It is well recognized that clients are unique and bring their own perspective to the therapeutic relationship (Canadian Association of Occupational Therapists & Dept of National Health and Welfare 1991). As the experts in their own occupational functioning, they uniquely understand how their condition affects their everyday life. As such, only clients can relate to their experiences, know their own needs and be able to make choices that affect them individually. However, to enable them to make informed choices and set achievable goals, clients have the right to be given information in a manner they understand. They should expect to have their opinions considered and their values respected (Polatajko 1992). Providing choice means that client-centred care should address individual needs and values (Rebeiro 2000b).

Client-centred practice is about partnership. The assessment and intervention process is about relating the client’s needs to the constraints of their environment and the roles that the client assumes. The therapist becomes a facilitator rather than a director of intervention. The shift in power occurs as the result of the client taking on greater responsibility for their own health and welfare and directing more of the intervention process (Sumsion 1993). However, a person’s desire and ability to participate will be influenced by their diagnosis and the phase of their illness. Despite this, client participation is the ideal method for decision-making in healthcare (Larrson-Lund et al 2001). With partnership comes responsibility, for both the client and the therapist, with the client articulating their needs as goals and the therapist negotiating expected outcomes. Clients may be exposed to risks to individual safety when defining their own problems and seeking solutions. Risks and failure can be a valuable learning experience, but the client must be competent to recognize the risks cognitively and to seek necessary safety factors (Hobson 1996). The therapist should not support actions that are unethical, could lead to harm or be deemed as malpractice (Law et al 1995). Therapists have an ethical and moral responsibility to ensure that clients are informed about risks and to advise them on techniques and activities that may support risk avoidance (Moats & Doble 2006). They should be explicit with the client when they do not support them following an action plan that would otherwise cause harm, and should document this accordingly (Canadian Association of Occupational Therapists 1993).

Historically, occupational therapists have used remedial activities to gain improvement in functional performance. Client-centred care means intervention is structured by the goals and expected outcomes agreed between client and therapist. Achievement of these goals may come about as a result of changing roles or environment, skills or occupations rather than pure remediation. The emphasis throughout is on listening to the client and enabling them to achieve their goals. Enabling is a process that involves clients as active participants in occupational therapy (Townsend et al 1999).

Contextual congruence is about understanding the situation within which a client lives and recognizing the individual nature and circumstances of each person, their roles, interests, culture and environments. It is about seeing people as individuals, rather than as a medical diagnosis. Protocols for assessments and interventions for diagnostically identified clients are not supported within client-centred practice, as this directs intervention from a medical or mechanistic approach rather than a client-centred one. Finally, recognizing the influence that the environment has on the outcome of intervention is vital.

Services should be constructed to meet the needs of clients rather than clients fitting the service. Therapists should work with the client to enable them to access services smoothly and efficiently, with honesty and realism. A service defined as client-centred should also be client-friendly; it should be welcoming and focused on clients’ needs rather than service issues. Clients should be able to select appointment times to suit them rather than the therapist. In the UK, for example, Choose and Book is a national electronic system that gives people the choice to select their outpatient appointment times and dates (NHS Connecting for Health 2004). Information regarding waiting times and therapeutic procedures should be publicly available.

Intervention based on the client’s expressed goals and values demonstrates respect for the diversity of the values held. Therapists must be aware of the potential influence that their own values may have on the client and should not impose them. Differences will occur, but client-centred practice is all about sharing and listening, as well as recognizing the strengths and resources that a client brings to the therapeutic encounter (Law et al 2001).

The client-centred nature of occupational therapy acknowledges the individual as the central element of treatment (Donnelly & Carswell 2002). However, who is the client? The client is usually the individual who is referred to the service, but a contemporary view suggests that the client may also be carers, family, support groups or others (Sumsion 1997). It is important, therefore, always to be clear about the real client in a therapeutic encounter and keep focused on their needs.

The importance of engaging in an effective partnership with an individual is vital. Understanding the meaning of partnership requires the therapist to recognize that to achieve the end goal requires working together. Several studies have noted the dissonance that occurs when the therapist’s and client’s expectations of the results of therapy are at odds (Law et al., 1995, Banks et al., 1997, Sumsion and Smyth, 2000 and Blank, 2004). These studies found that the client’s perception of the problem was usually much more relevant than that of the therapist. Partnership is about working together to achieve goals — goals that are focused on what the client wants to achieve. Those that are important to them and are framed within an agreed clear intervention plan are more likely to succeed. A practical way of achieving this is for the client to have a copy of their goals and intervention plan. Another is to use a client-centred outcome measure: for example, the Canadian Occupational Performance Measure (COPM) (Law et al 1990) (see Chapter 7). Clients whose views on intervention and service issues are sought are likely to experience increased confidence about engaging in a working partnership with therapists.

