Canadian Journal of Occupational

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Implementing Client-Centred Practice: Why is it so Difficult to Do?

Seanne Wilkins, Nancy Pollock, Sarah Rochon and Mary Law
Canadian Journal of Occupational Therapy 2001 68: 70
DOI: 10.1177/000841740106800203

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

• SEANNE WILKINS • NANCY POLLOCK • SARAH ROCHON • MARY LAW

KEY WORDS Seanne Wilkins, Ph.D., OT(C), Sarah Rochon, M.Sc.(T), BSc(OT)
is Assistant Professor, School of is Professional Associate (Honourary
• Canadian Occupational Performance Measure Rehabilitation Science, Lifetime), School of Rehabilitation

• Client-centred practice, occupational McMaster University, IAHS, Science, McMaster University,

4th floor, 1400 Main Street West,
therapy
Hamilton, Ontario, L8S 1C7
• Professional practice E-mail: swilkins@mcmaster.ca
Nancy Pollock, M.Sc., OT(C)
is Associate Clinical Professor,
School of Rehabilitation Science,
McMaster University, Hamilton,
Ontario
Hamilton, Ontario
Mary Law, Ph.D., OT(C) is Professor
and Associate Dean, School of
Rehabilitation Science, and
Co-Director, CanChild Centre
for Childhood Disability Research,
McMaster University, Hamilton,
Ontario

ABSTRACT RÉSUMÉ
70
This paper explores the challenges of implementing Cet article examine les enjeux de la mise en oeuvre de la pratique de
client-centred occupational therapy practice. While many l’ergothérapie centrée sur le client. Bien qu’un grand nombre
volume 68 • issue 2

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.
d’ergothérapeutes adhèrent aux principes de la pratique centrée sur le
client, il semble qu’il soit plus difficile de les mettre en oeuvre dans la
pratique quotidienne. Les résultats découlant de trois études qualitatives
menées auprès de trois populations (c’est-à-dire, soins centrés sur la
famille pour les enfants et leur famille, soins à domicile à base
communautaire et soins aux personnes âgées en établissement) sont
utilisés pour illustrer les enjeux qui sont répartis en trois grandes
catégories : enjeux à l’échelon du système, à l’échelon de l’ergothérapeute
et à l’échelon du client. Les changements proposés à chaque échelon sont
examinés. Les organisations, les ergothérapeutes et les clients doivent tra-
vailler ensemble pour favoriser ces changements et veiller à ce que
chaque client reçoive des services d’ergothérapie respectueux, positifs,
coordonnés, souples et personnalisés.

