Article Canadian Journal of Occupational Therapy

80(3) 141-149
DOI: 10.1177/0008417413497906

Client-centred occupational therapy ª CAOT 2013

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Recentrer l’ergothérapie au Canada sur les valeurs

fondamentales de la pratique centrée sur le client

Karen R. Whalley Hammell

Key words: Autonomy; Critical thinking; Culture; Models; Power.

Mots clés : autonomie; culture; modèles; pensée critique; pouvoir.

Abstract
Background. The Canadian occupational therapy profession has proclaimed its allegiance to client-centred practice for three
decades. However, official definitions of client-centred practice have been inconsistent, and its defining features, underlying
assumptions, and power relations have been subjected to little critical reflection. Purpose. The aim was to reflect critically
on Canadian conceptions of client-centred practice and its core values. Key issues. Definitions of client-centred practice have
evolved and changed, suggesting that the occupational therapy profession in Canada may have abandoned those values that
originally underpinned its vision of client-centred practice by electing to focus on the enabling skills of therapists. However,
evidence suggests that clients value those qualities of client-centred practice that underpinned the profession’s original vision.
Implications. This paper proposes a renewed focus on respect—respect for clients; respect for clients’ strengths, experience,
and knowledge; respect for clients’ moral right to make choices concerning their lives—and on fostering respectful, supportive
relationships with clients.

Abrégé
Description. Pendant trois décennies, la profession de l’ergothérapie au Canada a proclamé son allégeance à la pratique centrée
sur le client. Toutefois, les définitions officielles de la pratique centrée sur le client ont été inconstantes, et les caractéristiques,
suppositions sous-jacentes et relations de pouvoir qui la définissent ont fait l’objet de peu de réflexion critique. But. Faire une
réflexion critique face aux conceptions canadiennes sur la pratique centrée sur le client et ses valeurs fondamentales.
Questions clés. Les définitions de la pratique centrée sur le client ont évolué et changé au fil du temps, ce qui suggère que
la profession de l’ergothérapie au Canada a peut-être abandonné les valeurs qui sous-tendaient initialement sa vision de la pratique
centrée sur le client, en choisissant de mettre l’accent sur les compétences en habilitation des ergothérapeutes. Cependant, des
données probantes indiquent que les clients valorisent les caractéristiques de la pratique centrée sur le client qui sous-tendent la
vision originale de la profession. Conséquences. Cet article propose de recentrer la pratique sur le respect; le respect des
clients, le respect des forces, de l’expérience et des connaissances des clients, le respect du droit moral des clients de faire
des choix face à leur vie; et de favoriser les relations respectueuses et de soutien avec les clients.

Funding: No funding was received in support of this work.

Corresponding author: Karen R. Whalley Hammell, Box 515, Oxbow, SK, Canada, S0C 2B0. E-mail: ik.hammell@sasktel.net

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142
F
or the past three decades, the Canadian occupational
therapy profession has been proclaiming its allegiance
to client-centred practice (see Canadian Association
of Occupational Therapists [CAOT], 1997, 2002; Department
of National Health and Welfare [DNHW] & CAOT, 1983),
‘‘an approach to service which embraces a philosophy of respect
for, and partnership with, people receiving services’’ (Law, Bap-
tiste, & Mills, 1995, p. 253). It was more than a decade before a
formal definition of client-centred practice in Canadian occupa-
tional therapy was articulated (Law et al., 1995), and in subse-
quent years, this definition has evolved and changed.
The World Federation of Occupational Therapists’ (2010a)
position statement titled Client-Centredness in Occupational
Therapy declares that ‘‘occupational therapy is client-centered’’
and that ‘‘occupational therapists are person-centred in their
relationships with all their clients’’ (p. 1). Similarly, on its offi-
cial e-mails, the CAOT claims to promote the ‘‘client-centred
profession of occupational therapy.’’ These statements imply
that the occupational therapy profession, by definition, is cli-
ent-centred—that if we are ‘‘doing’’ occupational therapy, we
are inevitably engaged in client-centred practice (Hammell,
2013). Indeed, the assumption that occupational therapists con-
sistently practice in a client-centred manner has become central
to the profession’s political rhetoric and self-image (Hammell,
2010), despite the dearth of supportive evidence (Hammell,
2013). In reality, client-centred practice and its defining features,
underlying assumptions, and power relations have been sub-
jected to little critical reflection within the occupational therapy
profession.
Although the principles underlying client-centred practice
have intuitive appeal, this concept is not unproblematic. It is
clear that the profession’s espousal of client-centred practice
reflected a sincere desire to engage in occupational therapy that
genuinely addresses the priorities and needs of service users. It
is also apparent that current rhetoric concerning client-centred
(or ‘‘person-centred’’) practice may be inapplicable to people
whose cultures differ from dominant ‘‘norms’’ and that impos-
ing client-centred practice as this is currently conceptualized
may thwart rather than facilitate this humanistic endeavour.
Moreover, despite the reality that we live in an unequal world
in which such intersecting factors as race, gender, class, sexual
orientation, physical ability, and educational and financial sta-
tus significantly determine access to power and privilege
(Pease, 2010), the power dynamics at play in therapist–client
interactions are seldom acknowledged or critiqued. Clearly,
only the privileged can overlook or ignore the impact of inequi-
table power relations on the ill, injured, and disadvantaged
people who seek our professional services.
A previous paper examined the authenticity and veracity
of the occupational therapy profession’s espoused commitment
to client-centred practices (Hammell, 2013). However, critics
contend that ‘‘the issue for rehabilitation is not as much being
more ‘person-centred’ as it is to produce a consistent and
operative concept out of the notion of person-centredness’’
(Gzil et al., 2007, p. 1623). Accordingly, this paper focuses
on the core values of client-centred practice and upon the
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Hammell
inconsistent definitions of client-centred practice that have
been evolving within the CAOT’s literature. It will not address
the actual practices—client-centred or otherwise—of occupa-
tional therapists.
