Client based practice: Essential to the Occupational Therapy Discourse, but is it understood?
A presentation by Brock Cook & Frances Worster at the OTAQLD14 State Conference.
5. What is Client Based
Practice?
'demonstrate respect for clients, involve them in decision making, advocate with and for
clients m meeting their needs and otherwise recognise clients' experience and
knowledge' (p49, CAOT 1997)
#OTAQLD14
âŚ..according to the literature
An approach to providing occupational therapy which embraces a philosophy of respect for
and partnership with people receiving services. Client-centred practice recognises the
autonomy of individuals, the need for client choice in making decisions about occupational
needs, the strengths clients bring to a therapy encounter, the benefits of client-therapist
partnership and the need to ensure that services are accessible and fit the context in which
a client lives (Law et al, 1995, p253).
âPerson centred practice for older persons is treatment and care provided by health services
[that] places the person at the centre of their own care and considers the needs of the
personâs carerâ (Victorian Government Department of Human Services, 2003).
6. What is Client Based
Practice?
âbecause goal-directed therapy is crucial to working in a rehab setting, CCP is also key as you need
goals meaningful to the client to encourage participation. Working with a few clients that have TBI's, one
of the main challenges I've come across is that insight, judgement, motivation and initiation can be
heavily impacted from brain injuries. As you can imagine, these factors are going to influence goal-setting.
I think it is essential to involve family and friends to enhance the goal-setting process to try to
overcome these barriers while facilitating a structured goal-setting process to encourage self-discovery.â
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âŚ..according to Therapists
âto be responsive to the familyâs/carerâs ability to take on the information/therapy provided by
specialists/therapists. As a consequence, our support is often provided in ebbs and flows, and even
though this is not ideal to progress a clientâs skills to support greater participation, I believe that this is
something that must be respected: Families are often balancing many competing baskets and we are a
small part of their world. Empowering families to take on more active roles in their childâs progress in
therapy is so important, but must respect their competing emotional and energy reserves.â
âThe client / family were at the centre of it and it felt like they were empowered to make the decisions
(using other team members information to allow this to be informed). Language is turned around to meet
the needs of the client / family e.g. âWhat do you want to achieveâ and âHow do we work on this
togetherâ. Open and honest communication where there is the ability for all team members (including the
client and family) to share their perspective and then come to a mutually agreeable decision / point. This
sometimes means that the clinician needs to 'step down' from their thoughts / views to respect the wishes of
the family, and I believe this does not take away from the integrity of the therapist / their duty of care as
long as they have outlined what they would recommend and the reasons why and this is documented.â
7. What is Client Based
Practice?
âŚ..according to people we work with.
âThey perceived the occupational therapy environment as contrived and as limiting choices and
opportunities for exploring personally meaningful occupation. A focus upon the illness rather
than the individual served to diminish any partnership between the client and therapist and
exclude the client from decision-making processes.â (Rebeiro, 2000)
âfear 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 marginalization.â (Cooring, 1999)
âhealth 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.â
(Gerteis, Edgman-Levitan, Daley, & Delbanco, 1993)
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8. Why is CBP
important?
âŚand what happens when it breaks down?
13. References
Canadian Association of Occupational Therapists (1997) Enabling occupation: an occupational therapy perspective.
Ottawa: CAOT Publications ACE.
Corring, D. (1999). The missing perspective on client-centred care. Occupational Therapy Now, 1(1), 8-10.
Fisher, AG. (2013) Occupation-centred, occupation-based, occupation-focused: same, same or different? Scandinavian
Journal of Occupational Therapy. 20(3):162-73
Gage M (1994) The patient driven interdisciplinary care plan. Journal of Nursing Administration, 24(4), 26-35.
Gage, M. (1995) Re-engineering of Health Care: Opportunity or threat for occupational therapists? Canadian Journal of
Occupational Therapy. 62(4) p197-207
Gage M, Polatajko H (1995) Naming practice: the case for the term client- driven. Canadian Journal of Occupational
Therapy 62(3), 115-18.
Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T. (Eds.). (1993). Through the patientâs eyes: Understanding and
promoting patient-centered care. San Francisco: Jossey-Bass.
Rebeiro, K. (2000). Client perspectives on occupational therapy practice: Are we truly client-centred? Canadian Journal
of Occupational Therapy, 67(1):7-14
Sumsion, T. (2000) A Revised Occupational Therapy Definition of Client-Centred Practice. British Journal of
Occupational Therapy, 63(7):304-309
Townsend E (1998) Using Canada's 1997 guidelines for enabling occupation. Australian Occupational Therapy Journal,
45, 1-6.