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he purpose of this paper is to explore the challenges of
T implementing client-centred occupational therapy prac-
tice. As Sumsion (1993) noted, despite the introduction of
the Guidelines for client-centred practice of occupational
therapy in 1983 (Department of National Health & Welfare &
Canadian Association of Occupational Therapists [DNHW &
CAOT], 1983), the integration of client-centred occupational
therapy practice remains a difficult task. While many occupa-
tional therapists believe in the principles of client-centred
practice and espouse them, it seems much more difficult to
implement these into everyday practice. Over the more than
15 years, there have been many developments in the
theoretical aspects of client-centred practice yet a gap
appears to persist between theory and practice.
We will discuss some of the challenges in implementing
client-centred practice using results from three different
studies in which we have been involved. One study involved
implementation of family-centred service for children’s
rehabilitation centres (Law et al., 1997).The other two studies
involved initiation of the use of the Canadian Occupational
Performance Measure (COPM) (Law et al., 1991, 1994), an
outcome measure based on the Canadian client-centred
model of practice and a tool that facilitates this practice
model. One study was conducted in an agency providing
community based services (Rochon et al., 1996), the other in
a facility providing various levels of care for older adults
(Wilkins & Mitra, 1994).
What is client-centred practice?
The term client-centred practice was first used by
Rogers (1939) in describing a practice focussed on enabling
individuals to find solutions in a nondirective manner. While
the 1983 guidelines for occupational therapy outlined the
process of client-centred care, client-centred practice itself
was not defined (DNHW & CAOT, 1983). The first definition of
client-centred practice in the Canadian occupational therapy
context was introduced by Law, Baptiste and Mills (1995) as
an approach to service which embraces a philosophy of
respect for, and partnership with, people receiving
services. Client-centred practice recognizes the autono-
my of individuals, the need for client choice in making
decisions about occupational needs, the strengths
clients bring to the therapy encounter, the benefits of
client-therapist partnership and the need to ensure that
services are accessible and fit the context in which the
client lives. (p. 253).
The current definition used in the Canadian guidelines
explicitly includes clients at various levels. Client-centred
practice is defined as
collaborative and partnership approaches used in
enabling occupation with clients who may be individu-
als, groups, agencies, governments, corporations or
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Wilkins et al.
others; client-centred occupational therapists demon-
strate respect for clients, involve clients in decision
making, advocate with and for clients’ needs, and other-
wise recognize clients’ experience and knowledge.
(Canadian Association of Occupational Therapists
[CAOT], 1997, p. 180)
After a review of available models of client-centred
practice, Law (1998) has identified the following concepts as
common to models of client-centred occupational therapy
practice:
"
Respect for clients and their families, and the choices
they make.
Provision of information, physical comfort, and emotion-
"
al support with an emphasis on person-centred
communication.
"
Facilitation of client participation in all aspects of
occupational therapy services.
"
Client and families have the ultimate responsibility for
decisions about daily occupations and occupational
therapy services.
"Flexible, individualized occupational therapy service
delivery.
"Enabling clients to solve occupational performance
issues.
"
Focus on the person-environment-occupation relationship.
Literature review
Despite the centrality of the client in a client-centred model
of practice, there has been little work done to identify clients’
expectations of client-centred practice. Three notable excep-
tions are the work of Gerteis, Edgman-Levitan, Daley, and
Delbanco (1993) and, relative to occupational therapy,
Corring (1999) and Rebeiro (2000). The work of the 71
Picker/Commonwealth Program for Patient-Centered Care is
volume 68 • issue 2
described in a book entitled Through the patient’s eyes
(Gerteis et al., 1993). Established in 1987, this program is a
collaboration between Beth Israel Hospital in Boston and the
Harvard Medical School, with the goal of promoting an
approach to hospital and health services which considers the
patients’ needs and concerns as they define them. Through
focus groups and discussions with recent patients and with
service providers, the researchers identified seven
dimensions of patient-centred care: respect for patients’
values, preferences and expressed needs; coordination and
integration of care; information, communication and
education; physical comfort; emotional support and allevia-
tion of fear and anxiety; involvement of family and friends;
and transition from hospital to community and continuity of
care over time.
Recently in the occupational therapy literature, more
attention has been given to the clients’perspectives (Corring,
1999; Corring & Cook, 1999; Rebeiro, 2000). Corring’s
CANADIAN JOURNAL OF
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 Wilkins et al.
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. In the clients’ relationships with service providers as
well as within the social and mental health 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. The effects of these on the clients were 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 marginal-
ization. Finally the third theme was related to the need to be
perceived as a valued human being, to be recognized as
having strengths and short-comings and to be considered
worthwhile. This last theme is a principle espoused in every
definition of client-centred practice, however, the partici-
pants clearly reported on experiences which were not very
client-centred.
Rebeiro (2000), in her discussion of two in-depth
interviews with consumers of mental health services,
identifies four themes which reflect the participants’ ideas
about client-centred practice: the provision of an accepting,
supportive environment; the provision of choice; the
provision of personally meaningful occupation; and
recognition of the individual within the client. Although
these themes reflect components of client-centred
