The Client as the Expert on their Lives: Facilitating Client centred practice

1
The Client as the Expert on their
LivesFacilitating Client centred practice

• Moving Forward Together Facilitating Empowerment
  in Mental Health Conference
• June 5, 2009

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Objectives

• Have an understanding of client centred practice
  (CCP) and its components
• Discuss barriers to implementing client centred
  practice at the micro-, meso-, and macro- levels.
• Explore potential strategies at these various
  levels
• Discuss using outcome measurement tools such as
  the Client centred Practice Evaluation (CCPE) as
  an educational and practice-reflection tool

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Objectives

• Review an existing outcome measurement tool that
  occupational therapists use to gauge client
  perception of occupational performance outcomes
  (Canadian Occupational Performance Measure- COPM)
• Describe a case study example using the CCPE and
  COPM
• Discuss current progress with clinicians own
  experience using the CCPE tool
• Describe current occupational therapy programming
  within a tertiary, inpatient psychiatric unit

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Self-reflection questions

• Client
• Are my health needs being met?
• Are they asking me what I want, what my goals
  are, how I envision what recovery means to me?
• Am I being encouraged to make my own choices?
• Are the important people in my life engaged in
  the decision-making process?

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Self reflection questions

• Clinician
• Am I comfortable in sharing some of the power
  with the client?
• Do I feel the need to make all the decisions/ be
  right most of the time
• What are my attitudes and perspectives around
  client-centered practice? What are my beliefs
  around advocating at the meso and macro level?
• Is CCP relevant and important to my other
  colleagues I work with?
• Am I comfortable working in situations when there
  is conflict/ disagreement among a group of people
• Do I encourage my clients to advocate for their
  own needs/ rights so they dont have to depend on
  me so much?
• How comfortable am I in dealing with issues at
  the meso- and- micro level- which require greater
  involvement?

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What is Client-centred practice?

• Historical Evolution
• Term was coined by Carl Rogers in 1930s
• Identified the therapist-client relationship as
  consisting of empathy, respect, active listening,
  and understanding
• His stance was on the active participation
• Client-centered movement continued in the 60s
  and began to be utilized in the field of social
  work
• CCP first appeared in the occupational therapy
  literature in 1983 and numerous articles were
  published afterward
• A number of articles were published in the 90s
• (Walker, Pollack, 2001)

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What is Client-centred practice?

• Multi-dimensional and may manifest differently
  with different clients in different contexts
• Collaborative and partnership approaches used in
  enabling occupation with clients.client-centred
  occupational therapists demonstrate respect for
  clients, involve clients in decision-making,
  advocate with and for clients needs, and
  otherwise recognize clients experience and
  knowledge (CAOT, 1997)
• Core concepts (Law et al, 1995)
• Collaboration partnership
• Respect (cultures, values, life styles)
• enablement of client in decision-making
• Accessible Contextual congruence
• Client responsibility and autonomy

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Why is CCP important?

• Research shows that providing CCP in service
  delivery, leads to improved client satisfaction
  and adherence to health service programs
  (Greenfield, Kaplan, Ware, 1985 Hall et al,
  1988, Wasserman et all, 1984)
• Enabling the client to make decisions has also
  shown to lead to improved functional outcomes ,
  occuaptional performance, and compliance with
  treatments (Law et al, 1995)
• Developing a client-therapist relationship leads
  to improved client participation and
  self-efficacy (Dunst et al, 1994 Greenfile et
  al, 1985, as cited in Law et al, 1995)
• Helps validate a persons sense of worth
• Allows the client to take more responsibility for
  their own health and recovery process

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What is Client-centred practice? (cont)

• Client-centred practice views
• The person as the expert in their own lives
• Clients are aware of their own limitations/
  boundaries, have experienced previous successes
  and downfalls, and reluctances are based on
  previous experiences and fears
• Clinicians are there to guide the treatment
  goals, provide solution-oriented strategies, and
  assist with the process of prioritization,
  re-assessment, and modification.

