faglig

Client-centred practice – an Indian

occupational therapy perspective
Abstract
Background: Although client-centred practice is considered a vital part of occupational therapy practice in western countri-
es, there has been little discussion of the applicability of this approach in non-western countries.
Purpose: The purpose of this project was to explore the applicability of client-centred practice as an approach in a medical-
ly oriented setting in an Indian cultural context, and the main question concerned Indian occupational therapists’ percepti-
ons of client-centred practice as an approach in a medically oriented setting in India.
Method: Qualitative methods were used and data were gathered from nine Indian occupational therapists through audio
recorded focus group interviews. Content analysis was used to identify three themes: How the participants define client-
centred practice, factors that influence client-centred practice in India, and the participants’ description of how they use
client-centred practice.
Conclusion: The results suggest that practicing this approach in this type of setting can be challenging due to many factors.
The conflict between a medical model and client-centred practice, cultural impacts on practicing a client-centred appro-
ach in India, and the client’s ability to understand information and communicate problems are highlighted. In the discussi-
on it is indicated that there is a need for further investigations on the relevance of health literacy in client-centred practice,
to find an appropriate way of using a client-centred approach in a medically oriented setting, and to explore the use of cli-
ent-centred practice in non-western contexts.
Keywords: Client-centred, occupational therapy, India, culture

AV ODA PETTERSEN OG INGUNN SVILAAS

Introduction hat different from what we had experienced in Norway.

We were therefore curious to find out whether this appro-
he approach client-centred practice is a considerable ach is equally important and applicable in a culture very
T part of the curriculum of the occupational therapy
(OT) education at Oslo University College (Høgskolen i
different from ours, namely in India.
Aspects of client-centred practice are mentioned as a
Oslo 2010). Our third year clinical placement was con- vital part of OT practice in several countries (Norsk
ducted at a hospital in India. Our impression from this Ergoterapeutforbund 2006, College of Occupational
was that the use of client-centred practice there is somew- Therapists 2010, American Occupational Therapy
Association 2010). According to a review by Awaad
(2003), OT frameworks are mainly developed in western
countries, and research on their relevance and applicability
in other cultural settings is limited. A lot of research has
been conducted on client-centred practice in western
countries (Duggan 2005, Maitra & Erway 2006,
Mortenson & Dyck 2006, Sumsion 2004, Sumsion &
Law 2006, Sumsion & Smyth 2000, Wilkins, Pollock,
Rochon & Law 2001, Wressle & Samuelsen 2004). Some
research on this topic has also been conducted in non-wes-
tern countries such as Taiwan, Singapore and Korea
Oda Pettersen jobber som (Chen, Rodger & Polatajko 2002, Yang, Shek, Tsunaka &
Ingunn Svilaas jobber
ergoterapeut ved Medi - som ergoterapeut ved
Lim 2006, Kang et al 2008). Chen et al. (2002) and Yang
sinsk klinikk, OUS, Ullevål
Klinikk for kirurgi og nev- et al. (2006) suggest that there is a need for further rese-
sykehus, samt som miljø- arch to explore cultural influences on client-centred prac-
terapeut på Fredensborg rofag, ortopedisk avde-
ling, OUS, Rikshospitalet. tice. Hence there is a need to explore client-centred practi-
bosenter, Velferdsetaten, ce as an approach in a non-western OT setting.
Oslo Kommune.
Email: The aim of our project was therefore to explore the app-
odapettersen@[Link] licability of client-centred practice as an approach in a
medically oriented setting in an Indian cultural context.
Det er ingen interessekonflikter. To explore this, our main question was: What are Indian
occupational therapists’ perceptions of client-centred prac-

40 Ergoterapeuten 03.12
 faglig
tice as an approach in a medically-ori-
ented setting in India? We narrowed
our focus to a medically-oriented set-
ting because the participants in this
project work in a hospital strongly
influenced by a medical model. The
terms client-centred practice and cli-
ent-centred approach will in this arti-
cle be used interchangeably.

Methodology
Design
A qualitative method was chosen as
this method is useful when the goal is
to develop an understanding of indivi-
duals’ views, attitudes and behaviours
(Moore 2006). Focus group interviews
were used as the method of data collec-
tion, as we wanted to bring forward
different viewpoints of the topic client-
centred practice. According to Kvale
and Brinkmann (2009) this method is
preferred to get such information.