occupational therapy, her participants had different
experiences in occupational therapy. They perceived the
occupational therapy environment as contrived and as
limiting choices and opportunities for exploring personally
72 meaningful occupation. A focus upon the illness rather than
the individual served to diminish any partnership between
volume 68 • issue 2
the client and therapist and exclude the client from
decision-making processes. Rebeiro argued that 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.
Most of the work on client-centred occupational
therapy practice has been done at the level of the therapist.
What difficulties arise for the therapist in the implementation
of a client-centred approach to occupational therapy?
Toomey, Nicholson and Carswell (1995) identified barriers
when a home care organization decided to utilize the
Canadian Occupational Performance Measure (COPM) (Law
et al., 1994). The COPM, which is based on the conceptual
model of occupational performance presented in the
guidelines for client-centred practice (DNHW & CAOT, 1983,
1986, 1987), provides occupational therapists with a tool for
measuring the outcomes of occupational therapy
interventions. The focus of the COPM is on the goals of the
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recipient of the services relative to occupational
performance and embodies the concepts inherent in
client-centred practice.The study by Toomey et al. (1995) was
designed to investigate the utility of the COPM, however it
also identified some challenges related to the adoption of a
client-centred practice model. Some therapists found the
tool useful while others did not. The authors hypothesized
that this difference may reflect resistance to adopting a new
theoretical model. They concluded that if a therapist was
comfortable with the client-centred approach, the COPM
facilitated that approach. It helped clarify the role of
occupational therapy. They recommended that therapists
need to act as collaborators and teachers, educating clients
about how the therapeutic process works and how clients
can take control of that process.
Sumsion and Smyth (2000), in a study of occupational
therapists in the United Kingdom, identified participants’
perceptions of therapist barriers to client-centred practice as
well as methods of resolving barriers. A questionnaire
including barriers and resolutions drawn from the literature
was completed by 36 participants. 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). The highest ranking methods to resolve
barriers included: case examples showing how to practice in
a client-centred fashion, management and peer support for
the use of client-centred practice, involvement of all staff in
client-centred practice, and staff education time to learn how
to practice in a client-centred fashion (p. 19). The researchers
concluded that, given the difficulties around goal setting,
therapists should explicitly check the congruity of their goals
with clients and foster enabling, client-centred attitudes.
Lawlor and Mattingly (1998) describe some of the
challenges inherent in adopting a family-centred model of
practice. Based on their ethnographic research, they believe
that people underestimate the degree of change required by
both practitioners and families to implement a family-
centred model. Some of the difficulties are related to the
culture within which health practitioners are educated and
the systems within which they practice. "Even when a
practitioner and family member are eager to create an
effective partnership, the way practice is traditionally
structured, particularly within institutional cultures, can make
such a partnership difficult to form" (p. 261).
There has also been some interesting work on client-
centred practice conducted by other health providers.
Clemens, Welte, Feltes, Crabtree, and Dubitzky (1994)
conducted a qualitative study with case managers (nurses
and social workers) to determine to what extent case
managers’ statements of client-centred theory were reflected
in self-reports of their practice. They identified a recurrent
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theme of contradictions between client-centred theory and
directive practice. On one hand, there were statements that
were consistent with the philosophy of client-centred care
but on the other hand, there were contradictions between
statements of theory and reported practice. These latter
contradictions were most likely to occur with more challeng-
ing clients including those with questionable competencies;
those who were competent but living alone and refusing
care; those who were competent but unsafe and refusing
placement; and those who were in disagreement with their
families.The inconsistencies arose in what the case managers
said they did in general and in what they reported they did
with specific clients in practice. Conflict arose with the case
manager’s perception of the client’s best interests and safety;
with competing pressures of heavy case loads; with gate-
keeping responsibilities to determine eligibility for public
resources; with obligations to protect client safety; and with
being caught in the middle of the wishes of the clients and
family concerns about safety.
While the studies described above have touched on the
challenges at the contextual or organizational level, less work
has been done in this area. Without the support of the
environment it may be very difficult for a therapist to prac-
tice in a client-centred way. While much of the work of
Gerteis et al. (1993) deals with the challenges of providing
patient-centred care at the level of the health care provider,
they raised some important contextual issues. They argued
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. This disruptive behaviour often results
in the patient being labelled as non-compliant. In contrast,
they suggested that clients’ needs and circumstances should
be considered on an individual basis. Clients need to be
taught negotiation strategies through patient education so
that they might be empowered to discuss issues with health
care providers. Relative to the organization, they focused on
the need for the organization to be staff-centred as well as
patient-centred. They discussed the organizational culture
which includes a philosophy that shapes relationships
among employees and clients, norms that govern behaviour,
values that members share, rules of the game and the
climate or feel of the organization. Culture is hard to change;
it evolves over time. Becoming client-centred requires more
