11. The client-centred frame of reference
Davina M. Parker
Client-centred practice is a fundamental element of occupational therapy, and studies to define its parameters have done much to name and frame our current practice.
Occupational therapists have always held, as a core value, the client as the primary focus of occupational therapy intervention, but when faced with the theory of client-centred practice and the reality of working-day pressures, there is little to ensure that this occurs.
Theory-based models have done much to provide occupational therapists with a rationale for their thinking, but little has been done to explore the application of client-centred practice as a frame of reference with which to mould and shape practice. This chapter guides the therapist and aspiring practitioner through the occupational therapy process to enable the theory of client-centred practice to link clearly with the reality of practice.
• describes what being client-centred means in practice
• emphasizes the role of each therapist’s personal values
• explores how to be client-centred throughout the occupational therapy process
• emphasizes respect and partnership
• discusses how best to work together to achieve goals.
Client-centred care is considered the optimum way of delivering healthcare, as clients’ perspectives are regarded as important indicators of quality in healthcare (Gan et al 2008). Client-centred practice is increasingly encouraged and advocated as the way ahead for occupational therapy internationally (Palmadottir, 2003, Conneeley, 2004 and Falardeau and Durand, 2002). The reality of being a client-centred therapist can, however, be a demanding and sometimes bewildering, but for many also a rewarding, way to practise. It requires a true understanding of how to deliver client-centred practice and a recognition that it permeates all aspects of interactions with people.
So what is client-centred practice all about? Put simply, client-centred practice is a process in which occupational therapy revolves around the client as the focal point of intervention (Maitra & Erway 2006). This chapter will help you to understand and use a client-centred frame of reference in practice. The chapter aims to:
• define the client-centred frame of reference
• describe the context of client-centred practice
• explore the principles of a client-centred frame of reference
• provide examples of the application of the client-centred frame of reference in practice.
A case study is presented throughout the chapter to illustrate ways in which client-centred practice can be achieved by applying this frame of reference. This should assist both students and therapists to link theory with practice more readily. Throughout this chapter, the task for you, the reader, is to examine your own working style for evidence of client-centred practice. Reflective questions at the end of the chapter will help you achieve this.
Historical roots of client-centred practice
Client-centred practice is firmly rooted in the work of Carl Rogers, who used the term ‘client-centred practice’ in his book, The Clinical Treatment of the Problem Child (Rogers, 1939, Rogers, 1951, Law et al., 1995 and Corring and Cook, 1999). In this text he described and emphasized a variety of factors including:
• the importance of individuality
• the sense of self
• the influence of the environment
• values development
• goal-directed behaviour, both in relation to the development of the individual and as part of the client–therapist relationship.
Two of the most important points he made in the articulation of client-centred practice were the skill of listening and the exploration of the quality of the therapist–client interaction (Law et al 1995).
Rogers, along with other theorists such as Abraham Maslow, tried to separate the humanistic approaches of human interaction from the more mechanistic and biological approaches favoured by Freud, Skinner and others at the time (Simon & Daub 1993). His approach stressed the importance of some key elements: empathy, respect, active listening and an understanding of the person’s self-actualization. These themes echo the structures underpinning a client-centred frame of reference in occupational therapy.
Background to client-centred practice
Much of the development of client-centred practice in occupational therapy has taken place in Canada. During the 1980s the Canadian occupational therapists explored and described the links between the theoretical framework of occupational performance and the core values of client-centredness. In the Guidelines for the Client-centred Practice of Occupational Therapy (Canadian Association of Occupational Therapy, Department of National Health and Welfare 1983 and Canadian Association of Occupational Therapy and Dept of National Health and Welfare, 1991), the acknowledgement of the worth of, and the holistic approach to, the individual was explicit. Law et al (1995) presented a detailed discussion of the fundamental issues of client-centred practice, in their pursuit of a definition and a greater understanding of its application in practice. They described the key concepts of client-centred practice as:
• contextual congruence
• respect for diversity.
These concepts are now described in greater depth to aid understanding of how to apply a client-centred frame of reference in practice.
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.
Accessibility and flexibility
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.
Respect for diversity
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).