Participants
A total number of nine occupational
therapists divided into three groups
contributed in the interviews. They
were currently employed at a hospital
in India. Their caseload consisted
mainly of acute inpatients, but occasi- Same tractor, same purpose, different wrapping.
onally they were also seeing outpati-
ents. OT took place at the hospital’s
OT department, and the therapists did not go on home each other. The interviewer intervened as little as possible
visits. as recommended by Kvale and Brinkmann (2009). The
Berg (2009) recommends a good range of respondents, interviews were audio recorded.
as this may mirror a wider population. To ensure this, the We wanted to explore client-centred practice from the
occupational therapists we selected had their origins from viewpoint of the participants as they experience it in their
different parts of India, were educated at different univer- context. The analysis is therefore based on phenomenolo-
sities, had a varying amount of clinical experience, and gical philosophy (Kvale & Brinkmann 2009). The data
were currently working in paediatrics, orthopaedics and was analysed stepwise using content analysis as this met-
neurology. Four of them were male and five were female. hod helps to identify patterns, themes, biases and mea-
This type of sample is, according to Berg (2009), called a nings in materials such as interviews (Berg 2009).
nonprobability purposive sample and cannot be conside-
red representative for a wider population of occupational Limitations
therapists in India. The participants are made anonymous, According to Larsen (2008) there is a risk that the partici-
and the names used are pseudonyms. Since English is the pants will say what they think the interviewer wants to
second language for both the participants and the intervie- hear. This is particularly relevant in this project, as the
wers, quotations are used frequently to limit possible mis- concept client-centred practice is developed in our part of
understandings. the world. This risk was limited by encouraging the parti-
cipants to be honest when expressing their opinions.
Procedure and data analysis The participants and the interviewers had different cul-
The participants were asked questions under three topics: tural backgrounds. This makes it important to be aware of
(1) The definition of client-centred practice; (2) The how «foreign cultures may involve different norms for interac-
applicability of client-centred practice in India; and (3) tion concerning initiative, directness, modes of questioning
The use of client-centred practice. and the like» (Kvale & Brinkmann 2009, p. 144). We had
In the interviews the topics were introduced, and the clinical placement in India eight weeks prior to the inter-
participants were encouraged to discuss the topics with views, and this enabled us to establish familiarity to the