than a declaration from administration. It must be a genuine
part of the values held by everyone within the organization.
From this literature review, it is evident that while one
may support the principles of client-centred practice and
intend to practice in a client-centred way, there are still
obstacles to implementation of a client-centred approach to
occupational therapy practice. Through the data collected in
three studies, we will explore the challenges of implement-
ing client-centred occupational therapy at the level of the
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Wilkins et al.
system, the therapist, and the client. We will then present
strategies for change that might assist occupational
therapists in making the transition from theory to practice.
Methods
We will be using findings from three studies as the basis for
discussing challenges or barriers to client-centred
practice. Each study is described briefly.
The first study was completed to obtain service
providers’ perspectives about implementation issues sur-
rounding family-centred service in children’s rehabilitation
centres in Ontario, and to identify challenges, supports, and
other important issues encountered by service providers in
implementing Family-Centred Service (FCS). Family-centred
service is a philosophy of service delivery built on a partner-
ship between service providers and families (Hostler, 1994).
Similar to client-centred occupational therapy practice,
important assumptions underlying family-centred service
are 1) parents know their children and want the best for their
children, 2) all families are different and unique, and 3) opti-
mal child functioning occurs within a supportive family and
community context (Rosenbaum et al., 1998). Children’s
rehabilitation services had made a commitment province-
wide to implement family-centred services. A qualitative
research methodology was used to conduct in-depth
interviews with 13 service providers from seven children’s
rehabilitation centres. Service providers were selected using
a purposeful sampling strategy, focused on obtaining
interviews from both service providers and managers.
Participants from both small and large centres were
included, and participants had a range of years of experience
working in children’s rehabilitation. For the interviews,
probes were developed focussing on gaining an under- 73
standing of the participants’ perceptions of family-centred
volume 68 • issue 2
service, how family-centred service was being implemented
at their centres, and discussing supports, challenges and
issues related to the implementation of family-centred
service.
The second study involved an occupational therapy
agency providing Community-Based Service (CBS) in its deci-
sion to introduce the COPM to be used for a trial period
instead of the routine protocol for assessment of new clients
(Chiu & Blumberger, 1997). In partnership with the authors, a
qualitative research project was conducted examining the
philosophies of practice espoused by the clinicians and the
relationship between these philosophies and the level of
comfort with the use of the COPM (Rochon et al., 1996) . The
occupational therapists, who agreed to participate (n=10),
initially wrote a metaphor to describe their practice. They
were then interviewed individually and encouraged to
expand on the ideas in the metaphor and to reflect on what
these ideas meant about their views of clients and the
CANADIAN JOURNAL OF
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 Wilkins et al.
process of therapy. Following a training workshop conducted
by one of the COPM authors, the COPM was introduced and
each therapist completed it with 10 clients. A follow-up
interview was conducted to determine the impact the use of
the COPM had on their practice.
The third study was conducted with occupational
therapists working in a large facility providing various levels
of care for older adults-Older Adult Service (OAS) (Wilkins &
Mitra, 1994). The purpose of the study was to examine the
process of implementing the COPM within the facility. The
questions guiding the research were: Does the use of the
COPM make practice more client-centred than the usual
practice within the facility? Do occupational therapists report
a subjective change in their practice with the introduction of
the COPM? Are there barriers to using the COPM within the
facility? Nine occupational therapists working in various
levels of care within the facility were interviewed about their
current practice (the process, the theoretical framework used
and any contextual constraints). A training workshop was
given by one of the authors of the COPM. The occupational
therapists then began using the COPM with their clients,
completing evaluation sheets on issues related to using the
COPM with their clients. They also participated in focus
groups centred on how the utilization of the COPM was
going, and situations in which it worked well or did not work.
During the final phase of the project the occupational
therapists were interviewed again regarding how their
practice had changed or stayed the same over the course of
the study.
Analysis
All interviews in the three studies were audiotaped and
transcribed for textual analysis.The transcripts for each study
74
were reviewed by the respective researcher(s) independent-
ly (ML=FCS; SR, NP, SW & ML=CBS; SW=OAS). Thematic codes
volume 68 • issue 2
were developed to identify emerging themes and issues
within and across the studies. Discussion by all researchers
followed to ensure that the major themes were representa-
tive of the three studies.
There is an important distinction that must be made
between the FCS and the CBS and OAS. In the latter two
studies, the COPM was being introduced to facilitate a
change within each service in order to evaluate the
outcomes of occupational therapy interventions, while in the
FCS the discussion was still at a theoretical level.
Findings
Challenges in implementing client-centred practice were divided
into three broad categories:challenges at the level of the system,
at level of the therapist,and at the level of the client.Each of these
will be discussed. Within each of these categories, common
themes will be illustrated with quotations from interview data.
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At the level of the system
Support for client-centred practice
Participants suggested that, in order for a service to be truly
client-centred, there needed to be a commitment from all
levels of the organization. In the FCS, participants felt
strongly that a participatory process of change, in which