Wilkins, S. Pollock, N. Rochon, S and Law, M. (2001) Implementing Client-Centred Practice: Why is it so Difficult to
Do? Canadian Journal of Occupational Therapy, 68(2):70-79
"Pieter Bruegel the Elder - The Tower of Babel (Vienna) - Google Art Project - edited" by Pieter Brueghel the Elder (1526/1530â
1569) - Levels adjusted from File:Pieter_Bruegel_the_Elder_-_The_Tower_of_Babel_(Vienna)_-_Google_Art_Project.jpg,
originally from Google Art Project.. Licensed under Public domain via Wikimedia Commons -
http://commons.wikimedia.org/wiki/File:Pieter_Bruegel_the_Elder_-_The_Tower_of_Babel_(Vienna)_-_Google_Art_Project_-
_edited.jpg#mediaviewer/File:Pieter_Bruegel_the_Elder_-_The_Tower_of_Babel_(Vienna)_-_Google_Art_Project_-_edited.jpg
#OTAQLD14
Image Reference
I talk a lot.
I talk a lot. I often talk and write just to figure out what I actually think and feel. It is an extroverted act to processes an introverted experience.
I have been thinking. About words. About how words have the power to share and convey meaning, by differentiating one thing from another, making the intangible concrete. Yet there is often so much confusion in what words we use. Often we use the same words, yet mean very different things.
I suggest to you that we are involved in a client-based/focussed/driven/centered "tower of Babelâ, busily involved in the motions of communication without sharing meaning and, more importantly, without conveying the meaning of a client-focus into our practice
As Therapists and we appear to have a good grasp as to the meaning of what it means to be Client Based, but is this reflected in the experiences of our Clients?
For ethical reasons, we were not able to poll our own clients, but a study by Rebeiro looked at Client Centered Practice from the consumers perspective. She found that the participants ideas around CCP were not reflected in the Occupational Therapy Service they had received.
Cooring (1999) was also investigating the correlation between what clients expected of CCP and what they actually received but specifically within a Mental Health setting. Three main themes were identified by the clients with regards to the client/service provider relationship.
1. Client perceives OT as as gatekeeper (and at times a barrier) - (specific outcome driven i.e. sudden cure or equipment to solve issue, not process driven)
2. Misunderstanding of current service limitations and bureacracy: âOh, CPL gives away free showerchairsâ, âYou are the Department of Veteransâ Affairsâ
3. Therapist must satisfy service requirements that do not have anything to do with OT - i.e.. stats, large caseloads with limited outputs/resources and indeed Rebeiro states that the âpromotion of client-centred occupational therapy may be more possible outside of the medical model and within the framework of health promotion and wellness models.â (2000)
4. cultural barriers (ie. booking interpreter)
5. Not listening to clientâs goals (ie. younger client wants to be more physically active and for ADLs to be the rehab, but OT modifies home environment to reduce movement - may be more relevant adaptation for elderly person)
"Client- driven practice is described as a relationship between the professional and client that places decision making control in the hands of the client. Operationalisation of this intervention model is based on a philosophy of client empowerment and a belief that the perception of the client is the only reality that matters."
Gage, M. (1995) Re-engineering of Health Care: Opportunity or threat for occupational therapists? Canadian Journal of Occupational Therapy. 62(4) p197-207
A CALL TO ACTION
Preserve the Value of the Profession (Advocate at national and state levels)
how? what is effective advocacy?
Educate the Public (we need great marketing!) - âoccupational?!?! but iâm not ready to go back to work!â
How? Talk with friends/clients/strangers about what OTâs do and not just what youâre going to do for them.
Capacity Building within the OT profession
How? networks and resources, working intelligently
Individual level - Self care - reflection, prof. development,
managing burn-out
how? OT is an emotionally draining job. We put a lot of ourselves into what we do. Look after yourself! You canât help others if youâre not looking out for yourself. Quality over Quantity
leave a Legacy
how? Educate your prac students. Teach them about the intricacies of the client-therapist relationship. This is something that is nigh impossible to teach with case studies in a classroom.
Putting the Client into CCP - relationship building with client, communication, negotiating goals and priorities, honesty, professionalism, client is active
how? Knowledge is power. take the time to reflect on your work, specifically about the how your aims, your workplaceâs aims and the clients aims intersect and more importantly how they differ.