Moreover, although occupational therapists at the
CanChild Centre for Childhood Disability Research at McMas-
ter University have articulated the principles and elements of
‘‘family-centred’’ services (see Law et al., 2003) and have stud-
ied in depth the impact of these services on families, these prin-
ciples have not been officially sanctioned or promoted by the
profession’s national association, so are not discussed in the
context of this paper.
The intent of this paper is to encourage occupational
therapists to reflect critically on conceptions of client-centred
practice promoted by the profession in Canada. Critical think-
ing is an intellectual practice that challenges assumptions,
ideologies, and taken-for-granted ways of thinking and is con-
cerned with issues of power (Eakin, Robertson, Poland,
Coburn, & Edwards, 1996; Gibson, Nixon, & Nicholls, 2010;
Hammell, 2013). Thus, critical reflection on our professional
assumptions encourages us to ask: If our primary aim is to
engage in occupational therapy practices that genuinely
address the priorities and needs of service users, does current
client-centred (or person-centred) rhetoric facilitate or obfus-
cate this endeavour? (Leplege et al., 2007; McPherson & Sie-
gert, 2007). It is hoped that reflecting critically on Canadian
conceptions of client-centred practice will encourage occupa-
tional therapists to refocus on their original core values.
Canadian Conceptions of Client-Centred
Practice
The impulsion toward client-centred practice derived from the
demands of Western consumer movements for greater client
involvement in the decisions concerning their lives and from
occupational therapists’ sincere desire to work in ways that
would be less standardized and prescriptive and more respon-
sive to clients’ needs and lives (DNHW & CAOT, 1983; Law
& Mills, 1998). Originally conceived as an approach to the prac-
tices of psychology and counselling (Leplege et al., 2007),
client-centred practice was subsequently embraced not only by
occupational therapists but by practitioners in other health care
professions, such as physiotherapy (Chartered Society of
Physiotherapy, 1996), social work (Law et al., 1995), and nur-
sing (Copperman & Morrison, 1995).
The earliest definition of client-centred practice in the
Canadian occupational therapy literature was articulated by
Law et al. (1995).
Client-centred practice is an approach to providing occupa-
tional therapy, which embraces a philosophy of respect for,
and partnership with, people receiving services. Client-
centred practice recognizes the autonomy of individuals, the
need for client choice in making decisions about occupational
needs, the strengths clients bring to a therapy encounter, the
Canadian Journal of Occupational Therapy 80(3)
benefits of client-therapist partnership and the need to ensure
that services are accessible and fit the context in which a cli-
ent lives. (p. 253)
Subsequently, in Enabling Occupation: An Occupational
Therapy Perspective (CAOT, 1997), client-centred practice
was defined as ‘‘collaborative and partnership approaches used
in enabling occupation with clients’’; and client-centred occu-
pational therapists were said to ‘‘demonstrate respect for cli-
ents, involve clients in decision making, advocate with and
for clients’ needs, and otherwise recognize clients’ experience
and knowledge’’ (p. 180). These two important and influential
declarations (see Law et al., 1995; CAOT, 1997) reflect similar
core values. Both explicitly value respect for clients, both
prioritize collaborative relationships and/or partnerships
between therapists and clients, both identify the need for client
choice and involvement in decision making, and both explicitly
respect clients’ strengths (experience and knowledge).
When Enabling Occupation: An Occupational Therapy
Perspective was revised (CAOT, 2002), client-centred practice
was depicted as ‘‘individualized, group and organizational
level approaches that enable clients to participate as decision-
making partners in their therapy’’ (Townsend, 2002, p. 6). This
depiction represented a renewed focus on decision-making
partnerships, although because there was no reference to the
other values that underpinned prior definitions—notably,
‘‘respect’’—the Canadian occupational therapy profession’s
definition of client-centred practice began, at this juncture, to
lose consistency. I believe it also lost its orientation.
Enabling Occupation II: Advancing an Occupational
Therapy Vision for Health, Well-Being, & Justice Through
Occupation (Townsend & Polatajko, 2007) does not include
the term client-centred practice in its glossary but refers
instead to client-centred enablement. This term appears to
reflect an aspiration to frame client-centred principles within
the specific discourse of occupational therapy, in which
‘‘enablement’’ was declared in 2007 to be ‘‘occupational thera-
pists’ core competency’’ (Townsend, Beagan, et al., 2007, p.
109). In the glossary, Enabling Occupation II states that
client-centred enablement is ‘‘based on enablement founda-
tions and employs enablement skills in a collaborative relation-
ship with clients who may be individuals, families, groups,
communities, organizations, populations to advance a vision
of health, well-being and justice through occupation’’ (Town-
send & Polatajko, 2007, p. 365). This manifesto for practice
thus retains reference to collaborative relationships but omits
previous values of respect, choice, and explicit recognition of
clients’ strengths, experiences, and knowledge. More attention,
in this definition, is focused on who might constitute a client as
well as on the overarching vision of the Canadian occupational
therapy profession, claimed to be the achievement of health,
well-being, and justice through occupation.
However, client-centred enablement is a contentious term.
Hammell (2013) observed that
the concept of enablement – defined by dictionaries as a
process of allowing, permitting, making able, giving power,
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143
making possible – implies a hierarchical relationship in
which the powerful allow opportunities and bestow abilities
on the powerless. [thus] placing the words ‘‘client-centred’’
beside the word ‘‘enablement’’ constitutes an oxymoron.
(p. 175)
Moreover, the word enablement is not inherently positive.
Amongst those concerned with addictions, for example, the
label enabler carries very negative connotations. Neither does
a collaborative relationship with clients seem wholly compati-
ble with a form of practice in which only the (enablement)
skills of the occupational therapist are privileged without any
mention of the strengths, experience, and knowledge that
clients contribute. Indeed, the Canadian Model of Client-
Centred Enablement (Townsend, Polatajko, Craik, & Davis,
2007) is a model in which therapists act and therapists ‘‘do,’’
and clients’ contributions are not mentioned.