management and front-line staff worked together with
families in implementing change, was most effective. In such
a participatory process, both parents and service providers
felt more freedom to express issues, needs and concerns. An
initial focus on attitudes and beliefs, and enabling service
providers to feel proud of what they do, appears to have
made a difference in the change process. There was an
increased focus on communication within the centre and
with families.
We’re trying to set the tone right at the beginning, a sense
of we’re going to do this together. (FCS)
Especially in times of diminishing resources, when we are
going to have to make some hard choices, the families are
the ones that are going to be able to tell us what is ulti-
mately more important to them.(FCS)
These comments were in contrast to the community
based service and the service for older adults.These contexts
were much more diverse than that experienced in the
children’s centres. In these two settings, the implementation
of the COPM was at the level of the occupational therapists
working within selected programs and this change to using
the COPM was not specifically supported by the
organizations. Working on a team that had not adopted a
client-centred model of practice made it difficult for the
occupational therapist to espouse this philosophy. Some
participants discussed the restrictions placed on them by
organizationally defined issues and concerns. Working as a
consultant often required intervention around a specific
issue.
I try to give the residents options. They have a say up to a
point but when it becomes an issue of safety, the institu-
tion's rules take over. It's an issue of the safety of the other
residents. (OAS)
A lot of times, we’re sent in for very focused reasons ... the
client hasn’t asked for a safety assessment, it’s been home
care or the doctor or the family. (CBS)
Nonetheless, it was possible for particular services or units to
support a client-centred approach despite the lack of this
general philosophy within the organization. One therapist
described her experience on a palliative care unit.
Care is directed by the patient. If they don’t want to eat,
they don’t eat. If they don’t want their medication, they
don’t get it. (OAS)
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Strategies for change
Even with an understanding of the concepts and issues
involved in client-centred care, the key challenge was in the
day-to-day implementation of concepts into practice. An
important challenge in implementing client-centred practice
is knowing exactly how to make specific changes to enhance
service. While people talk about beliefs and commitment to
values around client or family-centred service, service
providers felt a need to develop practical strategies for
implementation. For example, participants working in
children’s rehabilitation centres stated that it would be useful
for centres to share more information with each other about
day-to-day practical strategies which had been successful in
enhancing family-centred service. This sharing, as well as
knowledge about how to educate and collaborate with
clients, may facilitate change.
The whole organization hasn’t really done a whole lot to
try and move us in the direction where they say we need to
go. I mean, they tell us where they want us to go, they don’t
actually show us how. (FCS)
How do you inform, how do you educate, how do you
impart [information] or act as a resource and not tell the
client what to do? (CBS)
In the study of children’s rehabilitation centres, each
centre approached change in a different way. Some centres
began with change at an individual clinical level, while others
began with changes to the centre’s mission and guiding
principles. It appeared that both methods of change can
work satisfactorily. The more important factor identified by
participants in determining the satisfaction with the change
process was the management style within a centre. Service
providers who were integrally involved in changes towards
family-centred service were much more satisfied with the
process. A participatory management style, in which
everyone gets a say in changes, was perceived by service
providers to allow them time to sort through ideas and come
up with priorities. They expressed more satisfaction in being
involved in this process. In centres where service providers
were not as involved in the change process, they were not as
satisfied. This also led to greater struggles with how to shape
change towards family-centred service. Although it takes
more time, having all interested parties participate in the
change process is important. As well, whether it is at the level
of executive director or a service unit, it is important that
there is a person or a group who guides and facilitates the
change process.
How could you have a change process go on and not be
participatory if you’re going to be family-centred? (FCS)
I would say the problem is leadership ...The organization has-
n’t really done a whole lot to move us in the direction ... (FCS)
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Living the philosophy
In situations where there was a commitment by the
organization to move to a more client-centred approach to
service, there seemed to be more potential for change. This
was in contrast to other situations in which some
participants felt that, while client-centred practice was the
ideal, it was difficult to implement in practice without the
support of the team or the organization. ‘Talking the talk’ is
easier than ‘walking the walk.’
We’re trying to live it out. You can’t just talk about it, you
have to live it. .... we see a family in the hall that looks lost,
you’ve got to take a minute to send them in the right
direction. If a family is unhappy with something, you’ve got
to listen to what they’re saying and you’ve got to do
something about it. (FCS)
I don’t think my practice is client-centred. The team thinks
life is better for the patient. I think we talk about being
client-centred. We all believe in it but in our practice we are
not. Let me give you a classic example if a patient is not
wanting to get up. We want the patient up because we feel
better that the patient’s up ... we say it is better for you to be
up than in bed. (OAS)
Time and resources
Time constraints were identified by all participants as a
significant challenge to implementing client-centred
practice. There is a perception that client-centred practice
takes more time. Some participants perceived that client-
centred service meant that there would be more demands
