What are the origins of client centered practice in occupational therapy?
The first guidelines for Client entered Practice and Occupational Therapy, were published in Canada. (Canadian Association of Occupational Therapists, 1991) Drawing on the work of humanist Psychologist, Carl Rogers (1950) Rogers description of working Collaboratively with people emphasized that clients are active participants, not passive recipients, of care; a view that fits well with one occupational therapy’s founding principle of doing with people rather than doing to or for them. (Townsend & Polatajko, 2013).
Why is client centered practice important in occupational therapy?
Centred practise is an approach to providing occupational therapy. Which embraces a philosophy of respect for, and partnership with, people receiving services. Client centered practise recognised the autonomy of individuals, the need for client choice in making decisions about occupational needs, the strengths clients bring to therapy encounter, the benefits of client therapist partnership and the need to ensure that services are accessible and fit for the context in which a client lives. (Law et al., 1995,p. 253)
Clients describe client centered practise as being collaborative practise undertaken by therapists who clearly value and respect their clients, who seek and respect clients experience and knowledge, who choose closeness over distance and attachment, who create supportive and accepting relationships with clients, and who are kind. (Whalley Hammell, 2013b, p. 175)
What is client centered practice and what are some of its key features?
Client centered practice key features:
* Power: Implementing authentic client centered practice necessitates an understanding of the influence of power. This includes awareness of one’s own power and position as a therapist; the ways in which health professionals and social conditions can disempower people or limit their ability to express their views, make choices and direct their lives. Client centered practice involves working actively to reduce power and inequality’s and to support clients to exercise power themselves.
- Listening and communicating: Effective listening and communicating is essential to addressing issues of power. For example, using language that the client can understand, communicates respect and intent to work in partnership and provides information that the client needs in an accessible way. Listening is essential to understand clients lives and situations; clients feel they are valued and respected when they feel listened to. Communication information effectively to facilitate understanding is essential to enabling clients to make choices and decisions that affect them.
- Partnership: Partnership involves working together in a respectful and supportive manner. Characteristics of effective partnership working include developing an understanding of the others experience, flexibility, willingness to share knowledge and to negotiate courses of action.
- Choice: Choice is a key element of working in partnership. Respect of clients, values, preferences and rights are central to enabling and supporting clients choice and decision making. Opportunities for choice can be ensured through occupational therapy processes with clients, for example, choices within sessions, choices about interventions, equipment and support provided, and choices about the focus and goals of occupational therapy services.
- Hope: Appreciating the importance of hope, encouragement and fostering a sense of accomplishment is critical in client centered interventions. People’s hopes vary so that seeking to understand the clients’ hopes is important. When it is difficult for clients to see progress or that something good will happen, holding hope for clients is also important.
- Respect: Respect for clients. Respect for clients, strengths and diversity of experience and knowledge. Respect for clients rights to make choices and decisions about their own lives and situations.
- Strength focus: Seeking to understand and deploy the talents, abilities, resources and strengths of a client, family, group, or community.
What factors may influence the implementation of a client centred approach in practice?
- Physical environment
- Social
- Institutional
- Cultural environment
- Age
- Gender
- Language preference
- Socio economic status
- Values
- Religious beliefs
- Cultural beliefs
- Experiences of trauma
- Disadvantage
- Discrimination
What values, knowledge and skills help to optimize the client centered nature of an occupational therapist practice?
Listening deeply for less visible explanations behind behavior and to consider how past and current power differences might be influencing behavior.
Professional expertise, provision of hope and sharing of information were valued, but participants also identified the need to genuinely partner with their therapists in order to feel understood.
Therapists must understand each client’s unique journey and their subjective experience of recovery, and to be willing to adapt therapy in line with the fluctuations in fatigue and low motivation. (P 127)
How might you use each of the strengths-based dimensions in practice?
- Listening respectfully to the person:
It is important to listen with interest and compassion and consider where the person’s story begins. A person’s story begins at a different time to the referral. The referral information is crucial because it can often set the tone for the therapeutic relationship, influencing what is heard and perhaps more importantly, what is not heard. Barker and Buchanan Barker (2005)
In occupational therapy Deep listening should include reflecting on how the occupational therapy lens may not necessarily privilege the person and their lived experiences, but instead it may privilege Western ideologies. (Gibson et al., 2020a) For example, there are distinct differences between Indigenous and Western conceptualizations of health, disability and occupations. Yet the lens of occupational therapy can be biassed, often favouring Western ways of knowing, being and doing. (Gibson et al., 2020a; Gibson et al., 2020b) (Page 132) - Using appropriate communication skills
Appropriate communication skills include occupational therapists using generic interview skills. Like active listening, asking open-ended questions and promoting strength based language. Examples of active listening skills include paying attention to the person, using facial expressions and gestures such as smiling or nodding, reserving judgement, summarising what you hear, and seeking clarification about what you are hearing.
Applying these skills can create the space required for people to lead the conversation and share the parts of their story that are most defining to them and their social and emotional well-being. This can help the occupational therapist to begin to learn the unique cultural, social, historical and political context the person may be speaking and acting from and within. (Page 132) - Building authentic partnerships
Authentic partnerships refer to developing relationships between two or more people which are trusting, meaningful and equal (Corrigan & Burton, 2014).
