January 1999
Table of Contents
In this Article
Why is the client perspective important?
Education of professionals by clients
Implications for occupational therapists
So how do we get there from here?
by Deborah J. Corring
Did you know that the term client-centred was first used by Carl Rogers as far back as 1939?
Did you know that Canadian occupational therapists have been discussing the concept for some 15 years now?
Have you noticed that one perspective has been pretty much missing from the discussion?
The perspective of the client has been virtually absent from our discussions of client-centred care. The omission of this perspective is somewhat puzzling when partnership, client involvement, and client empowerment are thought to be fundamental elements of this approach to practice (Law, Baptiste & Mills, 1995).
Why is the client perspective important?
Clients are increasingly demanding a voice in planning for a service delivery
system that is responsive to their needs. Respect, dignity, genuineness,
support, understanding, choice, caring, and a balanced partnership are
characteristics increasingly expected of professionals by clients (Chamberlin,
Rogers & Sneed, 1989; Church & Capponi, 1991; Ridgway, 1988).
Several studies of client involvement in service evaluation have demonstrated
that clients are capable of determining what services they find most satisfying,
and that such involvement can lead to better health outcomes (Foon, 1987;
Greenfield, Kaplan & Ware, 1985; Hart & Bassett, 1975; Lazare,
Eisenthal & Wasserman, 1975). And if this was not compelling enough,
there is growing evidence that client and professional opinions and perspectives
differ in many critical areas. Items such as the preferred approach to
service delivery, priorities of treatment goals, and definitions of "rehabilitation"
and "getting better" are but a few examples of the discrepancies
between the two groups (Mayer & Rosenblatt, 1974; Prager & Tanaka,
1980). Professionals cannot continue this discussion without the client
perspective. It is time to balance the discussion with perhaps the most
critical perspective—that of the client.
What do clients have to say?
A qualitative study completed as part of a master’s thesis (Corring,
1996) sought to capture a client definition of client-centred care. Focus
groups and participatory action research techniques were used to find
out what clients of mental health services thought about a client-centred
approach to practice.
Value the client
Focus group results indicate that clients want professionals to believe
in their clients’ potential, to value their life experience, and
to recognize their expert knowledge of themselves. As one client explains,
"we learn through our experiences how to stay well." Yet another
asserted "…give me my independence, my dignity, my pride cause
I’ll fight you for it if you don’t…We have pride and dignity,
we’re running our own lives."
Get close
Another critical element of client-centred care from a client perspective
requires the professional to get close. One client comments "…you
cannot help somebody without getting close, you have to give a damn…".
Another spoke of a long term relationship with a professional, and suggests
that "…if somebody finds once in their history somebody who
cares that could make all the difference."
Be welcoming
An attitude of willingness to help, to demonstrate your caring in the
way you treat people were descriptors of the type of reception clients
want from professionals. "It’s all in those little things, consideration,
sensitivity, respect — it is all shown in the way you treat people…"
explained one of the focus group participants.
Talking takes time
Clients need time to talk things through. They want professionals to listen,
to treat them as people, and to get to know them before they expect trust.
"Be there, talk to them and confide in them, find out what’s
bothering them, and be a help not a hindrance…".
Common ground
Common respect, common understanding, an atmosphere that promotes healing,
and a shared philosophy concerning partnership will help clients and professionals
find common ground. "(If you want to) see if it is client-centred
care… see if they (the clients) take control over their own lives,
not be controlled… I think we have to work towards less control"
said one client.
Service delivery changes
Individualized, caring services that allow for choice, decision making
by the client, and effective problem solving are the critical elements
from a client perspective of a responsive service delivery system. "Sincere
care, ’cause that is what health care is all about, sincere caring."
Education of professionals by clients
How better to increase understanding of what it is like to live with a
mental illness, to live on a very limited income then for clients to share
their knowledge as part of the education of professionals. "We have
to educate the professionals ourselves, us with the mental illnesses because
we have the experience of the illness. They see it from the outside, they
can help us but we have to help them."
Implications for occupational therapists
What clients have to say about essential elements of client-centred care
are well represented in the history of occupational therapy.
"Caring for and caring about the patient was as implicit as occupation" in the roots of occupational therapy (King, 1980, p.523). Getting close and caring, while maintaining a reflective vantage point are considered key elements of a therapeutic relationship (Brody, 1991). The development of a therapeutic relationship has long been considered essential to effective intervention in occupational therapy (Baum, 1980; Larson & Fanchiang, 1996).
But some occupational therapists susceptible to the effects of working in health services dominated by the medical model (Law et al., 1995; Townsend, 1992) have lost touch with these roots. Occupational therapists need to find a balance between using the tools of science without adopting "objectivism" as our primary value (Yerxa, 1980).
"The current move in the health care environment of the 1990s is forcing us back to the heart of occupational therapy" (Burke & Kern, 1996, p. 392).
Client-centred care should fit with our profession very well. Our focus on therapeutic relationships, holistic care, respect for clients and their expert knowledge of themselves, and the valuing of client choice will assist us through the journey away from the medical model to a care model that values the human being affected by the illness.