placed on them by clients and their families which they
might not be able to fulfill. Some participants identified that
the time to implement client-centred service had taken away
75
time from direct treatment. Other participants described the
constraints placed on them by the organization. They were
volume 68 • issue 2
required to resolve specific issues within a particular period
of time and this often meant not being able to address other
important concerns.
The toughest part I find in the job is the time restraint
imposed by [the organization], get in and get out in eight
visits.Well, to do a thorough assessment and give the client
lots of linkages, there’s not a lot of time left over at the end
of the day to deal with psychosocial issues. I think that’s
unfortunate because it is so integral to whatever the client
is doing, to the motivation and the chance that they will
follow through after I’m gone. (CBS)
I think sometimes you have to remind yourself not to step
in too quickly, not to tell people how to solve their
problems. Even though it could make your treatment
perhaps that much more efficient.In the end, it may disable
the client further. (CBS)
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 Wilkins et al.
Process issues
Policies and structures established within organizations can
also limit a therapist’s ability to practice in a client-centred
manner. Specific requirements or formats for documentation
can drive the therapy process. As mentioned previously, limi-
tations around the number of visits or the mandate or scope
of the service can constrain the formation of the partnership
with clients.
Because of how we report to Home Care, the information
that the Home Care coordinators require from us, I did not
have all that information readily available to me. (CBS)
I think sometimes I know as an occupational therapist
we’re supposed to be client-centred, but there are times
when you go into a home and you are just so fixated on
getting all the information and then you come up with
your own treatment plan, of course talking to the client
about it. But I think we sometimes lose sight that of course
we need to ask the client, what is the primary issue, what is
the priority with you? (CBS)
At the level of the therapist
Understanding client-centred practice
Some participants were able to define what client-centred
practice meant to them.
[It means] the client playing a very key role and me serving
the client, the client is competent to make decisions on
what he or she wants and really listening to what’s
meaningful to them, what they need. (OAS)
In other interviews, it was obvious that client-centred
practice or family-centred service was not well defined or
understood. However, some participants felt that the COPM
made their practice more client-centred or at least made
76
them more aware of the process involved in client-centred
volume 68 • issue 2
practice.
We’re trying to change a culture, so what we’re doing is
really working out attitudes and values, things that are
often hidden, you know, the lower part of the iceberg. (FCS)
I think my practice always has been client-centred. But the
COPM has made me realize, yes, what I'm doing is client-
centred and maybe I can do this or that to make it more
client-centred. (OAS)
Client-centred practice makes you very aware of how you
have to keep your own values to yourself ... be attuned to
the clients’ values. It makes you aware of how important it
is to listen. (OAS)
We’ve always done it
Some participants believed that client-centred practice was
not a new idea but one that has always been promoted by
occupational therapists. Similar views were held by those
working in children’s rehabilitation. Their view was that
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formalization or operationalization of family-centred service
concepts in the past several years had only articulated what
were long-held philosophies within children’s rehabilitation
centres. Family-centred service has been something that
service providers have tried to do in the past, but it has not
been well-defined or implemented using specific strategies.
However, other participants identified that there may be a
danger in thinking that children’s rehabilitation centres have
always provided family-centred service. They feared that this
"we’ve always done it" attitude will limit changes. These
participants viewed family-centred service as a never-ending
process in which centres need to be constantly aware of
improving service delivery and partnerships with families.
It has put a lot of things out in the open that have been
underlying the surface for a long time. We’ve been saying
those words that [the research unit] has put on paper, and
we’ve been saying them to parents for years. Half the staff
claims we’ve always done it that way, and aren’t we good,
but don’t actually, we haven’t actually done anything dif-
ferently for the last ten years. (FCS)
Power and partnership
Participants described client-centred practice as represent-
ing a shift from a traditional or paternalistic method of
providing service to providing service in a way that
emphasizes equality, sharing and partnership. But for some
participants this was a difficult transition. Some participants
did not recognize power issues while others felt that they did
not have the skills that were required to practice in a
client-centred way. They needed to have enhanced skills in
such areas as negotiation, collaboration and consultation.
Maybe it’s because I ask the questions first ... I don’t see
power very much in this at all. Because even the way that I
approach the question about whether I can help is never ...
this is what I’m going to do .... it’s always, I’m in your home,
this is what I propose to change, is it okay with you? (CBS)
We were educated to help the disabled (sic) and I think we
have a thing about we know better than the disabled (sic).
We know what’s wrong with life for them instead of letting
them make the decisions or let the family make the
decisions. We know what is best for the patient. (OAS)
At the level of the client
Who is the client?
Amongst some participants, there was concern about which
clients could benefit from client-centred care. In particular
they questioned the ability of some clients to be able to
participate fully in their own care. Often this concern was
related to clients with cognitive problems, poor insight into
their problems, language barriers, or depression. In these
situations, it was often the family members who became the
primary client of the occupational therapist. While in some
© CAOT PUBLICATIONS ACE