Leplege et al. (2007) reviewed the historical and concep-
tual dimensions of person-centred, or client-centred, practice
in rehabilitation and noted that there are multiple visions of
what client-centred practice is or ought to be. They concluded
that rehabilitation practitioners ‘‘might get a better sense of
what it should be and what it should do by focusing less on the
rhetoric of person-centredness and by putting more emphasis
on the investigation and operationalization of its key concep-
tual components’’ (Leplege et al., 2007, p. 1555). This would
currently be a difficult undertaking for the occupational therapy
profession in Canada because the key conceptual components
of client-centredness have been altered radically from those
originally espoused and embraced by the profession.
What Clients Value in Client-Centred Practice
Few researchers have explored clients’ experiences and perspec-
tives of client-centred rehabilitation practice, suggesting that the
professions’ claims to this modus operandi might be somewhat
fallacious. However, the reports of the few who have sought this
information are remarkably consistent, describing collaborative
practice undertaken by therapists who obviously value and
respect their clients; who choose closeness over distance and
detachment; who create supportive, accepting relationships with
clients; who seek and respect clients’ experience and knowledge;
and who are kind (Bibyk et al., 1999; Blank, 2004; Corring,
1999; French, 2004a; Mangset, Dahl, Førde, & Wyller, 2008;
Marquis & Jackson, 2000; Meade, Carr, Ellenbogen, & Barrett,
2011; Rebeiro, 2000).
Client-centred practice is characterized in these reports as
being undertaken by therapists who strive to reduce power
inequalities, who help clients to make choices and decisions
about their lives, who are neither authoritarian nor judgemen-
tal, and who listen to clients (Bibyk et al., 1999; Blank,
2004; Corring, 1999; Cott, 2004; French, 2004a; Marquis &
Jackson, 2000). Thus, although little effort has been expended
by the occupational therapy profession to explore clients’
perspectives on what constitutes practice worthy of the name
client-centred (Blank, 2004; Corring, 1999; Hammell, 2013),
these reports do provide some valuable insights.
Revue canadienne d’ergothérapie
144
Critical Reflection on the Operationalization of
Client-Centred Practice
Bright, Boland, Rutherford, Kayes, and McPherson (2012)
undertook a study to explore how client-centred practice was
operationalized in the context of their workplaces. The process
of critical reflection required by the study elicited the insight
that their practices prior to the research were not, in reality,
client-centred. Although they had perceived themselves to have
been responsive to clients’ lives, critical reflection enabled them
to recognize that ‘‘our dominant model of care was assessment-
based and deficit-driven. . . . Our relationship with clients was
driven by the need to assess, prescribe and treat. . . . We were
often setting goals for people, goals that worked with what our
service could offer’’ (Bright et al., 2012, p. 999).
The insights derived from critical reflection compelled
significant alterations to their practice and enabled a sophisti-
cated understanding of what is required to practice in an
authentically client-centred manner. These practitioner/
researchers discovered that ‘‘being with’’ clients might be more
important than ‘‘doing to’’ them (Bright et al., 2012). Being
with clients entailed a commitment to active listening, allowing
time to get to know clients and uncover and understand what
was meaningful to them, and supporting clients to prioritize
their hopes, plans, and goals. It also required therapists to view
their role differently, ‘‘moving from being an expert clinician
to more of a coach, handing power back to the client’’ (Bright
et al., 2012, p. 1001). Bright et al. (2012) concluded that ‘‘shift-
ing the focus from ‘what can I do for this person’ to ‘who is this
person and what do they need’ may be a strategy that promotes
a client-centred partnership with shared power’’ (p. 1002).
Client-Centred Practice and Autonomy
The assumptions that underpin current conceptions of client-
centred practice developed within a specific Western context.
Thus, the assertion that ‘‘client-centred practice recognizes the
autonomy of individuals’’ (Law et al., 1995, p. 253) is some-
times construed to be a specifically middle-class, Western
assumption that privileges and promotes egocentric notions
of individualism and independence while failing to recognize
that all people are interdependent, social beings (Cardol,
DeJong, & Ward, 2002; Saadah, 2002). For example, the claim
that ‘‘humans participate in occupations as autonomous
agents’’ (Townsend & Wilcock, 2003, p. 255) relies on the pre-
mise that all people, in all circumstances, have the opportunity
and desire to be autonomous agents: able to control their own
destinies unrestricted by cultural, social, political, or religious
norms or constraints (Saadah, 2002). This portrayal of
autonomy as agency—as the ability and desire to direct one’s
own life—tacitly advances an individualist ideology that is
considered normal, indeed admirable, in a Northern/Western
culture but that is not universally shared (Iwama, 2006).
However, autonomy refers both to the moral right and to the
opportunity to enact choices for one’s own life. Autonomy refers
not to absolute control but to an ability to influence, make
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Hammell
choices, and manage one’s life as situations and roles demand
and personal preferences dictate (Hammell, 2006). It is in this
sense that ‘‘respect for autonomy’’ constitutes one of the five
central principles of clinical ethics (French, 2004b; Jonsen, Sieg-
ler, & Winslade, 1998). From this perspective, the assertion that
‘‘client-centred practice recognizes the autonomy of individu-
als’’ (Law et al., 1995, p. 253) can be seen as a declaration of
respect: respect for clients’ moral right to make choices that
affect their lives. Medical ethicists employ person-centred evi-
dence to support their premise that ‘‘respect for persons’’ ought
to be the ‘‘first principle of bioethics’’ (Joffe, Manocchia,
Weeks, & Cleary, 2003, p. 106).
