Client-centred Occupational Therapy Practice Research Articles

Thinking critically about client-centred practice and occupational possibilities across the life-span

Background: Client-centred occupational therapy practice is tacitly guided by prevailing social values and beliefs about what are “normal” occupational possibilities. These values and beliefs privilege some occupations and negate others. Aim: This study aims to identify and problematize assumptions regarding the value of approximating normal occupational possibilities, showing how these assumptions influence and may diminish client-centred practice. Methods: Using empirical research examples it demonstrates how occupational therapists and clients are immersed in contexts that shape values and beliefs about what are considered “normal” occupations and how these taken-for-granted values structure occupational therapy practice. Conclusion: Critique of client-centred practice requires conscious reflexivity, interrogating our own and our clients’ predispositions to value some occupations over others. Engaging in critical reflexivity can help therapists develop new perspectives of how client-centred practice can be applied that includes enabling possibilities for occupations that would be missed altogether in the pursuit of “normal’.

Client-centred occupational therapy: the importance of critical perspectives

Background: The occupational therapy profession has proclaimed itself to be client-centred for over 30 years, but until recently this assertion remained largely unchallenged. Critical thinkers, who have begun to explore client-centred practice in occupational therapy, highlight the necessity for further critical reflection. Aims. This paper aims to define what constitutes “critical” thinking; and to persuade occupational therapists of the importance of employing critical perspectives towards the profession’s assumptions and assertions regarding occupational therapy’s “client-centred” practices. Major findings. Critical thinking is not solely a process of carefully and thoughtfully weighing various arguments or evidence, but of additionally appraising the ideological and structural contexts in which these positions or evidence have arisen. Critical perspectives towards occupational therapy’s client-centred practices identify the ways in which power is exercised by the profession, and culturally specific and disabling ideologies are perpetuated. Practice conclusion. Critical thinking enables occupational therapists to reflect on their own inequitable access to privilege and power, and reduces the potential for the profession to re-inscribe dominant ideologies that devalue disabled people and justify their inequitable opportunities. Because critical thinking demands a readiness to restructure one’s thinking, and decreases the risk of acting on faulty assumptions, it is an essential component of client-centred practice.

Client-centred practice in occupational therapy: Critical reflections

Aims: The occupational therapy profession has long proclaimed its commitment to a client-centred philosophy of practice and the assumption that occupational therapists consistently practice in a client-centred manner has become central to the profession's self-image and public rhetoric. However, client-centred practice has been subjected to little critical reflection within the occupational therapy profession. The aim of this paper is to foster critical reflection concerning the authenticity and veracity of the profession's commitment to client-centred practices. Major findings: Client-centred practice is defined without evident reference to clients' perspectives. Few occupational therapy researchers have sought clients' perceptions of the client-centred nature of their occupational therapy services. Occupational therapy research is neither consistently undertaken in a collaborative manner, nor are the profession's theories developed through explicit reference to a diversity of clients' perspectives. Professional practices and service evaluations do not consistently seek clients' viewpoints. Client-centred rhetoric is politically expedient and may be a professionalizing strategy employed to increase status and entrench power. Practice conclusion: Although exemplary client-centred occupational therapy practices exist, evidence suggests that the profession does not adhere consistently to its espoused client-centred principle in all its practices. The client-centred practice of occupational therapy should be subjected to assiduous critical reflection.

Religious and/or Spiritual Practices: Extending Spiritual Freedom to People with Schizophrenia

It continues to be a challenge to define and utilize spirituality in client-centred occupational therapy practice. Dialogue about spirituality is especially problematic for occupational therapists working with people with schizophrenia. To explore the meaning of religion and/or spirituality for people living with a diagnosis of schizophrenia. Nine community-based individuals with schizophrenia engaged in interviews about the meaning of religion and/or spirituality and demonstrated self-defined spiritual practices. Phenomenology, hermeneutic theory, and a symbolic interactionism framework provided methodological and analytic guidance. Participants employed religious and/or spiritual practices to cope with schizophrenia symptoms and make meaning of their lives. Individuals used multiple systems of meaning to explain their experiences. Religious and/or spiritual agency, an individual's sense of freedom to choose among the spiritual options, renewed their sense of empowerment. Therapists can engage in spiritual negotiation with clients by using well-worded empowering questions toward a common goal of life enhancement.