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What client centred practice is not

• It does not invalidate the clinicians skills and
  professional role
• It is not the client making all the decisions
• Rather, the decision-making is more of a
  collaborative and an informed process
• Clinicians work with the client and where they
  are at in terms of the stages of change model

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The various systems levels

• Micro-level at the level between the clinician
  providing direct treatment and the individual
  client/ families
• Meso-level at the level within your unit, within
  the facility/ place of employment
• Macro-level broader community, government/
  legislation, policy development

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Challenges to implementing CCP

• Micro- level
• Lack of knowledge and skill in CCP
• Discomfort in applying an approach when
  colleagues are not invested in this philosophy
• Power struggles
• Hierarchy within the health care system
• Different value systems
• Difficulty in communicating what CCP is to others
• Perspective that it will take more time
• Struggle with who is the client
• Who is the expert

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Challenges to implementing CCP

• Meso level
• Challenges in maintaining professional alliances
  with colleagues
• Team/ Department is not invested in making
  changes or is not in support of CCP
• CCP is not part of the vision/ mission statement
• Lack of action-oriented solutions and lack of
  funding
• Difficulties in accessing resources due to
  inclusion criteria
• Lack of clarity in the definition of CCP

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Challenges to implementing CCP

• Macro level
• Lack of knowledge on who to approach
• Terminology is challenging
• Time commitment
• Lack of knowledge in the area of policy
  development, legislation

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Elements of empowerment theory

• Empowerment the gaining of power
• According to Bernstein et al, (as cited in
  Oudshoorn, 2005, p. 62), empowerment is helpful
  in creating a more equitable distribution in the
  forms of power and results in positive outcomes.
  Outcomes generally improve ones overall
  well-being such as in health, self-esteem,
  quality of life and the facilitation of assertion
  of whomever life is being affected (Crawford
  Shearer Reed, Gibson Jones Meleis, as cited
  in Oudshoorn, 2005, p. 62).

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Elements of empowerment theory (cont)

• Focus is on the clients strengths and previous
  successes, not on their limitations or failures
• The clients knowledge precedes over the
  therapists
• Is a process and outcome
• Outcomes self-esteem, quality of life,
  improvement of overall health, feeling of sense
  of control over ones life
• Process collaboration, understanding respect

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Power its role in a clinician-client
relationship

• Exists in all relationships and at all systems
  levels power is inescapable
• Mortenson, B., Dyck, I. (2006).
• Interpersonal and social relationships
• Organized institutionally--gt documents, policies,
  procedures
• Power sharing occurs when each exercises an
  influence over the other by respecting their
  areas of expertise
• Recognition of power issues at all levels must
  be addressed in order to be truly client centred
• Power sharing requires releasing the perception
  that the clinician as the sole expertise in
  health care the client being actively engaged
  does not minimize the clinicians role to be a
  passive one

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Power its role in a clinician-client
relationship

• health care professionals place greater emphasis
  on safety rather than autonomy (Clemens Hayes
  Kane as cited in Moats et al 2006, p. 304)--gt
  form of disempowerment
• Lack of confidence in the clients abilities to
  make decisions based on physical and mental
  limitations--gt requires level of risk-taking
• Autonomy promotion versus risk avoidance concept
• (Moats Doble, 2006)

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Building therapeutic relationships

• Significantly important in mental health
• Need an alliance and trust before you can begin
  the work of identifying occupational performance
  issues and setting treatment goals
• Requires time, patience, and ongoing hope
• Requires skill such as appropriate
• self-disclosure
• demonstrating empathy
• active listening
• role-modeling
• confidence

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Barriers to implement CCP

• important to recognize that clients may have
  difficulties in
• Cognitive abilities
• Communication skills
• Difficulties with problem-solving,
  decision-making
• Cultures/ various ways of doing
• Perception of traditional health care services
• Acute illness vs. progressive illness vs. chronic
  illness
• important to use graded decisions
• Hobson (as cited in Moats 2007, p. 92) refers to
  the process of therapists advocating for a
  clients wishes and allowing them to participate
  in the decision-making process despite presence
  of cognitive deficits as graded
  decision-making. There exists a range of
  decisions, ranging from small to large scale
  decisions.

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Changing perspective

• Professional responsibility to continue to grow
  and further in our own individual practices and
  maintain continuing competence/ professional
  development
• Time- Initially is an investment in time but may
  further advocate the needs for future clients,
  may save time in the future
• Power in numbers belief that we can be agents of
  change
• Continuum of client-centred practice ( Mortenson
  Dyck, 2006)
• Reflectionfacilitates in changing behaviours to
  help improve professional practice (Stern et al,
  2001, p.147)

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Key occupational therapy enablement skills

• based on the Canadian Model of Client-Centred
  Enablement (CMCE)
• Enabling occupational performance is the essence
  of occupational therapyit is accomplished
  through restoring, enabling, or preventing loss
  of ability (Backman, 2005, p. 259)
• Adapt- to make suitable or fit into context
• Advocate- actions to create favorable conditions
  for health
• Coach- develop and sustain
• Collaborate- to share power and work with
  clients
• Consult- exchange views
• Coordinate- connecting clients with appropriate
  resources
• Design/ build- implement programs and services
• Educate- employ philosophies or teach new skills
• Engage-involve the clients in the doing aspect
• Specialize- Use specific techniques in particular
  situations

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Strategies to facilitate CCP

• Personal reflection
• Client
• What are my past experiences with health care
  staff and am I transferring those experiences
  with this clinician?
• What parts of my life am I unhappy with and am I
  willing to change that aspect of my life?
• Am I willing to accept help from other people who
  may not fully understand my life?
• What assumptions do I have about others providing
  help?
• Can I fully work with someone who may potentially
  have different value systems than my own?

