Throughout my career I have tried to follow the advice of Paulo Coelho (1988). He writes about dreams and that the only thing that makes them impossible to achieve is the fear of failure and the only way to learn is through action. However, it took me a while to incorporate these wise words into my professional life. Initially, I was a research phobic who was afraid of failure and would rather teach, work with clients and do administrative tasks than engage in research. However, I gradually came to understand that, like it or not, I was engaging in research on a daily basis. I did not have big research grants, and at this initial stage, I was not publishing but I was asking questions, the point where any research project begins. Some examples of these questions include the following: What was important to the clients with whom I worked? What were the approaches I used that elicited the best responses? What led up to the breakthroughs that made such a difference to the clients? At this stage in the journey I noticed that often the therapeutic outcomes were not directly attributable to what I did but more to how I did it. I was being a client-centred therapist and I realised it was time to take action. I wanted to know a lot more about this approach and why it seemed to make a difference.

Client-centred practice did not originate in occupational therapy, nor is it unique to our profession. However, we are leaders in this approach with particular emphasis in the area of mental health. The concept first appeared through the work of Carl Rogers (1939) when he outlined an approach that was non-directive and focused on concerns expressed by the individual client (Law, 1998). Canadian therapists were fortunate to have an opportunity to build on this work and that of Reed and Sanderson (1980) through a national taskforce jointly funded by the Canadian Association of Occupational Therapists (CAOT) and the Department of National Health and Welfare (DNHW). I had the privilege of chairing this group that consisted of occupational therapists from across Canada who worked in a range of areas of practice, as well as medical representatives. We worked together to produce several documents including Guidelines for the Client-Centred Practice of Occupational Therapy (DNHW & CAOT, 1983), Intervention Guidelines for the Client- Centred Practice of Occupational Therapy (DNHW & CAOT, 1986) and Toward Outcome Measures in Occupational Therapy (DNHW & CAOT, 1987).These documents introduced therapists to the concept of client-centred practice and the processes and procedures necessary for its implementation. The funding organisations asked the taskforce in which area of practice it would be most difficult to apply these concepts, and the overwhelming response was mental health. I am not convinced the answer to that question would be the same today, but that was the view in the early 1990s. As a result a subgroup of the main taskforce, along with some additional therapists, worked on the production of the publication titled Occupational Therapy Guidelines for Client-Centred Mental Health Practice (DNHW & CAOT, 1993). This document interpreted and applied the generic guidelines, from the original documents, to practice in mental health. Client-centred practice is not clearly defined as a distinct entity but there is a considerable amount of direction to therapists regarding how the approach should be applied, including the following:

• this approach refers to practice in which client’s experiences and knowledge are central and carry authority within the client–professional partnership (p. 5);
  
• occupational therapists have an ethical and moral responsibility to ensure that clients are as informed as possible of the options and risks associated with possible courses of action (p. 5); and
  
• a client-centred approach requires occupational therapists to actively seek and structure opportunities for clients to have real choices and authority commensurate with their skills and experience (p. 5).

However, concerns have been raised that having all of these nationally created and approved guidelines has not necessarily made us consistent and effective client-centred therapists. Ten years after the launch of the first national document, I was concerned that therapists did not clearly understand the implications of the proposed model on their practice. Were we truly involving the client as the decision maker in all stages of the therapeutic process? Were we ready to relinquish some of the power that this involvement might require? Were we clearly defining who the client was before we engaged in the process (Sumsion, 1993)? Unfortunately, the honest answer to these questions was ‘no’ at that time and in some ways is still ‘no’ today. Rebeiro (2001a) subsequently reiterated some of these same concerns and added an enlightened view by stating that ‘ by remembering the person, all that they were, are and can be, client-centred practice can help to bridge disability and illness with hope, instead of despair’ (p. 66).

Many committed therapists/researchers have taken the initial work and concerns forward to enable a deeper understanding of the importance of applying a clientcentred approach in mental health. Townsend (1998), a member of the original taskforce, continued to lead the way through publishing her critique on empowerment in the organisation of mental health services. Her work clearly showed that many aspects of a client-centred approach were not being applied. Instead, organisations were controlling decisions hierarchically, preserving exclusion and managing cases rather than working with the individual to design unique solutions. All of these issues conflict with a client-centred focus that supports consumer involvement in decisions, inclusion and an individual approach. Next, Corring and Cook (1999) examined the client’s perspective and found, in support of Roger’s original premise, that it is important for clients to be viewed as valuable human beings. In their study, clients spoke openly about the negative attitudes of the service providers, their superficial knowledge of clients, their use of techniques that did not meet the client’s needs and the importance of valuing the clients’ experiences and taking time to talk. Rebeiro is also an important contributor to this discussion (see more of her work in Chapter 8). The clients that she interviewed stressed the importance of choice, a focus on them as individuals rather than on the illness and inclusion in the decision-making process (Rebeiro, 2000). Her subsequent work reinforced the findings of Corring and Cook (1999) as the clients in her study wanted to be involved in environments that affirmed they were people of worth (Rebeiro, 2001b). These researchers have raised consistent, important issues that are fundamental to client-centred practice, including engaging with clients as individuals, taking time to get to know these individuals and enabling their choice of intervention.

