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First edition 1999
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Dedication
To Marjorie and Clarence for all they taught me
about love and my rural roots
To my colleagues and clients who have taught me the value of
pursuing my passion for client-centred practice
My sincere thanks to all the occupational therapists who
successfully apply a client-centred approach.
PR-F10171.indd v 2/1/06 12:26:26 PM
Chapter 1 Overview of client-centred practice ix
Contributors
Debra Cameron PhD OT Reg (Ont)
Assistant Professor, Department of Occupational Therapy, University of
Toronto, Toronto, Ontario, Canada
Working with children and their families for over 20 years has inspired
Deb’s ongoing interest in the benefi ts and challenges of providing client-
centred practice in paediatrics.
Anne Carswell PhD FCAOT OT Reg (NS)
Associate Professor, School of Occupational Therapy, Dalhousie University,
Halifax, Nova Scotia, Canada
Anne is one of the six co-authors of the Canadian Occupational Perform-
ance Measure. She has practised client-centred occupational therapy for
over 40 years and has conducted research in this area with older adults
who have dementia and their families.
Joanne Valiant Cook PhD
Associate Professor, School of Occupational Therapy, The University of
Western Ontario, London, Ontario, Canada
In her role as associate professor, Joanne shares her expertise regarding
psychosocial rehabilitation, client-centred care, qualitative research and
other subjects with a particular focus on helping students understand the
client’s experience of mental illness. Joanne’s clinical, consulting and
research experiences have been primarily in the fi eld of mental health and
illness with a particular focus on innovations in service programmes. Her
research strategies and designs have always been within the qualitative
paradigm of inquiry.
Deborah Corring PhD OT Reg (Ont)
Program Director, Regional Mental Health Care St Thomas, St Joseph’s
Health Care London, Ontario, Canada
Deb is the Program Director of a large clinical programme that has both
inpatient and outpatient components. The programme operates under a
psychosocial rehabilitation philosophy with a recovery focus. Deb has
worked in mental health for 33 years as a clinician, an administrator and
as a qualitative researcher. Her past and current research has focused on
PR-F10171.indd ix 2/1/06 12:26:27 PM
x Contributors
articulating the client perspective concerning several issues including quality
of life, satisfaction with services received, etc.
Marie Gage MSc BSc(OT) OT(C)
Collective Wisdom Management, Haliburton, Ontario, Canada
Marie teaches client-centred care planning to interdisciplinary care teams that
are interested in integrating their care. Marie also provides direct clinical
services to clients, with a variety of physical diagnoses, in their home.
Sandra Jean Graham Hobson MAEd LLD OT Reg (Ont)
Associate Professor, School of Occupational Therapy, The University of Western
Ontario, London, Ontario, Canada
Sandra has worked with older adults, many suffering from cognitive impair-
ment, and young adults with acquired brain injury. She has taught on the
topic of client-centred practice with both of these populations.
Mary Ann McColl PhD
Associate Director for Research, Centre for Health Services & Policy Research,
and Professor in the Departments of Community Health & Epidemiology and
Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
In addition to being co-author of the COPM, she has written a number of
books, including Introduction to Disability, Theoretical Basis of Occupational
Therapy and Spirituality and Occupational Therapy.
Davina Parker MSc Dip COT
Head of Occupational Therapy, University Hospital Birmingham NHS
Foundation Trust, Birmingham, UK
With her experience of implementing client-centred practice in clinical set-
tings, Davina’s interest lies in the application of the COPM and the challenges
that face the therapist.
Nancy Pollock MSc OT Reg (Ont)
Associate Clinical Professor, School of Rehabilitation Science, McMaster
University, Hamilton, Ontario, Canada
Nancy is a researcher with the CanChild Centre for Childhood Disability
Research where she studies family-centred practice. She is one of the co-
authors of the COPM and applies these concepts in her paediatric clinical
practice with children, families and teachers.
Debra Stewart MSc OT Reg (Ont)
Assistant Dean, Occupational Therapy Programme, School of Rehabilitation
Science, McMaster University, Hamilton, Ontario, Canada
Debra’s clinical and research interests are in the fi eld of paediatrics. She is a
co-investigator with CanChild Centre for Childhood Disability Research and
is involved in numerous projects related to adolescence and the transition to
adulthood for youths with disabilities.
