilité et le respect pour la diversité. Deux exemples de pratique sont
utilisés pour illustrer ces concepts et soulever la réflexion sur les obstacles
rencontrés par la pratique centrée sur le client en ergothérapie. Les résultats de
recherche concernant l'efficacité des concepts centrés sur le client en rapport
avec la satisfaction du client, les résultats fonctionnels et la conformité en
rapport avec les programmes de santé, sont passés en revue.
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Occupational therapists in Canada were one of the first health professional groups to describe and endorse a model of client-centred practice (Canadian Association of Occupational Therapists & Department of National Health and Welfare, 1983). Throughout the develop-ment of a clear framework for the unique contribution of the discipline of occupational therapy in Canada, the concept of client-centredness has been constant (CAOT, 1991; Law et al, 1999; Townsend, Brintnell & Staisey, 1990). The development of a client-centred approach reflects changes wanted by consumers who desire more control in defining health issues as well as changes in how health is viewed. According to the Ottawa Charter for Health Promotion (World Health Organization, 1986), health is viewed as a "resource for living". The implications of these changes have led to increased emphasis on consumer rights and public participation in health issues.
Although the Guidelines for the Client-Centred Practice of Occupational Therapy have been widely distributed and used in Canada (Blain & Townsend, 1993), there has been little discussion about the concepts and issues inherent in client-centred practice. In fact, in researching the literature for this paper, a definition of client-centred practice, along with a description of its concepts and assumptions, was not found. Because of the lack of discussion about the meaning of client-centred practice, it is difficult for therapists to understand and implement these ideas in their practice.
The purpose of this paper is to define and discuss concepts and issues fundamental to client-centred practice. Concepts such as individual autonomy and choice, partnership, therapist and client responsibility, enablement, contextual congruence, accessibility and respect for diversity will be examined. From these concepts, assumptions of client-centred practice emerge. The challenge of implementing the assumptions of client-centred practice on a day-to-day basis is illus-trated through two occupational therapy practice ex-amples. The paper concludes with a brief discussion of research evidence about the effectiveness of client-centred practice in enhancing client outcomes. The ideas raised in this paper should be of interest to occupational therapists in clinical practice, education, and research.
CLIENT-CENTREDNESS The underpinnings of the constmct of client-centredness are found in the original works of Carl Rogers just prior to World War II. Historically, the term client-centred practice first arose from Rogers in a book entitled The Clinical Treatment of the Problem Child(Rogers, 1939). Rogers recognized a number of key constructs of client-centredness (1951). He emphasized the impor-
tance of cultural values, the dynamic nature of the therapist-client interaction, the need for a client to have an active role in approaching problems and concerns, and the need for openness and honesty within the clinical relationship (Rogers, 1951). The most impor-tant contributions of Rogers in articulating client-centred practice were the concept of listening and his discussion of the quality of therapist-client interac-tions. Growth of the client-centred movement contin-ued into the mid-1960s with its main focus in utilization being within the discipline and practice of social work.
Though Roger's interpretation of client-centred prac-tice may be different from the occupational therapy interpretation, it is important to note from whence this term emerged. It was within the last two decades that the profession of occupational therapy in Canada articulated a congruence between the theoretical frame-work of occupational performance and the core value of client-centredness (CAOT, 1991). In the develop-ment of these concepts for occupational therapy, the importance of the relationship between client and therapist reflects the contribution of Roger's thinking. The initial version of the Guidelines for the Client-Centred Practice of Occupational Therapy (CAOT & DNHW, 1983) emphasized ideas about the worth of the individual and a holistic view of the individual. Ideas about client-centred practice have, however, evolved over time and now reflect the importance of client-therapist partnership, the rights of clients to make choices about occupations, the influence of a client's environment and the need for intervention at a societal and policy level (Law, 1991; Polatajko, 1992; Townsend, 1993).
CONCEPTS OF CLIENT-CENTRED PRACTICE
There is increasing evidence that occupational thera-pists, as reflective practitioners, value a therapist-client relationship defined by trust, caring and competence (Doble, 1988; Mattingly & Fleming, 1994; Peloquin, 1991). Client-centredness is a philosophy of practice built on concepts that reflect changes in the attitudes and beliefs of clients and occupational therapists. There are a number of concepts which form the underpinnings of a client-centred approach.