Authentic Partnerships provides opportunities for building and extending relationships, valuing and privileging diverse worldviews, developing reflexive and responsive services, facilitating cultural competency, and, importantly, supporting a human rights approach(Taylor & Thompson, 2011)
A three Pronged approach has been developed in order to establish partnerships with Aboriginal and Torres Strait Islander people. Consult page 133 – 134 to find this three pronged approach.
Define the 3 steps of preparation, Action and Maintenance when communicating
Preparation requires occupational therapists to critically reflect and develop an understanding of the Australian context. This involves reflecting on current ways of knowing, being and doing, and continually evaluating if these approaches are appropriate when working with Aboriginal and Torres Strait Islander people. Occupational therapists must be committed to respecting, understanding and incorporating diverse voices that will stem from these partnerships. This commitment may include learning about the community, community perspectives, and beliefs on local histories like prior relationships between Aboriginal and Torres Strait Islander people and service providers. There is a long history of services not doing the right thing by communities and it is important to understand and work towards healing any wrongs of the past. Even if you were not directly involved in past experiences.
Action is important when establishing relationships and continuing relationships within communities. You must take time to get to know the community, or even multiple communities that are within the confines of the service boundary. Discuss multiple ways that businesses can be done and be ready to create a new way of working. Develop shared partnership goals, shared communication processes, and shared accountability for all partnership outcomes. It is just as important to share partnership successes as it is any partnership challenges. (Gibson et al., 2015). Sometimes occupational therapists may work in a service that will not change in the way it conducts business to accommodate a human rights-based approach. If this is the case, then the occupational therapist will need to decide on the action they will take or not take. Actions may include advocating for change, leaving the workplace to find another workplace that aligns with your values, or accepting a less than desirable status quo in partnership arrangements. However, when operating in such environments that do not accommodate a human rights-based approach, note that indigenous clients may be skeptical about developing relationships.
Maintenance is essential when maintaining healthy partnerships. Being consistent and reliable is important. Continue to be present and follow up any promises made. Demonstrate integrity by doing what you say, even if no one else is present. If things change and you cannot do what you say. Then go back to your partners discussed and find out ways forward.
Common pitfalls for health service providers who form partnerships with Aboriginal and Torres Straight Islander people include the health service provider assuming the role of the leader or decision maker, being unable to navigate or reflect on one’s personal beliefs, discrediting and devaluing community members, not including communities perspectives, not fulfilling promises and finally projecting a mission day approach.
Critically reflecting on Australia’s political, social and historical contexts.
In order for critical reflection to take place you must move through discomfort and focus on correcting previous mistakes in order to achieve better outcomes in the future.
How can you broaden your understanding of the Australian political, historical and social contexts so that you can deepen your critical reflections?
Critical reflection refers to the ability to design, analyze, evaluate and readjust practice with the aim of improving professional outcomes (Lyons, 2010).
To reflect critically on Australia’s political, social and historical contexts, we require an understanding of colonization on a global scale.
Understand that perspectives dominating discourses about occupations continue to be based on Western and Judaeo-Christian ideologies and this restricts the applicability across cultures (Hocking, 2009). In more recent years, occupational therapy scholars are contributing to the literature by exploring and expanding beyond Western and Judaeo-Christian ideologies. Iwama (2006)
How might you use Aboriginal and Torres Straight Islander peoples science, practice and leadership to become aware of your gaps in knowledge?
Aboriginal and Torres Straight Islander people have a right to participate and lead any decisions that affect them ( Australian Human Rights Commission, 2010, p, 40)
As stated above, Occupational therapists hold a duty to consult and partner with Aboriginal and tourist Strait Islander people whenever a decision will affect an individual or community. For example, when developing group programs, consult with local elders and relevant community groups to ensure a need exists and that codesign of the program can occur.
Each community will have its ideas about decision making, structures and practices and you can assist in uncovering or Co developing these via longstanding partnerships. Importantly, diverse governance structures and practices exist within what you might view as on community, and as such, develop flexible and multiple partnership arrangements so all needs are met.
What strategies and actions will you take if you’re employed in a workplace that will not allow you to operationalize a strength based approach?
- Advocate for change.
- Consider your own continuation of employment.
- Understand why you aren’t allowed.
- Discuss this topic with coworkers and people higher up.
Why is a decolonizing lens essential to use in a strengths based approach?
- Innovative strategies need to be used to enable people to participate meaningfully (Nimegreer et al., 2011, in Hunt, 2013a)
- Evaluation with Aboriginal and Torres Strait Islander people is about self determination, empowering Aboriginal and Torres Strait Islander families to identify for themselves and exercise opportunities to live well according to Aboriginal and Torres Strait Islander values and beliefs. To do this, occupational therapists need to reshape accountabilities and organizational structures that support better evaluation.
- Evaluation process will fail all key parties when they do not address power and inequality’s, expect Indigenous people to function in Western bureaucratic processes, Favor Western knowledge over indigenous knowledges.
- Aboriginal and Torres Strait Islander peoples involvement in evaluation acknowledges that Aboriginal and tourist Strait Islander people are the best people to decide how to address issues faced by Aboriginal and Torres Strait Islander communities (Australian Human Rights Commission, 2010, p. 41), and Williams’ (2018) Ngaa binya Aboriginal and Torres Straight Islander Program Evaluation Framework provides an exemplar that individuals and organizations can use.