Thelma Sumsion, PhD MEd BSc(OT) OT Reg (Ont) FCAOT
Director, School of Occupational Therapy, The University of Western Ontario,
London, Ontario, Canada
Thelma has been interested in client-centred practice since the 1980s and in
2002 she completed her PhD studies in England related to defi ning this
concept.
PR-F10171.indd x 2/1/06 12:26:27 PM
Chapter 1 Overview of client-centred practice xi
Foreword
Christine Craik
The fi rst edition of this book was a milestone in client-centred practice,
bringing together in a clear and logical way the philosophy of client-
centred practice, the academic underpinning which contributes to its
development and – probably most important for therapists – the practical
application of the philosophy. The editor assembled a distinguished group
of authors with the knowledge and credentials to help us to understand
the concepts and implement them.
The book has assisted occupational therapists throughout the world to
put into effect the essence of the profession: the collaboration or partner-
ship between the client and the therapist working together to achieve the
client’s goals. Although this philosophy is central to occupational therapy,
understanding its true meaning and implementing it have always been
challenging. Most occupational therapists claim to work within a client-
centred model and this book has enabled us to do this more effectively.
For the second edition, the same groups of authors have updated and
expanded their chapters and there is now a new chapter on the important
area of paediatrics. Case studies are used to illustrate client-centred prac-
tice in a meaningful way.
The concept of client-centred practice has been afforded greater or
lesser recognition at different times during the history of the profession,
but it is clearly at the heart of occupational therapy. Currently, the need
to justify intervention according to a developing evidence base, to provide
value for money and to reduce complex interventions to a series of simple
protocols all represent challenges to working in a client-centred way. If
we strive to uphold the philosophy and reality of client-centred practice,
this second edition provides the inspiration and guidance to do so.
My fi rst question about this second edition was to ask if the poignant
story of Nick was to be included. Yes, it is still here. And who, having
read this exemplar of client-centred practice, could deny the justifi cation
of providing the red wheelchair?
Christine Craik
2005
PR-F10171.indd xi 2/1/06 12:26:27 PM
xii CLIENT-CENTRED PRACTICE IN OCCUPATIONAL THERAPY
Foreword
John Glossop
I am an ex-teacher and in 1983 I was disabled by a subarachnoid haemor-
rhage. I am a wheelchair user and a partially sighted hemiplegic. I am married,
have three children, a dog, a cat and two goldfi sh. I now have three grand-
children who have grown up treating disability with the same irreverence that
I do.
I am unique, I am not a collection of symptoms and physical problems, I
am more than the sum of my disabilities. My goals may not be your goals;
things which you consider necessary to your very existence may be of little
or no importance to me.
Before my brain haemorrhage I sailed competitively. An outdoor pursuits
centre went to great efforts to arrange for me to sail in a trimaran specially
adapted for the disabled. It took hours to rig the boat and winch me aboard.
Sailing must incorporate some degree of danger or adrenalin rush but this
was safe to the point of boredom and I have never sailed since.
I have to live with my disabilities 24 hours a day; I am disabled at weekends,
on bank holidays and even on Christmas Day. Crises do not occur to suit
professionals. Also, I am not a saint! I do things which I know are bad for
me and enjoy doing them. I am lazy and therapies are more likely to be effec-
tive when incorporated into my lifestyle. The therapeutic use of a heavy beer
glass should not be ignored and my coordination has been greatly improved
by repetitive action of fi lling and lighting my pipe, though the close proximity
of a fi re extinguisher is advisable.
I am a member of a family and their needs must be taken into considera-
tion. A bathroom full of ironwork is fi ne as long as there’s room for daughters,
who spend half a lifetime in there with face packs and hair dye; don’t offer
me a single bed no matter how medically sound. I am a husband and father
who happens to be disabled.
I had the pleasure of meeting Thelma Sumsion whilst speaking at an OT
conference and found that we had many ideas in common. I am a strong
proponent of client-centred practice and hope that in future this common
sense approach crosses into other disciplines.