AUTONOMY/CHOICE It is recognized that each client is unique and brings that perspective to the occupational therapy experi-ence (CAOT, 1991). Clients are experts about their occupational function. Only they can truly understand the experiences of their daily lives, express their needs and make choices about their occupations. "The real experts on disability are the people who live with a disability" (Canadian Association of Independent
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Living Centres (CAILC), 1992, p.58). Crabtree and Caron-Parker (1991) have suggested that Thomasma's freedoms - freedom from obstacles, to know one's options, to choose, to act and to create new options - be the cornerstone of occupational therapy service.
Clients have the right to receive information to enable them to make decisions about occupational therapy services that will or will not effectively meet these needs. They expect that their opinions will be sought, their values will be respected and that they will maintain their dignity and integrity throughout the therapy process (Polatajko, 1992). To enable this to occur, clients need to be provided with information in a format that is understandable and that will enable them to make decisions about their needs.
PARTNERSHIP AND RESPONSIBILITY Client-centred practice necessarily leads to a change in power so that clients have more say in defining the priorities of intervention and directing the intervention process (Kaplan, 1991; Sumsion, 1993). In client-centred practice, the goal of the client-therapist rela-tionship is an inter-dependent partnership to enable the solution of occupational performance issues and the achievement of client goals. Assessment and inter-vention reflects the client's visions and values, taking into account the roles that they have and the environ-ments in which they live. In such a therapist-client relationship, power is defined as a process by which the client and the therapist achieve together what neither could achieve alone (Crabtree & Caron-Parker, 1991; Law, 1991).
With partnership comes responsibility. The respon-sibilities of the therapist and client, in this practice model, change from responsibilities as viewed within a medical model. Traditionally, therapists have taken an active role in the assessment and definition of occupational performance issues and the delineation of methods to resolve those concerns. In a client-centred practice, the client has a more active role in defining both the goals of intervention and the desired outcomes of intervention. The role of the therapist shifts to one of facilitator in working with the client to find the means to achieve those goals (Kaplan, 1991). Client and therapist become partners in the interven-tion process. Therapists' responsibilities include pro-viding information which will enable client choice and utilizing their expertise to facilitate a broad range of solutions to occupational performance issues (Matheis-Kraft et al, 1990; Sokoly & Dokecki, 1992). Clients have a responsibility to be active participants in the therapy process, both in defining issues for therapy interven-tion and in facilitating the intervention process. Such a partnership leads to the therapist and client working together, questioning issues, trusting and learning
from each other throughout the therapy process. Clients may choose to define problems or seek
intervention which puts them at risk to themselves or at risk for failure. Therapists recognize that such risks are often valuable learning experiences, provided that the client is competent to understand the conse-quences of risks and the therapist is not supporting actions which are unethical, could lead to harm or could be considered as malpractice. In client-centred practice, it is important that therapists discuss openly with clients if they believe that the course of action the clients are undertaking puts them at risk. There may be situations when a therapist is uncomfortable with a client's choice, more because of a difference in values than the fact that the client is not competent to make that choice. Therapists must clearly outline when they cannot support clients in pursuing an action plan.
ENABLEMENT Occupational therapy practice in the past has focused largely on remediation of functional difficulties by facilitating change in individual performance compo-nents. A client-centred approach in which clients define the central issues for occupational therapy intervention supports a shift from a deficit model of intervention to an enablement model (Polatajko, 1992). Within such a model, therapists work with clients to enable them to achieve occupational goals that they have set for themselves. The occupational therapy process can focus on prevention, remediation, devel-opment or maintenance of occupational performance (CAOT, 1991). Achievement of these goals is facilitated through a variety of means, including changes in individual skills, changes in environments and changes in occupations. All intervention alternatives are ex-plored. In the therapy encounter, the process of providing services is important. There is a need for increased emphasis on the use of listening and empha-sis on the use of language that is understood by clients and provision of information to facilitate client deci-sion-making (Baxendale, 1993). Peloquin (1993) found that clients desire more than simply technical compe-tence from therapists. Clients value the caring which is shown by therapists who truly listen and learn from their experiences.
CONTEXTUAL CONGRUENCE The importance of clients' roles, interests, environ-ments, and culture are central to the occupational therapy process within client-centred practice. Occu-pational therapy assessment and intervention using a client-centred approach places importance on the individualization of assessment and intervention (Dunn, 1993; Law, 1991; Law, Baptiste et al, 1994). Consider-ation of the context in which a client lives demands a
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flexibility in the approach of the therapist in all intervention situations (Dunn et al., 1994). For ex-ample, the use of a set protocol of assessments and intervention for diagnostically defined types of clients is not supported within client-centred practice. Re-search about assessment has also indicated that results depend on the environment in which the assessment occurs (Park, Fisher & Velozo,1993). In practice, there may be situations where therapists use different levels of client-centredness, depending on the nature of the intervention and the needs of the client. One of the most challenging dimensions of client-centred practice is "how to adjust consultation style to the needs of the moment" (Moorhead & Winefield, 1991, p. 345). It is also important to note that a client of occupational therapy may not always be an individual. Clients can include other family members or can be communities, private companies, or organizations.
