The myth of participation in occupational therapy: reconceptualizing a client-centred approach

Participation is often the comprehensive objective of treatment but also an indication of the extent to which the process of occupational therapy is client-centred. The purpose of this study was to explore levels of participation during occupational therapy among clients in the area of mental health from the occupational therapists' perspectives. Additionally the authors sought to identify factors that might hinder client participation. Postal questionnaires were sent out to 670 Swedish occupational therapists working with persons with mental illness and learning disabilities. The questionnaire required therapists to rate clients' levels of participation during occupational therapy. Findings indicated that the most common level of participation for the clients was interdependent, meaning that problems, goals, and plans were identified jointly and collaboratively with the occupational therapist. However, more than 20% of the clients were described as being dependent. Almost 90% of the occupational therapists rated client participation in therapy to be very important and nearly 70% claimed that client participation in general needed to be increased. Occupational therapists rated the primary barriers to participation as being clients' inability to participate and organizational and financial problems. Implications of these findings for education in client-centred practice approaches are discussed.     

Agreement Between Occupational Therapists and Clients with Stroke on Three Outcome Measures

In recent years, the occupational therapy profession has been under increased pressure to document the outcomes of interventions in order 10 improve the quality of client care and to provide evidence of the effectiveness and efficiency of services to recipients and sponsors. The literature to date has focused primarily on establishing therapy outcomes from a therapist perspective. However, attention must also be paid to the views of our consumers regarding the outcomes of therapy. The purpose of this study was to determine whether clients and therapists agree regarding client scores on three outcome measures. The study included 4 occupational therapists and 20 clients with stroke who rated clients' status in terms of personal activities of daily living, instrumental activities of daily living and quality of life, at admission of clients as well as discharge from rehabilitation. The results indicated that there was generally only moderate agreement between therapists' and clients' ratings at both admission and discharge. These findings suggest that therapists should continue to spend time exploring client status with their clients so that both parties have the best possible understanding of the clients' capabilities, and the outcome of therapy. The findings also suggest the need to administer client outcome assessments as well as to utilize client self-reports.     

Sharing the agenda: pondering the politics and practices of occupational therapy research

Abstract

Aims: Occupational therapists espouse a client-centred philosophy of practice, yet little attention has been given to pondering the politics or client-centred practices of occupational therapy research. The aim of this paper is thus to foster reflection on occupational therapy's commitment to client-centredness in the practice of occupational therapy research. Major findings: Occupational therapy research is not consistently undertaken in a collaborative manner. Power resides in control of the research agenda and participants' priorities can be supplanted by those of researchers. However, examples from the literature and from the authors' research suggest that study participants may wish to influence the research agenda such that their needs and priorities are addressed. Practice conclusion: Client-centred principles appear to require occupational therapists to undertake collaborative research and to ensure that research agendas are informed by clients' priorities. Commitment to client-centred principles demands concerted efforts to identify and address potential barriers to meaningful client participation in the occupation of research. However, it is argued that if researchers and disabled people collaborate, and pool their knowledge and expertise, they may achieve research that is more philosophically compatible with espoused professional values; and that collaborative research may also inform more relevant and useful client-centred clinical practices.     

Client-centred practice in occupational therapy: Critical reflections

Abstract

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.     

Clinical reasoning and the occupational therapy curriculum

Several reasoning styles are used by occupational therapists when they evaluate clients' problems. This study investigated the influence of the occupational therapy curriculum in Hong Kong on therapists' clinical reasoning styles. Two groups of therapists with different clinical experience were recruited. Through interviews with the therapists after identifying clients' problems using the Canadian Occupational Performance Measure, their clinical reasoning styles were explored. The local occupational therapy curriculum was analysed to isolate the components that influence clinical reasoning. Results showed that more experienced therapists use conditional reasoning that considers clients' needs in their future lives whereas junior therapists use procedural reasoning that focuses on clients' disabilities. The analysis of the occupational therapy curriculum indicated that it prepared the students with an equal emphasis on theoretical and clinical subjects and fieldwork practice. The present curriculum was useful in providing educational preparation for novice therapists. However, the period of fieldwork practice can be lengthened to allow adequate maturation of clinical reasoning skills. Problem‐based learning can be incorporated to facilitate students' problem‐solving and self‐directed learning skills. Copyright © 2000 Whurr Publishers Ltd.     