Client-Centred Practice and Cultural Diversity
Critical theorists observe ‘‘that the way we think is a product of
our history and of the values promoted in our society’’ (Nelson,
2009, p. 99). Regrettably, Gerlach (2012) has noted that ‘‘the
[occupational therapy] profession’s ethnocentricity appears
remarkably resilient as Western assumptions, values, and
worldviews are perpetuated in largely subtle and silent ways’’
(p.156). One need not look far for an example. The CAOT
celebrates its success in exporting, without amendment, its
guidelines and manuals throughout the world (CAOT, 2002),
as if the rest of the world ought to learn from our wisdom (Ife,
2008) and as if models of occupation and ideas about client-
centred practice developed in a specific, Canadian context are
applicable to everyone, everywhere (Hammell, 2013). Critics
contend that they are not. Iwama (1999, 2006), for example,
noted that a client-centred approach to occupational therapy
would be extremely difficult to implement in a Japanese
cultural context, where service users expect to receive instruc-
tions from a professional ‘‘expert’’ rather than articulating their
own goals and expectations. Further, Western conceptions of
client-centred practice envision individual clients making inde-
pendent decisions about their own lives. This promotes and
perpetuates an explicitly individualistic view of client-centred
practice rather than expanding an understanding of clients as
potentially including couples, families, groups, and commu-
nities. Moreover, this ideology fails to reflect the perspectives
of the majority of the world’s people, who value interdepen-
dence, reciprocity, and sense of belonging and who may wish
to make decisions in consultation with others, congruent with
their roles and cultural expectations (Hammell & Iwama,
2012; Iwama, 2006).
Culture describes the knowledge, beliefs, values, assump-
tions, perspectives, norms and customs that people acquire
through membership in a particular society or group (Hammell,
2009a). Critical theorists contend that dominant theories of occu-
pation reflect the culturally specific perspectives of a minority of
the global population, being derived predominantly from highly
educated, middle-class, White, urban, Western, able-bodied
experiences (Hammell, 2009a, 2009b; Iwama, 2005). The same
argument could be made for the concept of client-centred
practice, which is promoted by the occupational therapy profes-
sion in Canada with little apparent effort to ascertain whether the
Canadian Journal of Occupational Therapy 80(3)
underlying assumptions are shared globally or, indeed, whether
they are shared by culturally diverse people within Canada.
Cultural diversity pertains not solely to ethnicity or race but to
any dimension of difference, including—but not limited to—
class, gender, sexual orientation, and ability (CAOT, 2007).
In an effort to counteract ethnocentrism, Beagan and
Chacala (2012) have suggested that occupational therapists
should strive for cultural humility. Cultural humility demands
a critical awareness of one’s own assumptions, beliefs, values,
and biases; an understanding of how one’s own perspectives
may differ from those of other people; and an acknowledge-
ment of the unearned advantages, privileges, and power that
derive from multiple dimensions of one’s own particular social
position. Instead of seeing clients as ‘‘different’’ from the
cultural norms of the therapist, cultural humility recognizes
that cultural differences lie within the therapist–client relation-
ship (Tervalon & Murray-Garcia, 1998). The starting point for
working across these differences consists in developing a
critical consciousness of one’s own power and privilege (Doane
& Varcoe, 2005). Aspirations toward cultural humility require
occupational therapists to examine critically the cultural values
and assumptions that underpin their theories and practices.
In addition, cultural humility emphasizes the need to
respect and be open to clients’ culturally based understandings
of their lives and to acknowledge the impact of structural
inequalities on their occupational opportunities and well-
being. The World Federation of Occupational Therapists
(2010b) has advocated for ‘‘culturally safe’’ practices, in which
clients do not feel diminished, demeaned, or disempowered by
ethnocentric or judgemental professional practices or structures
(Wood & Schwass, 1993). Whether or not occupational thera-
pists are delivering culturally safe services can be determined
only by clients, of course, but cultural humility may be one
approach to enhancing the possibility that they will deem our
practices to be ‘‘safe.’’ It could reasonably be argued that
cultural humility is an essential component of client-centred
practice in that it self-consciously acknowledges the power
inequalities that lie at the heart of client-therapist relationships.
Client-Centred Practice: Professional Power
Although ‘‘understanding the influence of power is fundamen-
tal to implementing authentic client-centred practice’’ (Sum-
sion & Law, 2006, p. 155), there has been little examination
of the historical and social positioning of occupational
therapists and clients or of the unearned privilege and power
that occupational therapists possess if and when they are mem-
bers of the dominant culture (Nelson, 2007). Positioning per-
tains to one’s social location in terms of such dimensions as
gender, class and caste, race, ethnicity, age, sexual orientation,
religion, physical ability, language, nationality, citizenship sta-
tus, migration history, education, professional and employment
statuses, and material wealth (Hammell, 2006). Entrenched
social structures confer unequal access to opportunities, power,
and resources for those in different social positions; thus posi-
tioning is not just an issue of cultural values and assumptions
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145
but of occupational opportunities, privilege, and power. Differ-
ences in positioning may both shape and limit the degree to
which clients feel able to participate in a collaborative partner-
ship with therapists.
Coleridge (1993) suggested that therapists are ‘‘unwitting
cogs’’ in an oppressive system in which professionals see
themselves as ‘‘experts’’ and in which they ‘‘relate to disabled
people from a position of power and dominance, not equality’’
(p. 75). The suggestion that occupational therapists are ‘‘unwit-
ting’’ cogs alludes, perhaps correctly, to the lack of critical
reflection within the occupational therapy profession concern-
ing our power, dominance, and claim to expert status and the
impact of this and other professionalizing strategies on our
abilities to work collaboratively with clients. The occupational
therapy profession has not engaged in sustained critical
reflection about the vulnerability of many clients and the asym-
metrical power relations that make meaningful partnerships
with professionals inordinately difficult. In addition, although
researchers have explored perceived barriers to client-centred
practice from the perspectives of occupational therapists (Kjell-
berg, Kåhlin, Haglund, & Taylor, 2012; Sumsion, 2005), little
attention has focused on clients’ perceptions of those profes-
sional practices and structures that constitute barriers to
client-centred occupational therapy. It is apparent that concerted
efforts are required to explore clients’ perspectives on the client-
centred nature of their interactions with therapists, the structural
and professional barriers that conspire to thwart client-centred
aspirations, and how these might be overcome.