ACCESSIBILITY AND FLEXIBILITY In client-centred practice, services are provided to clients in a timely and accessible manner. Services are constructed to meet the needs of the client, rather than the client fitting into a service model. A client-centred approach to practice is flexible and dynamic, with an emphasis on learning and problem solving. Therapists work to enable clients to access services with a minimum of bureaucratic red tape. The successful client-centred therapist exhibits an openness and hon-esty within the client-therapist relationship. This in-cludes the provision of a welcoming service with attention paid to such details as parking, waiting lists, information brochures and ongoing therapy proce-dures.
RESPECT FOR DIVERSITY Intervention based on clients' visions and values demonstrates a respect for the diversity of values that clients hold. It is important for therapists to recognize their own values and not impose these values on clients. What may seem to be an irrational choice by a client is often exactly what is right for that person at that time, based on all the information they have about their lives and values (Kaplan, 1991). The strengths and resources that a client brings to an occupational therapy encounter are recognized and used to facilitate the achievement of occupational performance goals. The client-centred approach recognizes that differ-ences in values and opinions will occur, but supports a mediation approach to the resolution of these conflicts.
DEFINITION AND ASSUMPTIONS OF CLIENT-CENTRED PRACTICE IN OCCUPATIONAL THERAPY
One of the difficulties in discussing client-centred practice in occupational therapy has been the lack of a definition of client-centred practice. Using the con-cepts discussed in the previous section, a definition of client-centred practice in occupational therapy was developed. Client-centred practke is an approach to providing occupational therapy, which em-braces a philosophy of respect for, and partner-ship with, peopk receiving servkes. Client-centred practice recognizes the autonomy of indi-viduals, the need for client choice in maldng decisions about occupational needs, the strengths clients bring to a therapy encounter, the benefits of client-therapist partnership and the need to ensure that servkes are accessible and fit the context in which a client lives. "The goal of the [client] centred philosophy is to create a caring, digni-fied and empowering environment in which clients truly direct the course of their care and call upon their inner resources to speed the healing process" (Matheis-Kraft, George, Olinger & York, 1990, p. 128).
From the concepts and definition of client-centred practice, assumptions about practice can be devel-oped. These assumptions can be used to guide the structure and process of occupational therapy practice as well as research directed at exploring the effects of a client-centred practice philosophy. They include:
Occupational therapists using a client-centred ap-proach recognize that clients and families are all different and unique and they know themselves best (King, Rosenbaum, Law, King & Evans, 1994).
Optimal client outcomes occur when clients and therapists work in partnership throughout the therapy process and focus on the resolution of client-defined occupational performance issues.
Provision of information to clients about their occupational function will enable them to make choices about what services they need and the desired out-come.
Optimal client outcomes occurs when occupational therapy services consider the environment and roles important to each client.
IMPLICATIONS FOR OCCUPATIONAL THERAPY PRACTICE
The concepts and assumptions of client-centred prac-tice raise a number of client-therapist partnership issues that must be addressed. These include 1) defining the nature of the presenting occupational issues; 2) discussing and deciding on the need for intervention and the desired outcome; and 3) deciding
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Example 1 Mr. S. was a 76 year old man who was admitted to an acute inpatient medical floor because of severe dehy-dration. Mr. S. was found at home, unable to get out of bed, incontinent and unable to manage any aspect of personal care. His spouse had a history of moderately advanced dementia, and did not pursue medical attention until there was severe physical deterioration. Occupational therapy was requested because of his dependence in basic activities of daily living. In therapy, Mr. S.'s main objective was to get well enough to return home. The occupational therapist worked with the client to facilitate a return to independence in self care skills. Eventually, he was able to perform all aspects of personal care independently. After this stage of successful rehabilitation, the client had many op-tions and choices to make regarding discharge from the hospital. Psychological assessment found Mr. S. to be competent to make his own decisions. The occupa-tional therapist provided information regarding the risks and consequences of returning to his previous living arrangement. With this knowledge, Mr. S. made an informed decision to return to a home environment that was placing him at a fairly high safety risk, with minimal community supports accepted by his wife.