"Our practice in the future should be evaluated not only on the basis of measurable, scientific outcomes, but also by what it contributes to the individual’s human dignity, sense of mastery, and self respect" (Yerxa, 1980, p.534).
So how do we get there from here?
Understanding how our profession became so tied to the medical model (Townsend,
1992); how the health system’s view of disability versus ability
has influenced our thinking and approach to practice (Martini, Polatajko,
& Wilcox, 1995); how caring for the human being has been compromised
in health care (Montgomery, 1993); as well as how professionals have engaged
in and promoted stigmatizing attitudes and behaviours (Dubin & Fink,
1992; Elliott, Hanzlik, & Gliner, 1992; Townsend, 1990) helps each
of us to examine our own approach to client-centred care.
In a follow up article this author will share client assessments of past and present practices with a view to exploring these factors further, and suggesting ideas for change.
References
Baum, C.M. (1980). Occupational therapists put care in the health system.
American Journal of Occupational Therapy, 34, 505-516.
Brody, H. (1992). The healer’s power. New Haven, CT: Yale University Press.
Burke, J.P., & Kaern, S.B. (1996). Is the use of life history and narrative in clinical practice reimbursable? Is it occupational therapy? American Journal of Occupational Therapy, 50, 389-392.
Chamberlin, J., Rogers, J.A., & Sneed, C.S. (1989). Consumers, families and community support systems. Psychosocial Rehabilitation Journal, 12, 93-106.
Church, K., & Capponi, P. (1991). Remembering ourselves - A resource book on psychiatric survivor leadership facilitation. Toronto, ON: Leadership Facilitation Program.
Corring, D.J. (1996). Client-centred care means I am a valued human being. Unpublished master’s thesis. London, ON: University of Western Ontario.
Dubin, W.R., & Fink, P.J. (1992). Effects of stigma on psychiatric treatment. In P.J. Fink & A. Tansman (Eds.), Stigma and mental illness. (Pp.1-7) Washington, DC: American Psychiatric Press.
Elliott, D., Hanzlik, J., & Gliner, J. (1992). Attitudes of occupational therapy personnel toward therapists with disabilities. Occupational Therapy Journal of Research, 12, 259-277.
Foon, A.E. (1987). Locus of control as a predictor of psychotherapy. British Journal of Medical Psychology, 60, 99-107.
Greenfield, S., Kaplan, S., & Ware, J.E. (1985). Expanding patient involvement in care-effects on patient outcomes. Annals of Internal Medicine, 102, 520-528.
Hart, W.T., & Bassett, L. (1975). Measuring consumer satisfaction in a mental health centre. Hospital & Community Psychiatry, 26, (8), 512-515.
King, L.J. (1980). Creative caring. American Journal of Occupational Therapy, 34, 522-528.
Larson, E.A., & Fanchiang, S.C. (1996). Life history and narrative research : Generating a humanistic knowledge base for occupational therapy. American Journal of Occupational Therapy, 50, 247-250.
Law, M., Baptiste, S., & Mills, J. (1995). Client-centred practice : What does it mean and does it make a difference? Canadian Journal of Occupational Therapy, 62, 250-257.
Lazare, A., Eisenthal, S., & Wasserman, L. (1975). The customer approach to patienthood - Attending to patients in a walk-in clinic. Archives of General Psychiatry, 32, 553-558.
Martini, R., Polatajko, H.J., & Wilcox, A. (1995). ICIDH - PR : A potential model for occupational therapy. Occupational Therapy International, 2, 1-21.
Mayer, J.E., & Rosenblatt, A. (1974). Clash in perspective between mental patients and staff. American Journal of Orthopsychiatry, 44, 432-441.
Montgomery, C.L. (1993). Healing through communication - The practice of caring. Newbury Park, CA: Sage Publications.
Prager, E., & Tanaka, H. (1980, Jan.). Self-assessment: The client’s perspective. Social Work, 32-35.
Ridgway, P. (1988). The voice of the consumers in mental health systems: A call for change. Burlington, VT: The Center for Community Change Through Housing and Support.
Rogers, C. (1939). The clinical treatment of the problem child. Boston, M : Houghton Mifflin.
Townsend, E. A. (1992). Institutional ethnography: Explicating the social organization of professional health practices intending client empowerment. Canadian Journal of Public Health, 83, 558-561.
Townsend, J. (1990). Stereotypes of mental illness: A comparison with ethnic stereotypes. In M. Nagler, (Ed.), Perspectives on disability (pp. 102-117). Palo Alto, CA: Health Market Research.
Yerxa, E.J. (1980). Occupational therapy’s role in creating a future climate of caring. American Journal of Occupational Therapy, 34, 529-534.
Deborah J. Corring, M.Sc.O.T., O.T.(C) is an occupational therapist with 26 years of experience in mental health, currently working as a programme co-leader at St. Thomas Psychiatric Hospital as well as operating an independent business, Client Perspectives, 126 Chalet Crescent, London, Ontario N6K 3C6
Tel. (519) 641-7118 • Fax (519) 641-4398
e-mail: dcorrin2@julian.uwo.ca
Coming in March
Identifying the client: The challenge of client-centred practice in a
fee-for-service industry -. by Debra Stoch
January 1999 Table of Contents
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