John Glossop
2006
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Chapter 1 Overview of client-centred practice xiii
Preface
My interest in client-centred practice began in the early 1980s when I
chaired the fi rst in a series of working groups organised by the Canadian
Association of Occupational Therapists. This work continued for many
years and resulted in several publications, many of which are discussed in
this text, designed to assist occupational therapists with the implementa-
tion of client-centred practice. The members of these groups were inspi-
rational and we all owe a great deal to their commitment to client-centred
practice.
Over the intervening years Canadian therapists have struggled with
many challenges related to the implementation of client-centred practice.
This text aims to address many of these challenges by combining infor-
mation about the theoretical and practical aspects of this approach to
practice.
The contributing authors were chosen because of their interest and
expertise in client-centred practice as well as their varied experiences in
working with a range of client groups.
I relocated to England in 1996 and quickly became aware of the inter-
est in this approach that therapists throughout the United Kingdom
shared with their Canadian colleagues. This shared awareness gave rise to
the fi rst edition of this book and the invitation to authors from both
Canada and England to share their expertise. I returned to Canada in
2002 and the dialogues that continued in both countries supported the
importance of this second edition. It continues to be my hope that thera-
pists in many countries will fi nd information in this book that will enable
them to remove the barriers to the implementation of client-centred
practice and to strengthen their commitment to this approach for the
benefi t of their clients.
T. Sumsion
2006
PR-F10171.indd xiii 2/1/06 12:26:27 PM
1
1
Chapter
Overview of client-centred practice
T. Sumsion
CHAPTER CONTENTS
Emerging importance of client-centred Outcomes and effectiveness 8
practice 1 Model of Occupational Performance 9
Models of client-centred practice 3 Relationship of the Model of Occupational
Defi nitions 5 Performance to other approaches 15
Client-centred programmes 7 Conclusion 16
This chapter presents the core concepts of client-centred practice that
must be clearly understood before successful implementation is
achieved. A variety of models and defi nitions is discussed with a focus
on the Canadian Model of Occupational Performance (CMOP).
Clinical examples are provided in the discussion of the components
of the CMOP, and the relationship of this approach to other
approaches used by occupational therapists is briefl y outlined.
EMERGING IMPORTANCE OF CLIENT-CENTRED PRACTICE
Client-centred practice is now an important approach to intervention in
many areas of occupational therapy practice across several continents. The
reasons for this reality are complex and are based on the realisation that
the client is the most important component of any intervention. Occu-
pational therapists’ values and beliefs support a client-centred approach
that embraces the client’s active involvement (Townsend & Wilcock
2004). However, in the daily work of a therapist it often seems that the
budget, the current approach to management or staff shortages prevail
and dictate how work is performed (Nelligan et al 2002). Inclinations to
succumb to these forces must be overcome and a balance achieved that
places the client fi rmly in the position of receiving the full potential of
engaging in a productive partnership with the therapist.
Health promotion, which emerged as an important concept within
health care in the 1980s, laid the foundation for clients to be involved in
Ch001-F10171.indd 1 2/1/06 2:03:04 PM
2 CLIENT-CENTRED PRACTICE IN OCCUPATIONAL THERAPY
health care and to be responsible for their own health. Health promotion,
as defi ned by the World Health Organization, is ‘the process of enabling
people to increase control over and to improve their health’ (WHO 1986,
p 1). The recognition of the importance of these concepts has facilitated
their integration into many programmes that fully support consumer
awareness. Further developments in the 1990s and beyond have seen
the emergence of consumer-led and self-help groups which strive to
meet needs outside the realm of professional involvement. These are truly
client-centred programmes. Consumer rights, human rights and the tech-
nological revolution have also hastened the development of client-centred
practice (Gage 1994, Law et al 1995).