Information Used by an Expert Paediatric Occupational Therapist When Making Clinical Decisions

Occupational therapists use a range of types and sources of information when making clinical decisions. It is unclear how this information is integrated. This paper describes an exploratory qualitative case study that identified the types and sources of information accessed by one experienced paediatric therapist and how this information was combined and prioritised when making clinical decisions. . Data were collected using observations of therapy sessions, key informant interviews, and semi-structured interviews. Data were analysed thematically. To inform clinical decisions, the participant prioritised information about each child in his or her context when making decisions. Other types of information from text books and journals, professional development activities and professional and personal experience, expanded her unique body of knowledge over time. Re-conceptualisation of how information use supports clinical decision making and expands a therapist's unique body of knowledge over time can support client-centred practice in occupational therapy.

Older persons’ navigation through the service system towards home modification resources

Home modifications are part of the occupational therapy interventions provided to persons with functional limitations in the home environment. Home modification services often involve many different actors, and persons experiencing a need for home modifications have to navigate through a network of service organizations and professional actors. The aim of this study was to explore and describe how older adults in one Swedish municipality tried to find their way and navigate through the service system in order to receive home modification services that could meet their experienced needs. A case study design was used, including four older adults with different experiences and expectations of home modification services. The relationship between the participants’ expectations, experiences, and their ways to navigate through the service system was described through the metaphor of a “geographical map”. Satisfaction with the service process was found when there was a match in understandings of responsibilities and eligibility between what could be read from the older persons’ map and the professionals’ perspective. The findings have implications for client-centred occupational therapy practice, indicating that this match can be achieved when professionals translate clients’ experienced problems in everyday life into a terminology that fits into the service system.

Implementing client-centred practice: why is it so difficult to do?

This paper explores the challenges of implementing client-centred occupational therapy practice. While many occupational therapists believe in the principles of client-centred practice and espouse them, it seems much more difficult to implement these into everyday practice. Findings from three qualitative studies with three different populations (i.e., family-centred care for children and their families, community-based home care, facility-based care for older adults) are used to illustrate the challenges which are divided into three broad categories: challenges at the level of the system, at the level of the therapist and at the level of the client. Suggestions for change at each level are addressed. Organizations, therapists and clients must work together to facilitate these changes and ensure that each occupational therapy client receives respectful, supportive, coordinated, flexible and individualized service.

Client perspectives on occupational therapy practice: are we truly client-centred?

In Canada, the guidelines for the practice of occupational therapy are named and framed as client-centred. Two in-depth interviews were conducted with clients of mental health services about their experiences with a hospital-based occupational therapy service. These occupational therapy clients described their experiences as prescriptive, and as less than client-centred. With the publication of Enabling occupation: A Canadian occupational therapy perspective (Canadian Association of Occupational Therapists [CAOT], 1997) and an increasingly refined focus on being client-centred, these interviews highlight the challenges of a client-centred practice within the current health care environment. These occupational therapy clients raise issues of importance for occupational therapy. The participants stated that the prescription of 'activity', a lack of choice, and a focus upon the illness as opposed to the individual, served to diminish any collaborative partnership with the client and eliminate the client from any decision-making process. This distancing from the client, in their opinion, served to greatly diminish any therapeutic value of occupation. The participants recommended a greater focus upon occupational choice, consideration of the individual within the client, providing accepting, supportive environments, and using professional expertise on occupation to guide the client towards participation in meaningful occupation. These recommendations are strikingly similar to the most recent guidelines for the client-centred practice of occupational therapy in Canada. A discussion of the implications of these findings for the client-centred practice of occupational therapy is offered.