My involvement in the guidelines project spanned more than 15 years. Throughout that time I continued to work in a variety of roles in the mental health system and endeavoured to apply the concepts we were discussing, writing and explaining to other therapists. I certainly experienced the challenges firsthand but wanted to know more about these issues. It was time to become a serious researcher. My opportunity to do so came in 1996, when I moved to London. I was teaching at Brunel University and I was offered the opportunity to engage in PhD studies. Here was the chance to build on my Canadian experiences, really delve into clientcentred practice and come to grips with its many challenging components. This phase of the journey covered 5 years and allowed me to engage therapists throughout the UK in many phases of a process to clearly define client-centred practice. There were Canadian definitions (Law et al., 1995; CAOT, 2002), but I wanted to contribute a consensus definition that truly incorporated the views of therapists working in differing geographical areas as well as a wide range of areas of practice. The research process incorporated a range of methods including the Delphi Technique, the Nominal Group Technique within a focus-group format, consensus meetings and interviews. This was an exciting journey in itself and the destination was reached through the creation of the following preamble to and definition of client-centred practice:

Preamble

There are many factors that influence the successful implementation of client-centred practice including a clear determination of who the client is and the recognition of the impact of resources.

Client-centred occupational therapy is a partnership between the client and the therapist that empowers the client to engage in functional performance and fulfil his or her occupational roles in a variety of environments. The client participates actively in negotiating goals that are given priority and are at the centre of assessment, intervention and evaluation. Throughout the process the therapist listens to and respects the client’s values, adapts the interventions to meet the client’s needs and enables the client to make informed decisions (Sumsion, 2000).

This definition echoes many of the important issues identified by the previous researchers referred to in this chapter, including forming partnerships with clients, engaging them throughout the therapeutic process and enabling informed decisions.

At this point in my research journey I had a more in-depth understanding of the components of client-centred practice and therapists’ views of these. However, I had no idea if this definition had any clinical applicability. The final phase of the study enabled me to take this definition into an out-patient mental health setting and conduct in-depth interviews with therapists about the barriers to and opportunities for its application. This was a positive experience, and I wanted to clone this group of therapists as they were truly client-centred and readily demonstrated the components of the definition. They challenged the system to enable clients to reach their goals by responding to the clients’ issues, juggling the reason for the referral, adapting interventions and providing relevant information. They did encounter barriers such as time, power struggles and cultural road blocks, but they worked with the client to overcome all of these (Sumsion, 2004).

However, I was aware that in many ways I was being a hypocrite as I was studying client-centred practice but had not yet involved the clients. Therefore, some initial interviews were undertaken to determine their views of the definition in relation to barriers to and opportunities for its implementation. It was clear that client-centred practice was important to this group and that they valued the information they were given to enable choices. They wanted to participate in determining goals, but to do so they had to overcome fear and issues presented by the severity of their illness (Sumsion, 2005). Overall, it appeared that the concepts presented in the definition including partnership, empowerment, active engagement, listening, adapting and enabling were important to both therapists and clients, but there was still more work to be done. During this time I also edited an initial book that was revised in 2006, to help therapists more clearly understand issues related to implementation with various client groups (Sumsion, 2006).

At this point the journey takes a slight pause as I decided to return to Canada. Once I was settled and had the challenges of my new position in some perspective, I undertook a project to replicate the final phases of the work completed in England to see if there were any similarities in the two countries in relation to the opportunities for and barriers to the application of this approach from the perspective of both therapists and clients. This work has been completed but not yet published. However, initial findings certainly do indicate many similarities. Canadian therapists also stressed the importance of enabling choice by not making decisions for the clients, explaining the likely outcome of various choices and enabling clients to have a say or at least some input into the decisions that affect them. It was felt to be impossible to work with the clients without effective rapport. These therapists also stated that it was wonderful to get to know the clients in a way that enabled them to become truly comfortable with the therapist. They recognised the importance of working in a partnership with the client with the therapists telling them what they could offer and listening to the clients’ needs and wants. They described this true partnership as one that meant equal kinds of responsibility and commitment. These therapists also accepted that they had to broaden their horizons to encompass the clients’ interests, look at the big picture and enable them to set and achieve their goals. The clients in this study expressed that the programme in which they were engaged fostered a culture of respect, empowered them, was flexible enough to ensure their needs were met and created an atmosphere of care and partnership.