Therapists in the United Kingdom are aware that the College of Occu-
pational Therapists supports the client-centred approach to intervention
by encouraging the involvement of the client as a partner in all stages of
the therapeutic process and stating within the Code of Ethics and Profes-
sional Conduct that services should be client-centred and needs led. This
document also reminds therapists that clients are unique and bring their
own perspective to the occupational therapy process (College of Occupa-
tional Therapists 2000). The Code of Ethics of the Canadian Association
of Occupational Therapists (CAOT) also advises members to demonstrate
respect for and appreciate the particular needs of the client (CAOT 1996).
It is important that therapists understand the implications of these state-
ments and have the necessary information to implement this approach.
Universities are also acknowledging the need to change the way future
therapists and doctors are educated. The medical school at a major Cana-
dian university has adopted a patient-centred method as the focus of the
curriculum. This method recognises that the patient has a disease but also
an illness experience that is unique to that individual. The student-centred
programme introduces a case at the beginning of each week. Students
interview the patient, discuss issues and spend the week learning what
they need to know to treat the patient (Western Alumni 1997). Through-
out this process the focus is on the patient, not the therapist.
The above examples might lead to the conclusion that client-centred
practice is fully supported by all health professionals. However, as will be
outlined in this book, there are many aspects of this approach that provide
a considerable challenge to the fundamental beliefs of many therapists.
There continues to be a struggle among health professionals concerning
the confl ict that arises between the client’s role in decision-making and
the values of the patient and the professional (Emmanuel & Emmanuel
1992).
All of these issues provided the impetus for this book, which attempts
to facilitate the implementation of client-centred practice. It has been
written for all therapists whether they work as clinicians, managers, educa-
tors or consultants, or are enrolled in an educational programme to
become a clinician. The information is also relevant to therapists in all
work settings, including hospitals, communities, schools, universities and
industries. The focus is both theoretical and practical with an emphasis
on providing solutions to some of the more challenging aspects of
implementation.
Ch001-F10171.indd 2 2/1/06 2:03:05 PM
Overview of client-centred practice 3
The book begins with an overview of a variety of models of client-
centred practice with a focus on the Canadian Model of Occupational
Performance, which was designed by and for occupational therapists.
Subsequent chapters address the client-centred approach, environmental
considerations and implementation issues. A manager provides detailed
information about how to implement a client-centred approach within a
clinical department. The next series of chapters addresses implementation
issues with specifi c client groups, including those with cognitive impair-
ments, the elderly, clients with mental health and physical problems, and
children. The fi nal chapter provides information about the Canadian
Occupational Performance Measure, which is an appropriate outcome
measure to conclude the discussion. All the contributing authors believe
in client-centred practice and share the wish that ‘client centred’ will be
more than just the latest catch phrase (Sherr Klein 1997).
This is a book about client-centred practice and therefore client is the
preferred term when referring to the person or persons with whom the
occupational therapist interacts. In subsequent chapters the term client
is used consistently. However, in this chapter the term patient is used
occasionally if that was the term preferred by the authors whose work is
being discussed. Both male and female pronouns are used to refer to
clients and therapists throughout this book with no preference to either
sex intended.
MODELS OF CLIENT-CENTRED PRACTICE
Client-centred practice is not unique to occupational therapy. Several
models that focus on the client have been proposed by other disciplines.
The Tidal Model is one example and encompasses four main components:
active collaboration with the client to plan and deliver care, empower-
ment, integration of services, and resolution of problems (Stevenson
2001). A client-centred approach has also been developed to address the
process of prescriptions for medication. This process clearly operates
around the client as the central feature and includes knowledge of the
client, the drug regimen and side effects as well as client advocacy and a
review of the process (Anonymous 2001).
Levenstein et al (1986) focus on the potential for patients and doctors
to have different agendas. The doctor’s agenda is to assign a differential
diagnosis through history-taking, physical examination and laboratory
investigation. The patient brings expectations, feelings and fears, and seeks
to understand the illness experience. In a patient-centred approach the
doctor’s aim is to ascertain the patient’s agenda and to reconcile this with
his or her own. This reconciliation leads to integration and a positive
outcome for both the client and the physician.
Integration is facilitated through the consideration of the six interacting
components of the patient-centred process that incorporate both knowl-
edge and skill (Stewart et al 2003). These components are:
Ch001-F10171.indd 3 2/1/06 2:03:05 PM