A Study to Determine a British Occupational Therapy Definition of Client-Centred Practice

This paper presents the results of a study that used the Delphi technique to create a draft definition of client-centred practice in occupational therapy. A brief literature review of the issues related to the Delphi technique is followed by details about the 64 therapists who participated in the four rounds of this study. They represented a range of geographical areas and areas of practice.In round one, the participants were asked to add items to or eliminate items from a list of components of client-centred practice chosen from the literature. These components related to the client, the therapist and client-centred practice in general. These items were placed in rank order in round two and further reviewed in round three. Round four provided the opportunity to comment on the first draft of the definition.Information is provided about the analysis of the results in each round. The resulting second draft of the definition is presented in the paper along with a discussion of the limitations of the study.

The Construction of Family Occupations: A Study of Families with Children Who Have Attention Deficit/Hyperactivity Disorder

Families are the main caregivers of children who have special needs and are essential in the client-centred occupational therapy practice. They also provide the immediate social and cultural environments of their children who have special needs. A qualitative study of daily experiences and adaptations of 17 families with children who have attention-deficit/hyperactivity disorder is described in this paper. The analysis of interviews with parents revealed that they developed and used strategies to enable their children' occupational competence. Further, whenever parents reported on the success of these strategies, they also described changes in the daily routines of other family members. The interactions between these enabling strategies and the daily routines of family members are presented and discussed in this paper.

Client-centred practice: what does it mean and does it make a difference?

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.

Involving clients in programme evaluation and research: a new methodology for occupational therapy.

Eliciting client satisfaction with services has become common in mental health settings and in the planning of service delivery systems. It is also compatible with the client-centred practice of occupational therapy. The traditional approach to collecting satisfaction information involves staff interviewing clients using questionnaires developed by staff. However, there is often a lack of variability in responses and the vast majority of clients report being satisfied. A review of the literature reveals that these favourable reports may be a result of social desirability and of clients being interviewed by treatment providers who have the power to give or withhold care. This paper reviews the relationship between occupational therapy and client involvement, examines the rationale for involving clients in programme evaluation and research, reviews the limitations with traditional methods of collecting information about client satisfaction, and discusses how clients are involved in evaluation and research in today's mental health care setting.

Client-centered practice: the true impact.

1993 marks the tenth anniversary of the release of the Guidelines for the Client-Centred Practice of Occupational Therapy which are now central to many clinical programmes and evaluation tools. This discussion paper presents some questions about how the model of client-centred practice is being applied by occupational therapists, and asks whether or not therapists clearly understand the implications of the model. The advantages of this model, such as the ability for the diverse definition of the term "client", its applicability to community practice, and the presentation of therapeutic challenges, are discussed. The author also provides her opinion about how the truly client-centred process should be applied.

Occupational Performance of Activities of Daily Living among Elderly Canadians in the Community

Sociocultural role expectations for occupational performance by individuals and groups differentiated on the basis of age, gender, and other social characteristics are of central interest to occupational therapy practice based on the occupational performance model. Data analysed from the public use microdata file of the 1985 General Social Survey of Canadians reveal important differences in social role expectations and patterns of occupational performance among a representative sample of elderly Canadians (N=3,130), as evidenced by their social support for certain activities of daily living. Significant gender and age differences are identified in the types and sources of social support provided and received, with elderly men much more likely than elderly women to receive help with housework, meal preparation, and grocery shopping. Such information contributes to the development of a broad national context for the client-centred practice of occupational therapy with elderly Canadians, and points to the need for further research on sociocultural influences on occupational performance across the lifespan.

Occupational performance measures: a review based on the guidelines for the client-centred practice of occupational therapy.

In 1987, Health and Welfare Canada and the Canadian Association of Occupational Therapists Task Force recommended that work go forward to develop an outcome measure for occupational therapy which reflects the Occupational Performance Model. The first step in this process was to review critically those outcome measures which assess occupational performance and that are currently available in the literature. This paper will present the review process, describe in more detail eight assessments that fulfilled many of the review criteria, discuss the limitations of these measures using the "Guidelines for the Client-centred Practice of Occupational Therapy as the framework, and make recommendations for the development of a new outcome measure for use in occupational therapy.

Quality assurance: the current challenge.