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Strategies to facilitate CCP

• Personal reflection
• Clinician
• What are my belief systems around.
• Am I able to respect other peoples choices when
  they are different from mine?
• Why did I react that particular way in that
  situation?
• If I were in that clients situation, would I
  want to be treated that way?
• Am I able to put my values and opinions aside in
  order to treat the client with a client-centred
  approach?
• What are my beliefs around independence and do I
  encourage my client to advocate for themselves as
  much as possible?

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Strategies to facilitate CCP

• Incorporate language that is consistent with
  client-centredness and focus on client strengths
• For example
• Client strengths/ abilities include________or
  he/ she demonstrates__________
• Comment on their initiation, motivation, social
  skills/ interactions, comprehension level,
  ability to make decisions or ask questions,
  future orientation
• Incorporate the clients value systems, some of
  their fears and where it stems from, how this
  impacts their occupational performance
• Write progressive reports and comment on
  improvements identified by BOTH the client
  clinician
• Try to avoid generalized statements such as poor
  insight/ judgment, inability to cope
• Incorporate hope, room for improvement in areas
• imagine you will be submitting this report to
  the client to review

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Strategies to facilitate CCP

• Enhance communication skills
• Assertiveness
• Use of I statements
• Encourage them to approach staff/ community
  resources independently to ask questions or
  inquire about information
• Negotiation
• Allow them to try new things out of their comfort
  zone part of the learning process is trial
  error learn from successes failures
• Autonomy promotion vs. risk-avoidance
• Problem-solving abilities
• Re-establishing and modifying goals
• Re-assess S.M.A.R.T. goals
• Address barriers to established goals but do not
  focus on negative aspects--gt keep solutions
  action-oriented
• Self-disclosure
• Removes the power barrier

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Strategies to facilitate CCP

• Role modeling behaviours
• Encourage them to ask direct questions to
  relevant staff members
• Be punctual, follow through on stated appointment
  times
• Allow them to discuss difficult issues in the
  here and now with relevant people
• Offer to assist them in the process but refrain
  from doing things for them
• Allow them to make deadlines
• Teach them that it is okay not to have all the
  answers

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Strategies to facilitate CCP

• Increase knowledge in CCP
• Liaise with colleagues and attend conferences
• Read articles on empowerment theory and
  application of this approach in your area of work
• Use of outcome measurement tools such as the
  Client Centred Practice Evaluation Tool (CCPE) or
  use
• Use measurement tools such as The Canadian
  Occupational Performance Measure that measures
  client perception of change in occupational
  performance issues over time

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Client Centred Practice Evaluation Tool

• A reflective tool consisting of 5 parts
• A measure to assist with identifying barriers and
  supports to enabling client centred practice
• Focuses on the established therapeutic
  relationship and environmental conditions
• A framework that can be used with multiple
  clients
• One of the first and only existing tools that
  provides a structured reflection tool to improve
  CCP (Ripat, et al, 2006)

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Client Centred Practice Evaluation Tool

• 1. Clinician questionnaire
• 2. Client questionnaire
• 3. Reflection
• 4. Compilation of Strategies
• 5. Action plans
• Part 1
• questions on therapeutic process and
  relationship on the clinician questionnaire use a
  1-5 point likert scale
• 1 2 3 4 5
• Definitely Definitely not
• Space at the end allotted for open ended comments
  on supports and barriers to facilitating CCP

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Client Centred Practice Evaluation Tool

• Part 1
• Environmental Scan on the clinician questionnaire
• Scale used
• T F B S N
• T true B barrier N not relevant
• F false S Support
• Part 2
• Therapeutic process and relationship and
  environmental scan for client questionnaire
• Not at all A little Quite a bit A lot

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Client Centred Practice Evaluation Tool

• Part 3
• Reflection Summary Form
• Used to summarize clinical reasoning skills on
  the sections of clinician perspective, client
  perspective, and environmental conditions
• Reflection is the central component of this
  framework
• The negative responses from Parts 1 and 2 are
  taken and documented in the relevant spheres.
• In the environment section, potential barriers
  are listed in that sphere.
• This information will be used to develop action
  plans

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Client Centred Practice Evaluation Tool