Listening is vital to understand truly what is and what is not said (Whalley Hammell 2002). Bibyk suggests that a client-centred therapist is welcoming, that they are non-threatening and non-authoritarian (Bibyk et al 1999). By being non-judgemental, they are in a better position to listen to the client and engage in conversation. Respect is about demonstrating value for a person’s views and opinions, not imposing your views on others. A client-centred therapist accepts a client for who and what they are and where they are at (Bibyk et al 1999). Falardeau & Durand (2002) suggest that respect of the individual goes beyond their opinions, choices and values; it includes their limitations and capabilities. Individual abilities and understanding may set limits on client interaction and in some circumstances it may be helpful to intervene against a person’s will, especially when issues of risk and safety have been identified. Being able to show respect for an individual, to listen and to demonstrate empathy provides the basis for a trusting relationship with a client. Such respect makes sense of this suggested definition, ‘client-centred care means I am a valued human being’ (Corring & Cook 1999).

Bibyk et al (1999) suggest that the absence of a struggle for power and control is one of the most tangible indicators of how it feels to be with a client-centred therapist. Client-centred practice shifts power in the therapeutic relationship from the therapist as the expert to the client as a partner (Townsend, 1998 and Canadian Association of Occupational Therapists, 2002). Clients are experts in their own condition and hold a wealth of knowledge about their own unique circumstances. Enabling the client to recognize this knowledge base and use it to aid recovery is what makes the client-centred approach so unique (Lane 2000).

One of the challenges of applying a client-centred frame of reference to practice is recognizing the shift from therapist-created goals to client-led ones. Many studies reinforce the need for clients and therapists to work together at defining, clarifying and achieving goals (Peloquin, 1997 and Rebeiro, 2000b). Negotiation can only start once a relationship has been forged with the client and when listening to and communicating with each other are comfortable. Active engagement in problem identification and planning is a fundamental part of working in a client-centred way (Law et al 1997). The therapist should use clinical reasoning skills to evaluate performance and match client skills with potential to achieve goals (Mew & Fossey 1996). Negotiation about how to achieve established goals, the risks involved and an agreed time frame demands constant attention and much sharing of information between therapist and client. The biggest barrier that prevents client-centred practice taking place occurs as a result of a therapist and client having different goals (Sumsion & Smyth 2000). This barrier can often be resolved through effective communication.

The use of language in communication is vital but do we speak the same language? In modern healthcare our client population is diverse and varied, and comes from many ethnic backgrounds. It is inevitable that a therapist may not share the mother tongue of the clients with whom they work. Therapists may need to access interpreters to assist, but that in itself may create a barrier to true client-centred working. The use of language is equally important: in other words, what and how things are said. Too often we as therapists hide behind our ‘professional’ language both to protect and to preserve a sense of our authority and knowledge. If we are really to apply a client-centred frame of reference to our practice, then we must consider the language we use when working with our clients. Clear information and simple explanations can go a long way to ensuring equality in the way we communicate with clients. The way that language is used is also important. Check out this example:

It is unrealistic to expect anyone to make decisions about their lives if they do not have relevant information or do not understand how to interpret that information to inform their decision-making. As clients acquire more knowledge of their condition, this promotes self-esteem (Christiansen 1991), but Parker (1995) suggests that this in turn may pose a threat to therapists, especially those who fail to understand about partnership in client-centred working. Honest and factual explanations about risk and safety are another way of informing clients and helping them to make safe and appropriate decisions about their care. The way we communicate is also important, backing up verbal explanations with clear and easily understandable written information, or clearly signposting clients to other sources of information, e.g. the Worldwide Web.

For the purposes of this chapter, Foster’s occupational therapy process will be used (Foster 2002), namely:

This process is a logical sequence followed by occupational therapists in most areas of practice. Its success is dependent on the rigour of data collection and its analysis at each stage. Frequently, the occupational therapy process is not a linear event but a cyclical one, which should be sensitive to the changing health and environmental needs of the client. The client should be engaged at all times throughout the process and should be guided by their occupational therapist’s clinical reasoning ability and expert knowledge of the condition (Hong et al 2000). The occupational therapist’s judgement and reasoning will, however, depend on experience, clinical expertise, data analysis and a true understanding and connection with the individual (Turner, 2002 and Carpenter et al., 2001) (Also see Chapter 17).