It is puzzling that the occupational therapy profession has
expended little effort in exploring issues of power when power-
lessness is central to the experience—and even the definition—
of disability (Barnes & Mercer, 2003). Indeed, to disable is ‘‘to
deprive of power’’ (Chambers, 1972). Powerlessness is most
likely to be experienced when there is a marked divide between
those wielding decision-making authority (like occupational
therapists) and those in subordinate statuses, like clients
(Barnes & Mercer, 2003). French (1994) observed that
professionals usually receive above average pay, high status,
and autonomy in their work. They have the power to control
the encounter with their patients or clients; setting the agenda,
managing time to suit their own schedules, defining problems
and the appropriate solutions to them and making all the
decisions. (p. 109)
When Foucault (1980) observed that knowledge is insepar-
able from power, he drew attention to the reality that the work
of rehabilitation—categorizing, assessing, measuring, and
adjusting individuals toward a socially constructed and valued
norm—is an expression and assertion of power (Hammell,
2006). However, it is apparent that the rehabilitation profes-
sions have barely begun the work of critiquing their location
within power, choosing, instead, to promulgate ‘‘notions of
innocent helping by dedicated professionals’’ (Rossiter, 2000,
p. 32). Hammell (2006) noted that while the word professional
is deemed praiseworthy by some people (notably, profession-
als), for clients, the observation that a therapist is ‘‘just a
Revue canadienne d’ergothérapie
146
professional’’ is used in a derogatory manner, denoting some-
one perceived to be cold, detached, ‘‘neutral,’’ and ‘‘just doing
her [sic] job’’ (French, 2004a, p. 101).
However, Rebeiro (2004) identified that occupational
therapy clients respect and value therapists who are able to
be professional in a ‘‘non-professional’’ way. They described
these special professionals as fostering respectful, equal, and
reciprocal relationships with clients and demonstrating consis-
tency between what was said and what was done. These find-
ings are echoed by other researchers who report that positive
relationships between occupational therapists and their clients
are able to transcend power differentials if therapists are warm
toward, listen to, and care for their clients; have obvious respect
for clients; show acceptance and genuine interest in clients; and
demonstrate that they can be trusted (Blank, 2004; Bright et al.,
2012). Blank (2004) muses, however, that ‘‘whether or not this
is a partnership is less clear’’ (p. 123)
Client-Centred Practice and Decision-Making
Partnerships
Accumulating data indicate that clients and patients may not all,
at all times, wish to take responsibility for their treatment deci-
sions, preferring to delegate at least some decisions to their
health care providers (Joffe et al., 2003; Palmadottir, 2003,
2006). This echoes Iwama’s (1999, 2006) observations above
and suggests that simplistic depictions of client-centred practice
as ‘‘individualized, group, and organizational level approaches
that enable clients to participate as decision-making partners in
their therapy’’ (Townsend, 2002, p. 6) may be misguided.
The premise that decision-making partnerships constitute
the core principle of client-centred practice is a recent claim.
Moreover, Palmadottir (2006) noted,
Evidence from research in rehabilitation suggests that clients
do not necessarily expect to be actively involved in the
planning and implementation of therapy. Not all clients are
interested in sharing responsibility and some will actually
choose to have professionals make decisions for them. (p. 399)
A Swedish study into client perspectives of occupational
therapy found that although some clients had experienced close
working partnerships with their therapists, others reported that
their therapist made most of the decisions; however, ‘‘none of
the participants complained about this arrangement and some
of them mentioned that it was based on their genuine trust in
the therapist’’ (Palmadottir, 2003, pp. 161-162). Those who
complained about their occupational therapy had experienced
little power, a lack of information, and no sense of where ther-
apy was heading. Those who described occupational therapy as
having a positive impact on their lives saw their relationship
with their therapist as equal and based on mutual trust and
respect (Palmadottir, 2003).
Research undertaken in England to explore clients’ experi-
ences of occupational therapy prompted the researcher to ponder,
Perhaps it is the case that, as a profession, occupational ther-
apy has made an assumption that clients wish to be partners in
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Hammell
health care when, in fact, what they need first is to feel valued,
listened to, and cared for. (Blank, 2004, p. 122)
Clearly, these findings should be used neither to condone
maternalism/paternalism nor to imply that efforts to enhance
shared decision making are misguided (Joffe et al., 2003) but
rather to contend that therapists need to ensure their clients
know they are cared for, listened to, valued, and respected; and
to suggest that authentic client-centred practice does not hinge
on decision-making partnerships.
Client-Centred Practice ¼ Respect
So far, this brief exploration of the concept of client-centred
practice has identified a recurring theme: that practice worthy
of the name client-centred is fundamentally about respect—
respect for clients; respect for clients’ strengths, experience,
and knowledge; and respect for clients’ autonomy and their
moral right to make choices concerning their lives. It is about
fostering respectful, supportive relationships with clients, and
it is also about listening. Evidence supports this assumption.
For example, Mangset et al. (2008) undertook a study to
ascertain those factors that contributed to satisfaction with
rehabilitation services among elderly people in Norway who
had experienced a stroke. The researchers reported that one
main category, ‘‘To be treated with respect and dignity,’’ was
identified as the core factor contributing to satisfaction. This
core theme had five components: being treated with humanity,
being acknowledged as individuals, having their autonomy
respected (which included respect for clients’ experience,
skills, and knowledge of their situation), having confidence and
trust in professionals, and having meaningful dialogue and
exchange of information. Importantly, being treated with
respect and dignity and having trust in service providers were
more closely associated with satisfaction with rehabilitation
than was being involved in treatment decisions.
The findings of this Norwegian study closely mirror those of
an American study that examined the relative influence of invol-
vement in decisions, confidence and trust in service providers,
and treatment with respect and dignity on patients’ evaluations
of their hospital care (Joffe et al., 2003). These researchers noted,
We suspect that patients’ willingness to trust can be explained,
in part, by the extent to which they perceive that providers
value them and the things that are important to them. One way
in which providers can convey that they value their patients
(and are therefore worthy of trust) is to treat patients with
respect.’’ (Joffe et al., 2003, p. 104)
This suggests that clients may trust the decisions made by
their therapists when they perceive themselves to be valued and
respected.