A definition of client-centred practice
Research and practice development has evolved since Law et al first defined client-centred practice in 1995; in particular, work carried out by Sumsion (2000) on a revised British definition has expanded our understanding. Client-centred practice is embedded in the Code of Ethics and Professional Conduct for Therapists (College, 1995 and College, 2000) and in professional standards (American Occupational Therapy Association 1998), where we are reminded that services should be client-centred and needs-led. These documents remind therapists that each client is unique and brings an individual perspective to the occupational therapy process (College, 1995 and College, 2000).
In 2000 Sumsion redefined client-centred practice by recognizing the need to relate the client-centred approach to the realities of clinical practice. In the preamble to the definition, success was placed firmly on knowing who the client was and recognizing the impact of resources on the process. This also reinforced some key elements of client-centred practice: namely, partnership, empowerment, engagement, participation and negotiation, all processes supported by active listening to, respect for and meeting the needs of clients to enable them to make informed decisions about their care.
This definition clearly shaped client-centred practice within the context of resource-limited health services but which still aspired to a working respect for and real partnership with people, whilst recognizing that many factors influenced its successful implementation.
To be comfortable using a client-centred frame of reference, the therapist should identify their own values and assumptions (Rebeiro 2000b) and check that they match the core values of client-centred practice: namely, respect, partnership and the ability to listen to the client. Essentially, the foundation of client-centred practice is the capacity of the therapist to view the world through the client’s eyes (Jamieson et al 2006). In order to achieve this, it is vital that therapists understand the key elements of this frame of reference.
Key elements of a client-centred frame of reference
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.
Respect and listening
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:
• ‘You must use your delta walker in the house or else you will fall and end up in hospital’ — a non-client-centred approach
• ‘You have told me you do not want to use your walking aid at home and I understand why, but I have concerns about your risk of falling. Have you thought about that?’ — a client-centred version.
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.
Definition of a client-centred frame of reference
A client-centred frame of reference is a framework that guides practice where the client is the focus of needs-led occupational therapy, delivered with respect and in partnership. In short: Think Person, Plan Practice.
Core beliefs of this frame of reference are:
• assumed values of respect, partnership and enablement
• a shared belief that the client is the centre of all therapeutic activity
• the client’s needs and goals directing how the occupational therapy process is delivered
• clinical reasoning and practice delivery structured to reflect those needs.
Applying the client-centred frame of reference in practice
In order to understand how to apply a client-centred frame of reference in practice, it is necessary to appreciate the complexity and challenges of such practice and demonstrate this with confidence (Chen et al., 2002 and Rebeiro, 2000a). Given that a frame of reference is there to provide structure to practice, it makes sense to consider how a client-centred approach can be applied throughout the occupational therapy process. A case example is used to illustrate this. Each stage includes questions to assist in the development of reasoning in the application of this frame of reference. It is also important that therapists and students have support, training and the opportunity for reflection in order to grasp the challenge of client-centred practice and to develop confidence and competence in its practice (Parker, 1995 and Lewin et al., 2008).
The occupational therapy process
For the purposes of this chapter, Foster’s occupational therapy process will be used (Foster 2002), namely:
• gathering and analysing data
• planning and preparing for intervention
• implementing intervention
• evaluating outcomes.
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).
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Referral, data-gathering and analysis
• To provide baseline information for assessment and intervention.
Data-gathering is continuous throughout the occupational therapy process and information is gained by assessment, observation, listening and analysis, all of which contribute towards the evaluation of progress and attainment of goals.
• Receiving a referral is the first information that the therapist has about a client.
• The referral itself may provide little information about the person and should act as a reason for contact rather than directing what must take place.
• Gathering of data may be indirect, noting information from the medical records, or direct, when first contact is made with the individual.
• All information gathered should be accurate and reliable, and must meet professional requirements by being documented within the records to provide an honest, contemporaneous record of the history of the client encounter.
How are referrals received? Does the occupational therapy service dictate who, when and how people are seen for occupational therapy or are users involved in that process? Can users self-refer? Do they have a choice?
• Review whether your service is clear about how people can access it.
• Change the process of referral, away from the traditional method of ‘medical referral’ by doctors, to a system based on client need or self-referral.
• Consult with and involve user representatives, to ensure their opinion influences how the occupational therapy service is delivered.
• Publicize how people can access occupational therapy by means of information leaflets, posters, website and audiovisual material.
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