This case study highlights the concepts of au-tonomy/personal choice, client responsibility for goal setting, and respect for diversity of the client. It is an example of a situation that involved a client making an apparently irrational choice, but a decision that was accepted as right for him at that time. The degree of client-centredness evolved throughout the therapy process. As Mr. S.'s acute medical crisis stabilized, he was able to assume more control for directing his therapy goals and interventions.
Example 2 Mrs. R. was a 39 year old woman diagnosed with fibro myalgia. The Home Care occupational therapist was requested to assist with management of daily activities. Initial assessment found that Mrs. R. had severe pain in
the arms, neck, back, and legs, stiffness limiting range of motion, chronic fatigue and problems sleeping. In addition, other concerns included being a single mother of two young boys, geographic isolation, recent mar-riage separation, and financial difficulties.
To identify and prioritize problems and goals, the Canadian Occupational Performance Measure was administered (Law et al, 1994). The occupational performance problems identified were sleeping dis-comfort, preparing meals, use of toilet and bathing, playing with children, and pursuing meaningful roles outside the home. The process of setting occupational performance goals was challenging for Mrs. R., as she was quite focused on her individual physical prob-lems. The use of the COPM, a client-centred assess-
the focus of occupational therapy intervention. In addressing these issues, it is important for therapists to determine who the client is, to respect the client's value system and culture, to facilitate the client in setting occupational goals, to provide education and informa-tion to facilitate personal choices and problem solving, and to use their skills to help the client achieve their occupational performance goals.
Because client-centred practice suggests a particu-lar philosophical approach, it is difficult to list specific implications for practice. The challenges of basing intervention on priorities and client choice, increasing client participation in programme planning, allowing clients to succeed but also to risk and to fail, changing therapist roles to enable facilitation and broadening the focus of intervention are all critical challenges to be met and resolved. These ideas may not mean changing one's clinical practice entirely, as occupational thera-pists have alway supported a holistic approach to practice. However, client-centred practice needs to be more clearly articulated in our day-to-day clinical activities and in how we approach interactions with clients.
Differences between a more traditional and a client-centred approach begin from the initial contact. In a recent survey, Neistadt (1995) found that the majority of occupational therapists use very informal methods to determine client priorities. In client-centred prac-tice, considerable thought should go into how an occupational therapy encounter begins. For example, key questions (listed below) could be used by thera-pists to analyse the nature of this aspect of practice.
e How much power does the client have at initial contact?
6 How much time is spent discussing the client's values and goals?
e How much of the occupational therapy assessment focuses on performance components compared to occupational performance issues?
e How much of the assessment process uses stan-dardized assessment procedures as compared to procedures tailored to the needs of the client?
e Is the client aware of the system within which they are receiving service?
e Is the occupational therapy intervention plan ad-dressing the roles and environments that are rel-evant to the client?
• Are educational materials tailored to the relevant needs of the client?
The following examples illustrate some of the key concepts and assumptions of client-centred practice as used within two occupational therapy clinical encoun-ters.
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ment focusing on occupational performance areas, facilitated a shift in the therapy process from a deficit model to an enablement model of goal setting and intervention. The client-centred assessment process allowed subsequent intervention and education to be focussed on client priorities throughout the therapy process. This helped to ensure that these sessions were meaningful, and it allowed the client to assume re-sponsibility for developing solutions which fit her lifestyle. Using the COPM also gave the client an indication of progress as the scores on the measure changed from 2.2 and 2.4 for performance and satisfac-tion to 5.2 and 4.9 after intervention.
Intervention involved providing education regard-ing the modification of her physical environment, implementing energy conservation and relaxation strat-egies, and counselling regarding a paced approach to resuming meaningful roles. By focusing on the poten-tial functional outcomes, Mrs. R. was able to identify the need to implement changes in her lifestyle. For example she decided that a scooter was acceptable because of the freedom it allowed for outings with her children. After this, the occupational therapist was able to provide her with practical methods of accessing a scooter for her regular use.
Central to this therapeutic process were the client-centred concepts of autonomy, personal control, part-nership, responsibility and enablement. The client/ therapist relationship fostered skills in self manage-ment for use by Mrs. R. in the present and for the future.
CHALLENGES TO IMPLEMENTATION
it must be recognized that working in a client-centred model of practice is challenging and complex. The therapist must be aware of obstacles that exist in the therapy process which may hinder the implemen-tation of client-centred principles. Obstacles may arise from various sources, including the client, the therapist and the organization.