A Respect Model of Client-Centred Occupational
Therapy Practice
If occupational therapists aim to address the question, ‘‘Who
is this person [family/group/community] and what do they
Canadian Journal of Occupational Therapy 80(3)
Active, engaged listening;
Critical awareness of power, privilege, and positioning;
Cultural humility;
Kindness, caring, and respect;
Respect for clients’ abilities, knowledge, experience, and strengths;
Respect for clients’ moral right to make choices concerning their
lives;
Striving to foster respectful, supportive relationships with clients;
Striving to understand clients’ resources, barriers, and
constraints to achieving well-being through occupation.
Figure 1. A respect model of client-centred occupational therapy.
need?’’ (Bright et al., 2012, p. 1002), we need to commit to
active, engaged listening, in which we seek to uncover and
understand clients’ occupational priorities, the roles that are
important and meaningful to them, the resources available to
them, and the barriers and constraints they confront in achiev-
ing well-being through occupation. Perhaps this requires a
Respect Model of Client-Centred Occupational Therapy (see
Figure 1), which focuses not on occupational therapists’ pur-
ported skills but on a set of required behaviours and attitudes
and evokes the core values underpinning client-centred occu-
pational therapy. Such a model would incorporate an explicit
focus on clients’ abilities and resources, on the barriers and
constraints that limit occupational opportunities, and on efforts
to uncover and understand how occupation might contribute to
meeting clients’ well-being needs. It would embrace a philoso-
phy of respect for clients—for their abilities, strengths, experi-
ence, and knowledge and for their moral right to make choices
concerning their lives. It would be about fostering respectful,
kind, supportive relationships with clients; about maintaining
a critical awareness of power and an attitude of cultural
humility; and also about listening. I propose that a model of
attitudes and behaviours based on foundational principles of
client-centredness could usefully precede a model of enabling
skills, the latter being of little value without the former.
Conclusion
Said (1979) argued that professionals should be on constant
guard against the received ideas handed down in their profes-
sion. However, critics contend that the occupational therapy
profession does not have an auspicious record of contesting
received ideas, of critical thinking, or of robust academic
debate (Duncan, Paley, & Eva, 2007; Hammell 2009a).
Evidence and critiques presented in this paper suggest that
the occupational therapy profession in Canada has abandoned
those values that underpinned its original vision of client-
centred practice, choosing to focus on the enabling skills of
therapists rather than on respecting clients’ strengths, experi-
ence, and knowledge. This may be a useful professionalizing
strategy— reinforcing therapists’ expert knowledge and
Downloaded from cjo.sagepub.com at Uni of Southern Queensland on June 22, 2015
147
skills—but it has little in common with client-centred philoso-
phy or with the self-defined priorities of clients.
Leplege et al. (2007) suggested that therapists should focus
on investigating the key conceptual components of client-
centred practice. This paper sought to explore the key concep-
tual components of client-centred practice and envisioned a
Respect Model of Client-Centred Occupational Therapy that
would enshrine the behaviours required of occupational thera-
pists who aspire to client-centred practices. Renewing the pro-
fession’s focus on these core values may contribute to ensuring
that occupational therapy practices are relevant, useful, and
respectful to clients.
Key Messages
 The Canadian occupational therapy profession has
amended its definition of client-centred practice to focus
on therapists’ enabling skills rather than on a philosophy
of respect for clients.
 Evidence suggests that clients value occupational therapists
who treat them with respect and who make them feel lis-
tened to, cared for, and valued.
 Client-centred practice is fundamentally about respect—for
clients; for their strengths, experience, and knowledge; for
their moral right to make choices concerning their lives—
and about fostering respectful, supportive relationships
with clients. Our documents should assert this.
Acknowledgements
Parts of this paper were presented during the Thelma Cardwell
Lecture, hosted by the Department of Occupational Science and Occu-
pational Therapy, University of Toronto, June 26, 2013.
References
Barnes, C. & Mercer, G. (2003). Disability. Cambridge, UK: Polity.
Beagan, B. L. & Chacala, A. (2012). Culture and diversity among
occupational therapists in Ireland: When the occupational therapist
is the ‘‘diverse’’ one. British Journal of Occupational Therapy, 75,
144–151. doi:10.4276/030802212X13311219571828
Bibyk, B., Day, D. G., Morris, L., O’Brien, M., Rebeiro, K. L.,
Seguin, P., . . . Wilson, J. (1999). Who’s in charge here? The cli-
ent’s perspective on client-centred care. Occupational Therapy
Now, 1(5), 11–12.
Blank, A. (2004). Clients’ experience of partnership with occupational
therapists in community mental health. British Journal of Occupa-
tional Therapy, 67, 118–124.
Bright, F. A. S., Boland, P., Rutherford, S. J., Kayes, N. M., &
McPherson, K. M. (2012). Implementing a client-centred approach
in rehabilitation: An autoethnography. Disability and Rehabilita-
tion, 34, 997–1004. doi:10.3109/09638228.2011.629712.
Revue canadienne d’ergothérapie
148
Canadian Association of Occupational Therapists. (1997). Enabling
occupation: An occupational therapy perspective. Ottawa, ON:
CAOT Publications ACE.
Canadian Association of Occupational Therapists. (2002). Enabling
occupation: An occupational therapy perspective (Rev. ed.).
Ottawa, ON: CAOT Publications ACE.
Canadian Association of Occupational Therapists. (2007). Joint posi-
tion statement on diversity. Retrieved from http://www.caot.ca/
default.asp?pageid¼2120
Cardol, M., DeJong, B. A., & Ward, C. D. (2002). On autonomy and par-
ticipation in rehabilitation. Disability and Rehabilitation, 24, 970–
974.
Chambers. (1972). Chambers’s twentieth century dictionary. Edin-
burgh, UK: Author.
Chartered Society of Physiotherapy. (1996). Rules of professional
conduct. Physiotherapy, 81, 460.
Coleridge, P. (1993). Disability, liberation and development. Oxford,
UK: Oxfam.
Copperman, J. & Morrison, P. (1995). We thought we knew . . . : Involv-
ing patients in nursing practice. London, UK: King’s Fund Centre.
Corring, D. J. (1999). The missing perspective on client-centred care.
Occupational Therapy Now, 1(1), 8–10.