situations, the family member as client may be most
appropriate, in other situations, it may be easier to deal with
the family member rather than the identified client.
Now I say I am client-centred but for me the client is often
the family member because the client is not aware there is
any problem [due to cognitive impairment], that they are
causing any burden for the family member. (OAS)
The client I’m seeing right now who, he’s depressed and he’s
drinking too much, but he could never articulate what he
wanted to be able to do. The issue was really more of a
family issue. (CBS)
This issue was also the case when therapists worked within
the school system.The teacher rather than the child or parent
may become the client. But also within this system there are
multiple clients and it is possible that the occupational
therapist may be working with people who do not
acknowledge that there is a problem.
A lot of my work is with teachers .... the teacher is the one
who has to work with that student ... we’re trying to ...
improve the child’s ability to work in the classroom and
help the teacher deal with that child .... you’re dealing not
with just the client, you’re dealing with the school system,
the principal, the teacher. (CBS)
If the teacher didn’t even initiate the referral ... it was the
principal or the parent pushed for it and the teacher
doesn’t even want you in the classroom .... it isn’t collabora-
tion. (CBS)
The ‘right’ client
Participants often described the ideal client who would
benefit from client-centred practice as someone who is
cognitively intact, insightful with good problem solving skills.
However, the majority of clients who need occupational
therapy do not have these characteristics.
With people who are more severely depressed, it's difficult
for them to set their own goals because initially it's hard for
them to think about things they want to do ... to think that
much into the future. (OAS)
[The "right" client is] basically someone who is cognitively
intact, has very good judgement, probably already has
some pretty good insight into how they’re functioning
within their environment. I guess along with that is some-
one who has pretty good problem-solving skills already. So
generally, with those clients, [the COPM] works extremely
well. (CBS)
Some participants believed that the COPM might
jeopardize their relationship with their clients particularly
those older adults who were maintaining their own
apartments. Admitting that they had "problems" to the
occupational therapist might result in them losing their
independence. From their perspective, they're ‘getting by’ just
fine. (OAS)
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Wilkins et al.
Power and partnership
As discussed above, being client-centred requires that the
identified client be willing and able to become involved in a
partnership with the occupational therapist. However, some
clients may be more comfortable with the therapist as
‘expert’. This new partnership requires that the therapist
provides the client with the information that he or she
requires in order to participate equally in the relationship.
With this information, the client can become empowered to
take control of particular aspects of his/her life.
I don’t really see myself as the one holding the power .... I
think it’s a two-way process between the client and myself.
I may see his problems differently than the client .... I give
my opinion but the client may not feel that this is a realistic
goal or it’s something that he wants to work on. So I need
to look at it from his point of view. (CBS)
As the therapist, you can slowly pull away from the client as
they are then able to make their own decisions or find their
own resources or make their own phone calls ....
gradually as you [help them] build that knowledge base,
the control can change and you can slowly pull away and
hopefully you leave someone with the skills to live a happy,
productive life. (CBS)
Discussion
The findings provide evidence of the continued struggle to
translate the theory of client-centredness into practice. Many
of the obstacles and barriers identified by the participants in
these research studies echo the findings of other authors
(Parker, 1999; Sumsion, 1999). The struggles occur at multiple
levels–at the level of the systems within which occupational
therapy services are provided, at the level of the individual
77
occupational therapist, and at the level of the client receiving
occupational therapy services. If client-centred practice is to
volume 68 • issue 2
be effectively implemented it requires change at each of
these levels.
At the level of the systems within which services are
provided, there must be a commitment to the principles of
client-centred practice by all of those involved.This may be at
the level of the organization as in the children’s centres or at
the level of the service unit as with the palliative care unit
within a hospital. The culture of the organization or service
unit must support the values of client-centred practice.
Management and staff must work collaboratively with clients
and their families to make the changes necessary to be more
client-centred. There must be open communication. There
must be a commitment to ongoing support and education
for the service providers and the clients. Some specific
strategies include:
identifying an individual or group who is responsible for
"
moving the organization towards a client or family
centred model of practice;
CANADIAN JOURNAL OF
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 Wilkins et al.

