Who are we trying to convince? A reflection on client-centred practice

Over the last 18 months, I’ve been through somewhat of a professional identity modification. What I thought I knew was challenged, changed, re-challenged, changed and challenged again.

This has left me curious mind to question every part of my profession and slowly evaluate what, if any, part each piece of knowledge plays in our professional paradigm.

Throughout this year I’m going to use this forum to publically brainstorm some of my pontifications. I’d love to hear your thoughts, inputs or opinions either in the comments or via the contact me page.

The first one I’d like to have a look at is Client-Centred Practice (CCP)and how our profession sits within that on paper and in reality. Bear in mind that my opinion is just that, my opinion and that my opinion is based on my interpretation if my life experiences and therefore is not a direct translation to everyone or anyone’s own experience.

I’ve been thinking a lot in the last 6 months or so about client-centred practice, how does it work, how should it work and how should this affect how an OT practices.

Most people I’ve talked to think they get what CCP is. “It’s when u work inclusively with the client.” See, simple…… or is it? There’s been a bit of research and papers around client-centred practice (mostly coming out of Canada) and most of it follows the same themes.

Lots of research has been done to define what client-centered practice is, developing guidelines, policies, including it in codes of ethics and models of service, but, very little has been done to look at just how aligned is our actual clinical practice with all of this “definition” research. A common story in OT right? :p

Wilkins, Pollock, Rochon & Law (2001) looked at why this might be the case and provided some recommendations for implementing and/or evaluating a clinicians use of client-centered practice. They cited a study by Sumsion, Smyth (2000) which was looking at perceptions of therapist boundaries to client-centred practice. They found that:

“The three highest rated barriers were related to goals and goal setting: the therapist and client have different goals, the therapists’ values, and beliefs prevent them from accepting the clients’ goals, and the therapist is uncomfortable letting clients choose their own goals (p. 19).

Another paper they looked at by Rebeiro (2000) looked at CCP from the consumers perspective. She found that the participants’ ideas around CCP were not reflected in the Occupational Therapy Service they had received.

“They perceived the occupational therapy environment as contrived and as limiting choices and opportunities for exploring personally meaningful occupation. A focus upon the illness rather than the individual served to diminish any partnership between the client and therapist and exclude the client from decision-making processes.” (Rebeiro, 2000)

As a complete side note, Rebeiro did mention one thing which is something I have been saying (to much confusion and bewilderment from colleges) for some time, “promotion of client-centred occupational therapy may be more possible outside of the medical model and within the framework of health promotion and wellness models.”

Another interesting study that Wilkinson et al (2001) looked at was one by Cooring (1999) who was also investigating the correlation between what clients expected of CCP and what they actually received but specifically within a Mental Health setting. Three main themes were identified by the clients with regards to the client/service provider relationship.

“qualitative study of people with mental illnesses identified three main themes: the client in the client/service provider relationship; the client in the social and mental health system; and client-centred care means I am a valued human being.” (Cooring, 1999)

With regards to the Client/service provider relationships as well as within the MH system, the participants reported “negative attitudes and stigma, an indifference to them as human beings, a status differential between themselves and service providers, a lack of trust,and the use of intervention techniques that did not meet client needs.” (Cooring, 1999)

The issues identified then translated into, “fear of hospitalization, fear of anger from service providers if they complained, and fear of their illness; disillusionment with service providers; poor self-esteem; and feelings of marginalization.”(Cooring, 1999)

The third theme, the “need to be perceived as a valued human being, to be recognized as having strengths and short-comings and to be considered worthwhile,”  is a principle embraced in nearly every definition of CCP. Cooring (1999) found, however, that “the participants clearly reported on experiences which were not very client-centred.”

A paper by Gerteis, Edgman-Levitan, Daley, & Delbanco (1993) reported that, “health care routines and technologies often require patients to be passive and submissive and that any attempts at assertiveness or control are considered to be disruptive by health care providers.” They argued that often behavior that was not seen as ‘towing the line’ would land the client with a label such as “non-compliant”.

So a lot of the evidence out there is pointing to the fact that:

YES, Client-centred practice is very important and has been included as a staple in most models of practice and codes of conduct etc.YES, It is important that we have a definition of what CCP actually is before we can do it
and… (i believe) YES CCP is the future of MH care.

BUT (there’s always a “but”)

Every paper I have read, that was about research aimed at creating a definition of CCP, used therapists as the subjects….not clients. Every paper that did ask clients what their expectation was of CCP was for the purpose of comparing it to the individuals’ experience of services received….and there was ALWAYS a massive difference between the two.
Every OT I’ve talked to feels they are already using CCP because they “asked the clients what their goals are” or “let them choose” between two treatments.

So if the evidence clearly points to the fact that what a client expects from CCP and what they are actually getting from therapists is VASTLY different then would it not stand to reason that possibly how “over 130 therapists” define CCP and how a client might define it would also be quite different? (Sumsion, 2000)

Then I was struck by a thought. It is possible that there are other terms that we are perhaps misguidedly grouping under the guise of ‘Client-Centred Practice’?

Professor Anne Fisher published an article in the 2013 Scandinavian Journal of Occupational Therapy that talks about the difference between “occupation-centered, occupation-based and occupation-focused” practice.  It raised some very valid points, one being that often people use these terms interchangeably when they may well be vastly different. So what if we sub out “occupation” and sub in “client”? Client-centred, client-based, client-focused interventions? Are they interchangeable? or are they all different things? What about”client driven?” would that fit under one of the previous three or is it something different again. Food for thought?

I feel that Occupational Therapists all too often bandy about terms without actually having a good understanding of what they are or how they affect clinical practice. e.g. “Occupation”.
I will admit that I don’t think this is a trend exclusive to OT as can be evidenced when looking at the use and understanding of “Recovery.”
Mental Health care has come a very long way in a very short period of time and has the hints of the early stages of another paradigm shift, but it will take time. Much more research needs to go into what actually is CCP and how it can be implemented, but I believe that this needs to be from the clients perspective.

References
Corring, D. (1999). The missing perspective on client-centred care. Occupational Therapy Now, 1(1), 8-10.

Fisher, AG. (2013) Occupation-centred, occupation-based, occupation-focused: same, same or different? Scandinavian Journal of Occupational Therapy. 20(3):162-73

Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T. (Eds.). (1993). Through the patient’s eyes: Understanding and promoting patient-centered care. San Francisco: Jossey-Bass.

Rebeiro, K. (2000). Client perspectives on occupational therapy practice: Are we truly client-centred? Canadian Journal of Occupational Therapy, 67(1):7-14

Sumsion, T. (2000) A Revised Occupational Therapy Definition of Client-Centred Practice. British Journal of Occupational Therapy, 63(7):304-309

Wilkins, S. Pollock, N. Rochon, S and Law, M. (2001) Implementing Client-Centred Practice: Why is it so Difficult to Do? Canadian Journal of Occupational Therapy, 68(2):70-79