Cott, C. A. (2004). Client-centred rehabilitation: Client perspectives.
Disability and Rehabilitation, 26, 1411–1422.
Department of National Health and Welfare & Canadian Association
of Occupational Therapists. (1983). Guidelines for the client-
centred practice of occupational therapy (H39-33/1983E). Ottawa,
ON: Department of National Health and Welfare.
Doane, G. H. & Varcoe, C. (2005). Family nursing as relational
inquiry. Developing health-promoting practice. Philadelphia, PA:
Lippincott Williams & Wilkins.
Duncan, E. A. S., Paley, J., & Eva, G. (2007). Complex interventions
and complex systems in occupational therapy. British Journal of
Occupational Therapy, 70, 199–206.
Eakin, J., Robertson, A., Poland, B., Coburn, D., & Edwards, R.
(1996). Towards a critical social science perspective on health pro-
motion research. Health Promotion International, 11, 157–165.
Foucault, M. (1980). Power/knowledge. New York, NY: Pantheon
Books.
French, S. (1994). Disabled people and professional practice. In S.
French (Ed.), On equal terms: Working with disabled people
(pp. 103–118). Oxford, UK: Butterworth Heinemann.
French, S. (2004a). Enabling relationships in therapy practice. In J.
Swain, J. Clark, K. Parry, S. French, & F. Reynolds (Eds.),
Enabling relationships in health and social care (pp. 95–107).
Oxford, UK: Butterworth-Heinemann.
French, S. (2004b). Reflecting on ethical decision-making in therapy
practice. In J. Swain, J. Clark, K. Parry, S. French, & F. Reynolds
(Eds.), Enabling relationships in health and social care (pp. 29–
43). Oxford, UK: Butterworth-Heinemann.
Gerlach, A. J. (2012). A critical reflection on the concept of cultural
safety. Canadian Journal of Occupational Therapy, 79, 151–158.
doi:10.2182/cjot.2012.79.3.4
Gibson, B. E., Nixon, S. A., & Nicholls, D. A. (2010). Critical reflec-
tions on the physiotherapy profession in Canada. Physiotherapy
Canada, 62, 98–100. doi:10.3188/physio.62.2.98
Canadian Journal of Occupational Therapy Downloaded from cjo.sagepub.com at Uni of Southern Queensland on June 22, 2015
Hammell
Gzil, F., Lefeve, C., Cammelli, M., Pachoud, B., Ravaud, J.-F., &
Leplege, A. (2007). Why is rehabilitation not yet fully person-
centred and should it be more person-centred. Disability and Reha-
bilitation, 29, 1616–1624.
Hammell, K. W. (2006). Perspectives on disability and rehabilitation:
Contesting assumptions: Challenging practice. Edinburgh, UK:
Churchill Livingstone Elsevier.
Hammell, K. W. (2009a). Sacred texts: A sceptical exploration of the
assumptions underpinning theories of occupation. Canadian Jour-
nal of Occupational Therapy, 76, 6–13. doi:10.1177/
000841740907600105
Hammell, K. W. (2009b). Self-care, productivity and leisure, or
dimensions of occupational experience? Rethinking occupational
‘‘categories.’’ Canadian Journal of Occupational Therapy, 76,
107–114. doi:10.1177/000841740907600208
Hammell, K. W. (2010). Contesting assumptions in occupational ther-
apy. In M. Curtin, M. Molineux, & J. Supyk-Mellson (Eds.), Occu-
pational therapy and physical dysfunction: Enabling occupation
(6th ed., pp. 39–54). Edinburgh, UK: Elsevier.
Hammell, K. W. (2013). Client-centred practice in occupational ther-
apy: Critical reflections. Scandinavian Journal of Occupational
Therapy, 20, 174–181. doi:10.3109/11038128.2012.752032
Hammell, K. W. & Iwama, M. K. (2012). Well-being and occupa-
tional rights: An imperative for critical occupational therapy. Scan-
dinavian Journal of Occupational Therapy, 19, 385–394. doi:10.
3109/11038128.2011.611821.
Ife, J. (2008). Human rights and social work: Towards rights-based
practice (Rev. ed.). Cambridge, UK: Cambridge University Press.
Iwama, M. (1999). Cross-cultural perspectives on client-centred occu-
pational therapy practice: A view from Japan. Occupational Ther-
apy Now, 1(6), 4–6.
Iwama, M. K. (2005). Situated meaning: An issue of culture, inclu-
sion, and occupational therapy. In F. Kronenberg, S. S. Algado,
& N. Pollard (Eds.), Occupational therapy without borders
(pp.127–139). Edinburgh, UK: Churchill Livingstone Elsevier.
Iwama, M. K. (2006). The Kawa model: Culturally relevant occupa-
tional therapy. Edinburgh, UK: Elsevier.
Joffe, S., Manocchia, M., Weeks, J. C., & Cleary, P. D. (2003). What
do patients value in their hospital care? An empirical perspective
on autonomy centred bioethics. Journal of Medical Ethics, 29,
103–108. doi:10.1136/jme.29.2.103.
Jonsen, A. R., Siegler, M., & Winslade, W. (1998). Clinical ethics (4th
ed.). New York, NY: McGraw-Hill.
Kjellberg, A., Kåhlin, I., Haglund, L., & Taylor, R. R. (2012) The
myth of participation in occupational therapy: Reconceptualizing
a client-centred approach. Scandinavian Journal of Occupational
Therapy, 19, 421–427.
Law, M., Baptiste, S., & Mills, J. (1995). Client-centred practice:
What does it mean and does it make a difference? Canadian Jour-
nal of Occupational Therapy, 62, 250–257.
Law, M. & Mills, J. (1998). Client-centred occupational therapy. In M.
Law (Ed.), Client-centred occupational therapy (pp. 1–18).
Thorofare, NJ: Slack.