• Part 4 Compilation of strategies
• Personal reflections
• Client-centred processes
• Practice settings
• Community organizations
• Coalition advocacy
• Political Action

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Client Centred Practice Evaluation Tool

• Part 5 Action Plan

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Overview of the CCPE tool

• Must be able to receive feedback- both positive
  and negative
• Must take the time to do reflection portion to
  make the CCPE tool effective and promote change
• Ideal to use with every client however may be a
  challenge if there are infrequent interactions
• Weigh out the positives and negatives with the
  CCPE tool being completed in 11 format or with
  giving the questionnaire to them in advance
  before returning it back to you

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Canadian Occupational Performance Measure (COPM)

• Is based on occupational therapy concepts and
  models- intended to complement other assessments
• Focuses on 3 areas of occupational performance
  self-care, productivity, leisure
• Incorporates the clients perception on their
  role expectations and occupational performance
  problem areas
• Addresses areas of occupational performance with
  respect to the importance of specific tasks and
  satisfaction level with their abilities within
  these areas
• Helps prioritize occupational performance--gt
  rating importance
• Measures satisfaction with performance

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Canadian Occupational Performance Measure (COPM)

• Administration
• Step 1 Problem Definition
• Semi-structured interview to determine
  occupational performance areas
• Focus on their personal role expectations with
  specific tasks
• Step 2 Problem Weighting
• Rate importance of the occupational task on a
  1-10 likert scale (1- not at all important 10
  extremely important)
• Step 3 Scoring
• Prioritize up to 5 problems theyd like to focus
  and work on
• Rate their subjective perception of their current
  performance and satisfaction with their
  performance status
• Step 4 Re-assessment
• Step 5 Follow-up
• Purpose is to determine whether ongoing treatment
  or discharge is indicated

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Canadian Occupational Performance Measure (COPM)

• For more information on the COPM
• Website- http//www.caot.ca/copm/index.htm

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Groups

• Health Snack Planning and Healthy Snack
  Preparation
• Snack Preferences
• Review of 4 food groups discussion around
  portion sizes
• Challenges around healthy eating (ie. Prices/
  budgeting, preparation, meal planning
• A.M. Stretch/ Meditation Groups
• Relaxation/ deep breathing techniques, mindful
  meditation, review of benefits of stretching,
  education around basic, gentle stretches they can
  do independently at home

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Groups

• Life skills management group
• Stress management
• Self-esteem
• Anger management
• Assertion
• Goal setting
• Boundaries
• Communication

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Occupational Therapy Treatment Interventions

• Potential additional groups
• Recovery is group
• Community Links
• Additional occupational therapy roles
• Functional assessments/ discharge planning
• 11 skills training--gt budgeting, meal planning,
  time management, connections to resources,
  transitonal discharge goal setting

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Case example Ms. H

• 45 year old lady diagnosed with depression and
  diabetes
• Lives independently in her own apartment
• 26 year old daughter, 22 year old son
• Divorced for 20 years, never re-married
• Worked as a waitress for 20 years but has been
  off work for the last year since being involved
  in a serious motor vehicle accident
• Has chronic back pain, low activity tolerance

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Case example Ms. H

• COPM Steps 1,2 3
• Prioritized goals (according to importance)
• Not able to eat a healthy diet that is consistent
  with the management of her diabetes (4 3)
• Isolation in her home--gt lack of various support
  systems (3 3)
• Not able to go shopping far from her home as a
  result of fatigue with moderate exertion (5 4)
• Boredom lack of involvement in activities she
  enjoys (5 5)

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Case example Ms. H

• Attend healthy snack planning/ preparation a.m.
  stretch groups
• Individualized weekly meal planning sessions
• Explore potential places where she can connect
  with art for leisure and assist with making that
  connection
• Explore support groups for family members
• 11 education on energy conservation techniques

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Case example Ms. H

• Re-assessment after 2 weeks (Step 4)
• Not able to eat a healthy diet that is consistent
  with the management of her diabetes (6 4)
• Isolation in her home--gt lack of various support
  systems (4 6)
• Not able to go shopping far from her home as a
  result of fatigue with moderate exertion (5 5)
• Boredom lack of involvement in activities she
  enjoys (6 6)

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Case example Ms. H

• Step 5 Follow up
• Continue progress in occupational therapy groups
  for the remainder of admission
• Transitional follow-up with goal setting with
  respect to meal planning and access to outpatient
  resources limit to no more than 3 weeks post
  discharge

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Case example Ms. H

• Compilation of strategies
• Review assessments and determine if they are
  congruent with CCP
• Teach client advocacy skills
• Incorporate client perspectives in to programming
  planning
• Conduct community needs assessment

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QUESTIONS?
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References

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