I am confident that any therapist who has attempted to implement a client-centred approach in a mental health setting could list the barriers that were encountered. However, there is some literature to which we can refer for clarification, or perhaps affirmation, of these challenges. Sumsion and Smyth (2000) found that the therapist and client having differing goals was the barrier that most prevented the implementation of a client-centred approach. The therapist’s attitudes, beliefs and values and the culture in the employment environment also posed formidable challenges. Wilkins et al. (2001) concluded, from the amalgamation of data from three different studies, that there were challenges presented by the system, such as support for the implementation of a client-centred approach, by the therapist, including the required transition from paternalism to sharing and partnership, and by the client, through the recognition that some client groups will be more receptive to this approach than others.

Throughout my professional career I have certainly encountered many of these barriers, but I confess to being one who frequently ignored them or tried my best to work around them. But, this is not always a successful strategy. In the early days of my career I worked on an adolescent in-patient unit. I tried valiantly to apply a client-centred approach but struggled to find a meaningful activity in which the clients would willingly engage. Finally, we settled on a car wash, which seemed to me to be a reasonably safe and productive activity. We agreed on the responsibility of the members of this partnership. The adolescents would decide on a date, make the advertising posters and, as only adolescents can, harass the staff to ensure their cars were all lined up. I was to secure the necessary equipment and obtain permission from the administration of the hospital. The sad outcome was that, no matter what I tried, including official memos, begging and pleading, I could not get the administration to approve this activity. They were very concerned about safety, including falls, and potential damage to vehicles. I tried for weeks, but in the end the activity did not occur as the environment had presented a barrier I could not overcome. I was left to deal with a renewed ambivalence among the client group and my own frustration at not meeting my obligations as a member of the partnership. We did work it through and were able to philosophically examine the lessons that were learned, but there is no doubt that the partnership experienced a significant setback. Some years later, a psychiatrist, who always seemed to get approval for every programme, taught me that it was easier to ask for forgiveness than permission, and perhaps that is a strategy I should have applied.

I learned other valuable lessons in this position. Almost 40 years later I still remember a young man with whom I worked very closely and with whom a client-centred approach was working very well. He came from a disadvantaged background and his goal was to complete his high school education. He worked very hard, and as his discharge date approached, we worked on strategies to help him face the obvious environmental challenges he would encounter in the community, such as not having a quiet place to study and friends who would try to entice him to engage in illegal activities rather than completing his school work. This latter situation should have triggered the realisation that he was returning to a large environment that did not support educational pursuits. Had the Canadian Model of Occupational Performance (CAOT, 2002) been integrated into my practice at this time, I would have clearly understood the importance of environmental issues. Then, I focused on the smaller issues and failed to see the big picture. Ultimately, he was not successful in reaching his goals in the community, which was, in part, attributable to my narrow focus. The lesson learned here was that a client-centred approach has to take place within the realities of the physical, social and cultural environments. The positive aspect of this phase of my experience was that I worked with a terrific team on this unit who were primarily client-centred. They went the extra mile to ensure client needs were understood and addressed and programmes were designed to allow the clients to achieve their goals, including education.

I also tried to implement the principles of client-centred practice in my work as a consultant. This role took me into the remote parts of northern Ontario where therapists worked with a range of client groups including those experiencing severe and persistent mental disorders. There was considerable variation in the number of accessible community resources, including those locations that were well served and those who were left to fend for themselves. I worked with these therapists to help them determine the priority issues, outline the available resources and, in some cases, determine a lobbying strategy. Here was a strong example of providing relevant information, within a different type of partnership, to enable choices that were frequently rather limited. There was also a clear requirement for the use of creativity, which, although not a documented element, is a strong component of client-centred practice if desired goals are to be achieved.

In my role as a manager in a large mental health facility and, today, in an academic department, I have also tried to practise what I was preaching. One of my main roles in these positions was to remove barriers so goals could be reached. Examples include starting new programmes that met an identified client need in times when programmes were being cut due to financial restraints; seizing opportunities to launch new graduate programmes to enable academic staff to have student supervisory experience; and helping academic staff to set priorities and give up historical practices so the age-old issue of not enough time could be addressed.

Time is definitely a major barrier to client-centred practice. However, my plea is that we just accept the fact that there is never enough time to do everything we either need or want to do in both our personal and professional lives. I think society would be much happier if we stopped beating ourselves up about this fact and just got on with it. Yes, it does take more time initially to engage in a client-centred process as we need to really understand the clients’ stories to enable us to help them set goals within a context that is meaningful to them. Once this engagement has occurred and they are working toward these meaningful goals, they will require less input from us. So, in the long run, this approach does not take more time (Sumsion, 2006). In support of this, Stewart (2003) found 19 articles that addressed the question of time and reported that the conclusions were inconsistent. These varied from no difference in the amount of time required to those that did take longer as this approach resulted in the discussion of a larger number of issues.