Occupational therapists are being challenged to measure and evaluate the care provided to their patients. This paper discusses the various stages of development of a quality assurance program within a large pediatric occupational therapy department. Several quality assurance activities undertaken are described, including the development of standards of clinical practice (based on the "Guidelines for the Client-Centred Practice of Occupational Therapy") and the development of assessment and documentation protocols. Outcome measurement in pediatric occupational therapy is addressed in relationship to the process measures which were developed in the department. The approaches to outcome measurement are outlined within the context of an audit attempting to evaluate the effectiveness of occupational therapy intervention based on five areas of evaluation.

Developing guidelines for client-centred occupational therapy practice.

The Canadian Guidelines for the client-centred practice of occupational therapy are national, generic, consensus guidelines developed to address growing concerns inside and outside the profession for assuring the quality of health services. From 1979 to 1987, successive Task Forces, sponsored by the Department of National Health and Welfare and the Canadian Association of Occupational Therapists, developed three volumes of guidelines. A pivotal guideline in Volume I is a conceptual framework of occupational therapy's central concern: occupational performance within an individual's physical, cultural and social environment. Volume I also outlines stages in the process of client-centred occupational therapy practice, and specific assessment and program planning guidelines. Volume II covers issues, concepts and fundamental elements of intervention, as well as specific guidelines for intervention, discharge, follow-up and evaluation. Volume III reviews issues in outcome measurement given occupational therapy's primary concern for occupational performance. The authors, members of the Task Forces, provide an overview of the development of and their hopes for the Guidelines. Uses and influences of the Guidelines have not been formally documented. However, projects are arising from the Guidelines and a new CAOT Client-Centred Practice Committee is proposing an updating process for the three volumes.

The Application of the Client-Centred Approach to School-Based Occupational Therapy Practice

The Guidelines for the Client-Centred Practice of Occupational Therapy (Department of National Health and Welfare and Canadian Association of Occupational Therapists, 1983) have been successfully applied to various institutional and community settings. However one of the most challenging appears to be the application to school-based practice. In this article the conceptual frame of reference and the practice stages in the occupational therapy process are directly applied to school settings. Philosophical differences are apparent and these are likely influencing the development of occupational therapy services in schools. A case study is used to illustrate some of the issues andthe preparation of guidelines for school-based occupational therapy services is recommended.

Application of the guidelines for client-centred practice to paediatric occupational therapy.

This paper outlines the process of incorporating the "Guidelines For the Client-Centred Practice of Occupational Therapy" into the practice of occupational therapy in an out-patient rehabilitation facility serving young people with physical disabilities. Specifically, the areas of practice addressed are screening and assessment. The process started in 1987 with an identification of the need to find a holistic framework that meets the complex needs of clients with chronic physical disabilities. The conceptual model of occupational performance, as outlined in the Guidelines, provided such a framework. The process of incorporating the Guidelines into the screening and assessment practices of occupational therapists at Erinoak Serving Young People With Physical Disabilities is described, with examples of documents developed by the department. Suggestions are given to integrate the conceptual model of occupational performance into the practice of occupational therapists working with children and adolescents with physical disabilities.

Using the World Health Organization's International Classification of Impairments, Disabilities, and Handicaps in Occupational Therapy

Health status, although commonly defined in terms of the presence or absence of disease, can also be defined in terms of performance or functional status. Loss of performance results in disablement. The authors summarize the conceptual framework and categorization in the World Health Organization's International Classification of Impairments, Disabilities and Handicaps (ICIDH) (1980) and the Model of Occupational Performance in the Guidelines for the Client-Centred Practice of Occupational Therapy (Health and Welfare Canada and the Canadian Association of Occupational Therapists, 1983; 1986). Complementary elements of the ICIDH and the Model of Occupational Performance appear to be recognition that performance is an element of holistic health influenced by the social, physical and cultural environment. Also, the ICIDH categories of disablement appear to be conceptually mirrored in the model's categories of occupational performance. The authors use client and service data to illustrate three uses of the ICIDH in occupational therapy: communication with other health professionals; program planning and management; and, clinical evaluation and research.