Reliability and validity of the Canadian Occupational Performance Measure for clients with psychiatric disorders in Taiwan

The purpose of the study was to examine the reliability and validity of the Canadian Occupational Performance Measure (COPM) in Taiwanese clients with psychiatric disorders. The COPM was translated into Mandarin and tested on 141 Taiwanese clients. The average age of the clients was 35.6 years; 94% were diagnosed with schizophrenia. The results of the study showed that the test retest reliability of the COPM was r = 0.842. The COPM identified occupational performance problems that included self-care (37%), productivity (25%), and leisure occupations (20%). Fifty percent of the therapists were receptive in adapting the client-centred approach and applying the COPM in their clinical practice. It was concluded that the COPM can be applied reliably to Taiwanese clients. Furthermore, the COPM was valuable in identifying information related to occupational performance that could not be identified elsewhere. Since 50% of the therapists felt reluctant about the appropriateness of the client-centred approach in their culture, it was important to examine the gap between clients' judgements and actual performance, as well as to evaluate the feasibility of the client-centred concept in clinical practice. Finally, the concept of the client-centred approach needs to be disseminated and communicated to the occupational therapy profession in order that the COPM can be adequately applied in mental health practice.     

Responsiveness of the Swedish Version of the Canadian Occupational Performance Measure

In a client-centred approach, clients and therapists work together to define the occupational performance problem, the focus of and need for intervention and the preferred outcomes. Application of specific theories or techniques to involve clients in goal-setting may influence the therapist to use a client participation approach. The Canadian Occupational Performance Measure (COPM) presents a structure for formulating the treatment goals identified by the client in co-operation with the therapist. The aim of this study was to test the responsiveness of the Swedish version of the COPM. After translation into Swedish, the COPM was introduced to 21 occupational therapists who performed data collection. A sample of 108 clients within geriatric, neurologic and orthopaedic rehabilitation identified 418 problems at initial scoring and reassessment. Inclusion criteria for patients were the need for rehabilitation interventions and the ability to communicate well enough in an interview. The results indicate that the Swedish version of the COPM is responsive to change, with 73% of the problems identified having a change in score of 2 points or more.     

Muslim Middle Eastern clients' reflections on their relationship with their occupational therapists in mental health care

Abstract

Persons with a Middle Eastern background represent a minority in Sweden which has significantly increased in size over recent years. The purpose of the present study was to explore the elements that shape the experiences and perceptions of clients with a Middle Eastern background living by Muslim norms who received occupational therapy in mental health care at the time of participating in the study. The study included interviews with 11 clients who received occupational therapy in mental health care. Data collection and analysis were carried out in accordance with the grounded theory approach. One core category, desiring a union, described the clients' desire for an alliance with the therapists that encompassed the realities and truths embedded in their values, preferences, world-views, and belief systems, as well as a wish to reconstruct their abilities to function and perform daily life tasks within their cultural contexts. The core category included sub-categories: desiring relationship, desiring affiliation, and desiring affirmation as well as some related components. The overall findings showed a tentative model in which the notion of mahram affinity was embedded. The results demonstrated that the clients' views regarding desiring a union had their support in collectivistic world-views that often clash with those of the therapists.     

Client-centred occupational therapy with children: A critical perspective

Abstract

Background: Client-centredness is a central theme within occupational therapy; however, its application within clinical practice has not been thoroughly examined within the literature. Aim: The aim of this practice reflection is to provide a critical perspective on client-centredness in occupational therapy practice with children. Methods: Two action points of the Canadian Practice Process Framework (CPPF): Set the Stage and Agree on Objectives and Plan are applied to examine the concept of client-centred practice using a common practice example. Results: There are multiple benefits to using a client-centred approach to goal setting and developing a therapy plan. Practical challenges to client-centred practice include a lack of time, organizational support, and professional autonomy. Therapists may exert power over clients by enforcing institutional policies that prioritize the client diagnosis and organizational processes. Conclusion: The authors support a client-centred approach to occupational therapy practice with children but suggest that therapists may feel conflicted in trying to apply these principles within the current context of rehabilitation for children. Occupational therapists are encouraged to identify opportunities where they can advocate for a client-centred approach to services.     

A responsive evaluation of mental health treatment in Cambodia: Intentionally addressing poverty to increase cultural responsiveness in therapy

Mental health issues are significant contributors to the global burden of disease with the highest incidence in resource poor countries; 90% of those in need of mental health treatment reside in low resource countries but receive only 10% of the world's resources. Cambodia, the eighth least developed country in the world, serves as one example of the need to address mental health concerns in low-income, resource poor countries. The current study utilises responsive evaluation methodology to explore how poverty-stricken Cambodian clients, therapists and supervisors experience Western models of therapy as culturally responsive to their unique needs. Quantitative and qualitative data were triangulated across multiple stakeholders using numerous methods including a focus group, interviews, surveys, case illustrations and live supervision observation and analysed using constant comparative analysis. Emerging findings suggest that poverty, material needs, therapy location and financial situations greatly impact the daily lives and mental health conditions of Cambodians and hinder clients' therapeutic progress. The local community needs and context of poverty greatly hinder clients' therapeutic progress in therapy treatment and when therapy does not directly address the culture of poverty, clients did not experience therapy as valuable despite some temporary decreases in mental health symptoms.     