I have learned many lessons from all of the people I have worked with, but it is the clients who have taught me the most valuable ones. Through my research I continue to be involved with a community programme for people with severe and persistent mental illness. This is definitely client-centred as all of the groups and activities are based around issues that the clients have raised. A client council oversees the programme that is run primarily by occupational therapists, and there is great diversity in what is offered, from music groups to a café and catering business, to discussion groups where problems are addressed. The clients choose the programmes in which they want to be involved. I recently attended a talent show that was organised by the clients and staff at this programme. People exhibited a wide range of talents from singing, playing musical instruments, reading poetry and displaying art and crafts. The room was full of people, and these clients, who were coping with a range of symptoms, stood up and shared their talents to thunderous applause. I do not know how you get much more client-centred than that as they were the focus of this programme and were being supported to meet this particular goal. The talent was quite varied, but the enthusiasm and courage was unanimous. These clients have taught me that adversity can be overcome and that, with the right encouragement and support, they can achieve their goals. Some of these clients have also willingly come into university and freely told their stories so that occupational therapy students can understand the many personal and environmental challenges they have overcome. Again, what courage! I often wonder if I would have the courage to face the adversities they have tackled. Would I be able to deal with the symptoms of an illness that I know will never go away? Would I be able to handle the loss of family and friends who cannot understand what I am experiencing? How would I deal with stigma expressed by a community that chooses not to incorporate me into their activities? So, for me the bottom line is that these people are to be admired and welcomed as teachers and colleagues. A client-centred approach enables all of us to include them in the programmes we are there to offer and to ensure that those they are clearly meeting identified needs. They face more daily barriers than I will ever face; so it is my responsibility to work in partnership with them to remove their barriers and advocate for the inclusion and achievement of their goals.

Recently, I attended a multi-disciplinary conference that was focused on client-centred practice and on ethical issues related to client-centred practice. Both included issues related to mental health, although that was not their primary focus. I also attend numerous sessions at local and national occupational therapy conferences with client-centred practice in the session title. I usually come away from these experiences asking myself if the presenters really understood what being client-centred meant – they simply failed to convey that understanding clearly as the right words were there but the actions taken were not truly client-centred. It is very difficult to be a client-centred therapist. It is hard to take the time to really understand the person’s story, to discuss realities related to goals, to advocate and/or remove barriers so those goals can be achieved, and to address safety, and not to let risks and fear of failure prevent your support of the chosen goals. Much more work needs to be done on all levels to really understand and activate issues related to power sharing, listening and communicating, making true partnerships work and enabling choice (Sumsion & Law, 2006). Overall, the clients I have spoken to tell me that we need to work on not taking away their hope, not being afraid to let them fail and enabling them to at least work toward their goals.

The invitation to write this chapter has provided me with an exciting opportunity to reflect on the connection between client-centred practice and my career. The conclusion I have reached is that it is very difficult to be a client-centred therapist. It means giving and asking a lot of yourself and being strong enough to carry on when the challenges for implementing this way of working seem simply insurmountable. If you are not truly interested in people, then you cannot be a client-centred therapist. You have to really want to know their stories as it is not good enough to know that you should do that from an academic perspective. You have to be willing to understand and appreciate the complexities of living with a mental illness. Rejection, avoidance, pain and suffering are all very real for this client group. You need to really care about them as people, learn what makes them tick and what is important to them.

Another word of caution regarding taking a client-centred approach relates to what I call the ‘opening-the-door factor’. You will not find any literature about this, but I have certainly learned that if I open the client-centred door with my clients, I have to be prepared to engage with whatever walks through. I cannot build rapport, engage in a partnership with them, and then be frightened off by an issue they raise that is important to them. Therefore, I really need to know myself and my comfort and confidence levels so I can engage, and perhaps redirect, but not be shocked and walk away. What am I prepared to engage in and what is outside of my comfort level? Personally, I know that I cannot work with people who have consciously physically abused others. I know I do not handle interactions with this client group well. I have tried to be open with my team about this and will redirect clients, who certainly deserve a meaningful interaction with a caring team member, to the person who can work comfortably with them.

I have worked with client-centred practice for a great many years and I am still learning about the complexities of this approach. Some of my failures still haunt me, but I have tried to learn from them to ensure I am offering my clients the best interaction possible. You can do the same.

My research journey built slowly to a climax, but my amazement at the courage of the clients with whom I work has only gained in strength. My final plea is that, as talented occupational therapists working in mental health settings, we accept the challenge of working in a client-centred way; that we commit ourselves to this approach and do whatever we can, no matter how small the effort may appear, to overcome the barriers that are presented by the system, ourselves and the clients. We can truly listen. We can ensure the clients’ goals are incorporated into the plan that is hopefully being designed with them rather than for them. We can let them take risks, as that is how we all learn.