Law, M., Rosenbaum, P., King, S., Burke-Gaffney, J., Moning-Szkut,
T., Kertoy, M, . . . Teplicky, R. (2003). What is family-centred ser-
vice? FCS Sheet #1. McMaster University, CanChild Centre for
Canadian Journal of Occupational Therapy 80(3)
Childhood Disability Research. Retrieved from http://www.can-
child.ca/en/childrenfamilies/resources/FCSSheet1.pdf
Leplege, A., Gzil, F., Cammelli, M., Lefeve, C., Pachoud, B., & Ville,
I. (2007). Person-centredness: Conceptual and historical perspec-
tives. Disability and Rehabilitation, 29, 1555–1565.
Mangset, M., Dahl, T. E., Førde, R., & Wyller, T. B. (2008). ‘‘We’re
just sick people, nothing else’’: Factors contributing to elderly
stroke patients’ satisfaction with rehabilitation. Clinical Rehabili-
tation, 22, 825–835. doi:10.1177/0269215508091872.
Marquis, R. & Jackson, R. (2000). Quality of life and quality of
service relationships: Experiences of people with disabilities.
Disability and Society, 15, 411–425.
McPherson, K. M. & Siegert, R. J. (2007). Person-centred rehabilita-
tion: Rhetoric or reality? Disability and Rehabilitation, 29, 1551–
1554.
Meade, M. A., Carr, A., Ellenbogen, P., & Barrett, K. (2011). Percep-
tions of provider education and attitude by individuals with spinal
cord injury: Implications for health care disparities. Topics in
Spinal Cord Injury Rehabilitation, 17, 25–37. doi:10.1310/
sci1702-25.
Nelson, A. (2007). Seeing white: A critical exploration of occupa-
tional therapy with Indigenous Australian people. Occupational
Therapy International, 14, 237–255. doi:10.1002/oti.236.
Nelson, A. (2009). Learning from the past, looking to the future:
Exploring our place with Indigenous Australians. Australian Occu-
pational Therapy Journal, 56, 97–102. doi:10.1111/j.1440-1630.
2009.00781.
Palmadottir, G. (2003). Client perspectives on occupational therapy in
rehabilitation services. Scandinavian Journal of Occupational
Therapy, 10, 157–166. doi:10.1080/11038120310017318.
Palmadottir, G. (2006). Client-therapist relationships: Experiences of
occupational therapy clients in rehabilitation. British Journal of
Occupational Therapy, 69, 394–401.
Pease, B. (2010). Undoing privilege: Unearned advantage in a divided
world. London, UK: Zed Books.
Rebeiro, K. (2000). Client perspectives on occupational therapy
practice: Are we truly client-centred? Canadian Journal of Occu-
pational Therapy, 67, 7–14.
Rebeiro, K. (2004). How qualitative research can inform and challenge
occupational therapy practice. In K. W. Hammell & C. Carpenter
(Eds.), Qualitative research in evidence-based rehabilitation (pp.
89–102). Edinburgh, UK: Churchill Livingstone.
Rossiter, A. (2000). The postmodern feminist condition. New condi-
tions for social work. In B. Fawcett, B. Featherstone, J. Fook, &
A. Rossiter (Eds.), Practice þ research in social work: Postmo-
dern feminist perspectives (pp. 24–38). London, UK: Routledge.
Saadah, M. A. (2002). On autonomy and participation in rehabilita-
tion. Disability and Rehabilitation, 24, 977–982.
Downloaded from cjo.sagepub.com at Uni of Southern Queensland on June 22, 2015
149
Said, E. W. (1979). Orientalism. London, UK: Routledge.
Sumsion, T. (2005). Facilitating client-centred practice: Insights
from clients. Canadian Journal of Occupational Therapy, 72,
13–20.
Sumsion, T. & Law, M. (2006). A review of evidence on the concep-
tual elements informing client-centred practice. Canadian Journal
of Occupational Therapy, 73, 153–162.
Tervalon, M. & Murray-Garcia, J. (1998). Cultural humility versus
cultural competence: A critical distinction in defining physician
training outcomes in multicultural education. Journal of Health
Care for the Poor and Underserved, 9, 117–125.
Townsend, E. (2002). Preface 2002 to enabling occupation: An
occupational therapy perspective [booklet]. Ottawa, ON: CAOT
Publications ACE.
Townsend, E. A., Beagan, B., Kumas-Tan, Z., Versnel, J., Iwama, M.,
Landry, J., . . . Brown, J (2007). Enabling: Occupational therapy’s
core competency. In E. A. Townsend & H. J. Polatajko , Enabling
occupation II: Advancing an occupational therapy vision for
health, well-being, & justice through occupation (pp. 87–134).
Ottawa, ON: CAOT Publications ACE.
Townsend, E. A. & Polatajko, H. J. (2007). Enabling occupation II:
Advancing an occupational therapy vision for health, well-being
& justice through occupation. Ottawa, ON: CAOT Publications
ACE.
Townsend, E. A., Polatajko, H. J., Craik, J., & Davis, J. (2007). Cana-
dian Model of Client-Centred Enablement. In E. A. Townsend &
H. J. Polatajko , Enabling occupation II: Advancing an occupa-
tional therapy vision for health, well-being & justice through occu-
pation (p. 110). Ottawa, ON: CAOT Publications ACE.
Townsend, E. A. & Wilcock, A. (2003). Occupational justice. In C. H.
Christiansen & E. A. Townsend (Eds.), Introduction to occupa-
tion: The art and science of living (pp. 243–273). Upper Saddle
River, NJ: Prentice Hall.
Wood, P. J. & Schwass, M. (1993). Cultural safety: A framework for
changing attitudes. New Praxis in New Zealand, 8, 4–15.
World Federation of Occupational Therapists. (2010a). Position state-
ment: Client-centredness in occupational therapy. Retrieved from
http://www.wfot.org/ResourceCentre.aspx
World Federation of Occupational Therapists. (2010b). Position state-
ment: Diversity and culture. Retrieved from http://www.wfot.org/
ResourceCentre.aspx
Author Biography
Karen R. Whalley Hammell, PhD, is an Honorary Professor
in the Department of Occupational Science and Occupational
Therapy at the University of British Columbia, Vancouver,
BC, Canada.
Revue canadienne d’ergothérapie