College-Student Client and Novice Therapist Perceptions of Each Other at Intake

The study examined college-student clients' and beginning therapists' perceptions of each other at intake. The therapists were 6 psychotherapy practicum graduate students (5 women, 1 man) and their 133 college student clients (77 women, 56 men) who sought help for the first time at a university counseling center. After the initiative session, clients rated therapists on the Counselor Rating Form-Short Version and therapists rated clients on the Therapist Personal Reaction Questionnaire. Therapists feelings that they did a good job during the interview were positively related to clients' rating the therapists as expert. If therapists disagreed with their clients on some basic matters and viewed the clients as needing help, they were rated by their clients as expert. The results emphasize the importance of training beginning therapists to identify the concerns or their clients.     

Participatory citizenship: Critical perspectives on client-centred occupational therapy

Abstract

Background/aims: This article aims to discuss client-centred practice, the current dominant approach within occupational therapy, in relation to participatory citizenship. Occupational therapists work within structures and policies that set boundaries on their engagement with clients, while working with complex, multidimensional social realities. Methods: The authors present a critical discussion shaped by their research, including a survey, discussions at workshops at international conferences, and critical engagement with the literature on occupational therapy, occupation, and citizenship. Conclusion: A focus on citizenship suggests reframing professional development based on the participation in public life of people as citizens of their society. While occupational therapists often refer to clients in the context of communities, groups, families, and wider society, the term client-centred practice typically represents a particular view of the individual and may sometimes be too limited in application for a more systemic and societal approach. Significance: The authors question the individual focus which has, until recently, been typical of client-centred occupational therapy. Placing citizenship at the core of intervention is a transformative process that assumes all people are citizens and conceives of health as a collective issue, influencing the way we educate, do research, and practise.     

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

Abstract

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’.     

On the Formative Stages of the Adult Screening Questionnaire

This article describes the formative stages of a screening tool for developmentally disabled adults, the Adult Screening Questionnaire (ASQ). ASQ offers occupational therapists a uniform approach for screening clients. Employing the ASQ will result with a client profile that leads to improved capability in screening outcomes for service delivery: prioritizing caseloads, identifying domains of need for comprehensive evaluation, facilitating clinical decision making, and reporting population needs. to administrators. These screcning outcomes contribute to determining the client evaluation and program intervention necessary for the service delivery process. Reported are rationale for the developmentluse of the instrument, previous validity studies, modifications, and pilot study testin for reliability. The Clients Profile will enable the clinicians to establish three priority levels according to clients' needs. In addition, each clients' needs are identified on nine domains of occupational therapy programmatic concern. A summay,of fipdings for five outcomes for service delivery is introduced. imltatlons and plans for further modification and study are discussed.     

Utilization of the iPad application: Aid for Decision-making in Occupation Choice

The purpose of the study was to develop and evaluate an iPad (Apple) application, Aid for Decision-making in Occupation Choice (ADOC), so as to promote shared decision-making in an occupation-based goal setting. This application involves the client choosing from 94 illustrations describing daily activities related to the category of "activities and participation". One hundred occupational therapy clients evaluated the ADOC for goal setting; the clients and 37 occupational therapists underwent a survey to determine their perceptions of decision-making in the goal setting. More than 90% of the clients felt that they could give their opinions using the ADOC regarding goal setting. The majority of the occupational therapists (>90%) felt that ADOC would be useful in their clinical practice for setting client goals. The results indicated that ADOC is a useful and acceptable tool for both clients and occupational therapists in shared decision-making in occupation-based goal setting.     

Sharing the agenda: pondering the politics and practices of occupational therapy research

AIMS: Occupational therapists espouse a client-centred philosophy of practice, yet little attention has been given to pondering the politics or client-centred practices of occupational therapy research. The aim of this paper is thus to foster reflection on occupational therapy's commitment to client-centredness in the practice of occupational therapy research. MAJOR FINDINGS: Occupational therapy research is not consistently undertaken in a collaborative manner. Power resides in control of the research agenda and participants' priorities can be supplanted by those of researchers. However, examples from the literature and from the authors' research suggest that study participants may wish to influence the research agenda such that their needs and priorities are addressed. PRACTICE CONCLUSION: Client-centred principles appear to require occupational therapists to undertake collaborative research and to ensure that research agendas are informed by clients' priorities. Commitment to client-centred principles demands concerted efforts to identify and address potential barriers to meaningful client participation in the occupation of research. However, it is argued that if researchers and disabled people collaborate, and pool their knowledge and expertise, they may achieve research that is more philosophically compatible with espoused professional values; and that collaborative research may also inform more relevant and useful client-centred clinical practices.     