Clients themselves may present barriers that alter the extent to which the therapy can be client- centred. For example, if a client does not have well-developed problem solving skills, the therapist may have to be more directive than with other clients. As well, some clients may be reluctant to assume responsibility for their care. This creates an obvious challenge to the therapist, and challenges the therapist to act as a mediator to ensure that these issues are discussed and to work for potential solutions.
The therapist may also be the source of some obstacles towards client-centred practice. The process of giving more power/control to the client threatens the traditional view of the therapist as expert, and may elicit feelings of discomfort. In addition, separating
personal and professional values from client values can be a challenge, especially when the client is making a decision that appears to entail unnecessary risk. One must be careful that the client-centred approach is not used to absolve therapists or the system of responsibility for providing excellent quality of service. If a client chooses not to adhere to recom-mendations, it is easy to assume that it is because the client is noncompliant. This may be the case, but it is important for the therapist to reflect back on the process and identify any barriers which may have prevented adherence. For example, did the client understand the rationale for such recommendations, any risks from non-adherence to them and any other options which were available?
The third source of barriers may be at the organi-zation or systems level. For example, in a programme setting dominated by the medical model, it may be difficult to implement some concepts of client-centred practice such as autonomy, responsibility and enablement. It may also be difficult to determine who is the primary client: the referred person, family, school, insurance company, hospital or industry.
The obstacles will vary depending on the clinical setting, and the personal characteristics of the client and therapist involved. This discussion has only high-lighted a few examples that may occur. It is important to be aware of the potential barriers to client-centred practice, so that they can be foreseen, identified and solutions created.
DOES CLIENT-CENTRED PRACTICE MAKE A DIFFERENCE?
While occupational therapists may be comfortable with and support the philosophy of client-centred practice, it is important to determine whether the concepts and values inherent in client-centred practice make a difference, both in the service provision process and in client outcomes. A review of the occupational therapy literature yielded very few stud-ies examining the effect of client-centred practice, so the review was expanded to examine studies in other disciplines as well.
Research findings indicate that providing respectful and supportive services, an aspect of client-centred practice, leads to improved client satisfaction and adherence to health service programs (Greenfield, Kaplan & Ware, 1985; Hall, Roter & Katz, 1988;Wasserman, Inui, Barriatua, Carter & Lippencott, 1984). In a review of the service process, King, King and Rosenbaum (1994) found that there is evidence that respectful and supportive treatment, information exchange and practices enabling client professional partnerships are all significantly associated with in-creased client satisfaction.
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Provision of information to clients to enable client decision-making has been shown to lead to both improved functional outcome and improved client satisfaction. In studies involving clients with diabetes or peptic ulcer disease, Greenfield, Kaplan and Ware (1985) evaluated the effect of providing client educa-tion. Clients were randomized into two groups, an experimental group which received a 20-minute edu-cational intervention about how to read their medical charts and ask for pertinent information, and another group receiving a standard education programme. Clients receiving the experimental intervention were more satisfied with their services and had improved functional outcomes one month later. Moxley-Haegert and Serbin (1983), in a clinical trial comparing parent education about developmental issues to parent edu-cation about general parenting or a control group, found that parents who received developmental edu-cation were more able, after one year, to identify key issues related to their child's development and had increased adherence to service programme sugges-tions. As well, children of parents who had received developmental education had improved developmen-tal outcomes after one year.
Development of a client-therapist partnership has been demonstrated to lead to increased client partici-pation, increased client self-efficacy and improved satisfaction with service (Dunst, Trivette, Boyd & Brookfield, 1994; Greenfield, Kaplan & Ware, 1985). An individualized flexible approach to occupational therapy intervention, where the client defines goals which then become the focus of intervention, has been shown to lead to improved occupational performance outcome and improved satisfaction (Law, Polatjko et al, 1994; Sanford, Law, Swanson & Guyatt, 1994).
CONCLUSION Client-centred practice is an approach to therapy that supports a respectful partnership between therapists and clients. It is the philosophical basis for the national occupational therapy guidelines published by the Canadian Association of Occupational Therapists (CAOT, 1991). Although client-centred practice is evident throughout the history of occupational therapy, its significance and implications for practice are only recently being explored in the occupational therapy literature and research. More research to understand the effect of promoting personal control and enablement through a client-centred approach is needed. It is important that the meaning and application of client-centred practice continues to be developed. The term client-centred is popular in many areas of health service, but using the term does not necessarily trans-late into a truly client-centred practice. As health care policy becomes influenced more by consumers, it is an
opportune time for occupational therapists to integrate the concepts of client-centred practice into programme planning and intervention.
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