seeking the input of clients and families by providing

" "
opportunities for feedback as well as for active
participation in the change process;
adopting a participatory style of management to engage
" "
everyone in the implementation of new directions;
rewarding efforts of staff who embrace this model of
"
practice ;
reviewing existing policies and procedures to determine
"
if they are imposing barriers to the adoption of
client-centred practice; and
assisting teams to work together with families and clients
"
thinking about how you provide information to clients
(Are clients adequately informed so they can make
choices?);
examining your client information materials (Are
materials clear and appropriately written for various
literacy levels? Do you have any translations available?);
"
asking clients how they prefer to work (What type of a
partnership works best for the client?); and
"
finding out what the client’s priority issues are through
whatever strategy works best.

through ongoing education and support.

At the level of the therapist, there appears to be a Conclusion
continuing need to increase knowledge and understanding Translating the principles of client-centred practice into
around what it means to adopt a client-centred philosophy. action is a very challenging task. Change is difficult and takes
Most therapists have a good grasp of the principles, but time. We have seen evidence of change over the past few
require support in translating those principles into action. years, however, there continues to be room for growth at all
Therapists need to reflect on their own practice style, how levels of the process. There is more potential for change in
they form relationships with clients, what messages they organizations that are committed to move to a more client-
send about how they work and what the client’s role is centred approach to service. Support at all levels within the
within the relationship. Some specific strategies include: organization facilitates change. Occupational therapists must
sharing ideas amongst therapists, practical suggestions
"
constantly reflect on their practice to ensure that they
for what works and what doesn’t work; continue to practice in a client-centred way. This is
mentoring each other by asking challenging questions
" particularly important with challenging clients and families.
about practice and encouraging reflection; Client-centredness occurs along a continuum depending on
providing education to facilitate the development of
" the ability of clients to take control of their situations.
skills in negotiation, client education and consultation; Awareness of power differentials in therapists’ relationships
soliciting feedback from individual clients formally or
" with clients must be acknowledged and steps taken by
informally about their perspectives on how client- therapists to enhance their skills in negotiation, collaboration
centred they found the service; and and consultation. Clients of occupational therapy services
discussing creative solutions for engaging the client who
" must be given the information they need to participate
is more challenging (e.g, who has some cognitive equally in partnerships with occupational therapists. It is only
impairment, limited communication abilities, etc.). with this information that clients can be empowered to take
78 At the level of the client, it is important that we control of particular aspects of their lives. In summary,
recognize that part of being client-centred is recognizing organizations, therapists and clients must work together to
volume 68 • issue 2

individual differences in how clients wish to relate to their facilitate these changes and ensure that each occupational
service providers. Client-centredness must be understood to therapy client receives respectful, supportive, coordinated,
exist along a continuum. Some clients may be comfortable flexible and individualized service.
articulating their needs and directing the service provision,
others may only be able to make simple choices. As thera-
pists, it is our responsibility to understand the clients’ needs
Acknowledgements
We would like to thank the therapists and organizations who
and act accordingly. We cannot say that client-centred prac-
participated in each of the three studies described in this
tice only works for some clients. We must find ways for it to
paper. Partial funding for these projects was received from:
work with all clients. Some specific strategies include:
Baycrest Centre for Geriatric Care, Toronto, Ontario; CanChild
clarifying from the outset, who is the client. Is it the
"

Centre for Childhood Disability Research, McMaster

person referred for service, the family, the teacher, the
University, Hamilton, Ontario; and Community Occupational
employer, etc. (Is it a single client? Are there multiple
Therapists and Associates, Toronto, Ontario.
stakeholders? Is there any conflict amongst the
stakeholders?);
thinking about how you introduce occupational therapy
"
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