Role for Occupational Therapy in Community Mental Health: Using Policy to Advance Scholarship of Practice

ABSTRACT

Occupational therapists must be aware of professional and policy trends. More importantly, occupational therapists must be involved in efforts to influence policy both for the profession and for the people they serve (Bonder, 1987). Using the state of Illinois as an example, this article reviews the policies and initiatives that impact service decisions for persons with psychiatric disabilities as well as the rationale for including occupational therapy in community mental health service provision. Despite challenges in building a workforce of occupational therapists in the mental health system, this article makes the argument that the current climate of emerging policy and litigation combined with the supporting evidence provides the impetus to strengthen mental health as a primary area of practice. Implications for scholarship of practice related to occupational therapy services in community mental health programs for individuals with psychiatric disability are discussed.     

Expanding client-centred thinking to include social determinants: a practical scenario based on the occupation of breastfeeding

Abstract

Background: Client-centred thinking in occupational therapy underemphasizes the influence of social determinants and societal-level factors on occupation across the life course. When client-centred thinking focuses solely on the local or immediate contexts of individuals, therapists may not fully recognize or understand how social determinants can create barriers to occupational participation and performance. Aim/Objectives: This article critically examines gaps in traditional thinking concerning client-centredness and demonstrates how the complex interplay between social determinants and societal-level factors may lead to occupational injustices. Material and methods: A practical example from a recent study on breastfeeding and accompanying scenario is used to examine limitations in current client-centred reasoning. The Life Course Health Development framework, a theoretical framework examining contexts of health disparities, is applied to illustrate the opportunity to expand thinking about client-centredness. Results: The Life Course Health Development framework may be a useful addition to client-centred thinking about social determinants of occupation. Conclusion and significance: Expanding client-centred thinking to include awareness, understanding, and respect for social determinants of occupation may enhance therapist–client interactions and outcomes of the occupational therapy process, and address gaps in current thinking that may contribute to occupational injustices.     

A survey on client-centered practice among danish occupational therapists

Background: In Denmark, the cost of healthcare services comprise 12% of the gross domestic product. A recommended method for optimizing effectiveness of and enhance client satisfaction with healthcare is client-centred practice (CCP), a central component of occupational therapy ideology. However, Danish occupational therapists’ perceptions of CCP, including the facilitators and barriers that may contribute to CCP, have never been examined.

Aim: To examine Danish occupational therapists’ perceptions of CCP.

Methods: A survey was conducted using an electronic questionnaire in a small, but representative sample of Danish occupational therapists from all regions and practices.

Results: Three hundred and forty-six occupational therapists (5%) responded. Of these, 98% rated CCP as important, 97% considered their work client-centred, and 92% were satisfied with their level of CCP. Having time to conduct self-directed work, using assessments to identify clients’ priorities, and CCP education, but not fixed regimes, were positively correlated with CCP.

Conclusion: Danish occupational therapists perceive to practice CCP and appear to have adopted the beliefs, theory and ideals of CCP, perhaps influenced by the egalitarian Danish culture. Self-directed work, means to identify and evaluate their clients’ wishes, and education facilitated CCP. Possible absence of occupational therapists not compliant with CCP makes further research warranted.     

The Tree Theme Method as an intervention in psychosocial occupational therapy: Client acceptability and outcomes

Background/aim:  The Tree Theme Method (TTM) is an intervention in which the client paints trees representing certain periods in his/her life. The intervention comprises five sessions, using trees as a starting point to tell one's life story. This study, which is part of an implementation project, aimed to examine the therapeutic alliance and client satisfaction, in relation to perceptions of everyday occupations and health-related factors, with clients going through a TTM intervention.
Methods:  Nine occupational therapists recruited 35 clients, at general outpatient mental health care units, for the TTM intervention. Self-rating instruments, targeting therapeutic alliance (HAq-II), different aspects of daily occupations (Canadian Occupational Performance Measure, Satisfaction with Daily Occupations), health-related factors (Sense of Coherence measure, Mastery Scale, Symptom Checklist-90-R) and client satisfaction (Client Satisfaction Questionnaire), were administrated before and after the intervention.
Results:  A good initial therapeutic alliance, experienced by both therapists and clients, was correlated to increased changes regarding occupational performance and self-mastery. According to the therapists' ratings, a good initial therapeutic alliance was correlated to increased sense of coherence and a decreased level of psychiatric symptoms. The results showed positive significant changes in occupational performance and health-related factors. High ratings of the therapeutic alliance by the therapists were also related to high client satisfaction.
Conclusions:  The TTM seemed to function well in psychosocial occupational therapy, but there is a need for further implementation studies to deepen our understanding of the treatment process, comprising both technique and formation of the therapeutic alliance.