Ergoterapeuten 03.12 41
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culture as recommended by Kvale and Brinkmann (2009). deau and Durand (2002) compare the medical model to a
client-centred approach. They find that these are quite
Theory opposite in many aspects. One of these aspects is the em-
phasis on illness in a medical model versus focus on occu-
Client-centred practice
pational performance in a client-centred approach. Anot-
Client-centred practice has become a fundamental part of her aspect is the power balance in the client-therapist rela-
OT practice during the last decades (Parker 2006). Carl tionship. In a medical model the therapist holds the po-
Rogers was the first to use the term client-centred in 1939. wer, is the expert, and is expected to cure the patient. The
At that time a medical model dominated the health care therapist controls the situation and may not give the cli-
system, and a client-centred way of thinking was quite ent’s requirements much space. The client´s experience is
contrary to this with its emphasis on active listening and sometimes be ignored and the client becomes passive in
understanding in the client-therapist relationship (Rogers therapy (ibid.).
1939 cited in Falardeau & Durand 2002).
In The Ottawa Charter for Health Promotion (World Culture and client-centred practice
Health Organization 1986) clients’ involvement in health Culture can be defined as: «patterns of values, beliefs, sym-
care and their opportunity to take control of their own bols, perceptions, and learned behaviours shared by members
health and wellbeing were stated as essential for achieving of a group and passed from one generation to the next» (Has -
«Health for All by the year 2000». In 1983 Canadian selkus 2002 cited in Lim 2008, p. 252). This means that
Association of Occupational Therapists defined the client- OT core concepts can mean different things for different
centred approach for the first time for occupational thera- people depending on their cultural background. A conse-
pists. Since then several definitions of client-centred prac- quence of this is that evidence of the applicability and
tice have been published in OT literature (Sumsion & effectiveness of OT models in one particular cultural con-
Law 2006). The definition used in this project is develo- text is not necessarily transferable to another cultural con-
ped by Sumsion (1999, 2000): «Client-centred OT is a text. A western perspective emphasises doing, individua-
partnership between the client and the therapist that empo- lism, analysis and problem-solving as opposed to being,
wers the client to engage in functional performance and fulfil collectivism, acceptance and contemplation in a non-wes-
his or her occupational roles in a variety of environments. The tern perspective (Lim & Iwama 2006). Yang et al. (2006)
client participates actively in negotiating goals which are conducted a study about cultural influences on OT in
given priority and are at the centre of assessment, intervention Singapore, where they discovered that some patients did
and evaluation. Throughout the process the therapist listens to not see independence as a valuable goal. They mention a
and respects the client’s values, adapts the interventions to collectivistic family system where the family members are
meet the client’s needs and enables the client to make infor- expected to help each other as a reason for this. Chen et al.
med decisions.» (Sumsion 2000, p. 308) (2002) studied experiences with client-centred practice in
According to a review by Sumsion and Law (2006) cli- adult neuro-rehabilitation in Taiwan. They suggest that
ent-centred practice is a partnership between the client cultural barriers to client-centred practice might be client’s
and the therapist which enables the client to set and achie- perceptions of the sick role as a passive role, and clients
ve goals and to gain control over his/her situation. The cli- expecting a cure. Sumsion (2004) found that such a passi-
ents participate actively throughout the intervention and ve role can make it difficult for patients to define goals.
supply information about their goals, wishes and perspec- Different beliefs and values held by the therapist and the
tives. The therapist provides relevant information and pos- patient can also create a barrier (ibid.).
sesses knowledge about the condition and its treatment.
Research shows that client-centred practice may improve Barriers to client-centred practice
satisfaction with services, increase adherence to therapy Research also shows other factors that influence client-
recommendations, and improve functional outcomes centred practice. Policies and structures such as time limits
(ibid.). and documentation can lead the OT intervention in a
direction that is not client-centred (Sumsion 2004,
Medical model Wilkins et al. 2001). Sumsion and Smyth (2000) and
According to Mattingly (1994) occupational therapists Wressle and Samuelsson (2004) found that a dominance
work within two different discourses. In the medical dis- of the medical model in OT intervention can be a barrier.
course the focus is on the «body as a machine», and in a If the referral for OT is restricted to the patient´s medical
phenomenological discourse the focus is on the «lived problems, this may conflict with the patient’s functional
body». A medical model separates disease from illness complaints (Duggan 2005, Sumsion 2004). Maitra and
experience and it focuses on diagnoses and treatment of Erway (2006) and Wilkins et al. (2001) say that aspects
disease. It has a strong emphasis in modern health care ser- connected to patients´ willingness and ability to involve
vices, especially in institutional settings (ibid.). In a study actively in therapy can make it difficult to work client-cen-
by Mortenson and Dyck (2006) occupational therapists tred. Maitra and Erway (2006) also found that therapists
described that they were strongly influenced by both these in hospitals tend not to use client-centred practice because
discourses, and that the client-centred discourse was expe- patients in hospitals have difficulties setting goals. Patients
rienced as less powerful than the medical discourse. Falar - with little education as well as low income can have diffi-

42 Ergoterapeuten 03.12
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culties participating actively in decisi-
on-making because they are used to
being told what to do (Sumsion 2004,
Yang et al. 2006). In a study by
Wilkins et al. (2001) the participants
described the ideal client for client-cen-
tred therapy as a client with good cog-
nition, insight and ability to solve pro-
blems. Few patients fulfil these criteria,
but it is the therapist’s responsibility to
find a way to work client-centred with
all clients (ibid).

Results
How the participants define
client-centred practice
In all the interviews the participants
emphasised focus on the client as a sig-
nificant factor in client-centred practi-
ce. The participants also discussed the
importance of providing information
for the patient to be able to make infor-
med decisions and set goals. The parti-
cipants argued how there need to be a
collaboration between the client and
the therapist when using a client-cen-
tred approach. The client has informa-
tion about himself and what he wants,
and the therapist has knowledge about
the client’s condition. The client and
the therapist negotiate, and the client
participates actively in the decision- Vegetables at the market in Mysore India.
making process.

Factors that influence client-centred practice in India physicians are also very body-oriented. Everybody seems to be
The context in which the therapy occurs can have an towards the body, whereas client-centred therapy in OT prac-
influence on whether or not the therapist can work client- tice is basically function-based. The whole system is seeing the
centred according to the participants. It is difficult to work body or symptom, when we are seeing function.»
client-centred if the patient has wishes that cannot be ful- The participants discussed how the patient’s condition
filled with available resources, or if time available is lac- can influence the use of client-centred practice. As Praveen
king. Praveen said: «A patient may want to be independent. said: «…client-centred cannot be applicable to all. …
... If to make that person functional I suggest we can make a Because from the client perspective, his understanding, his
ramp at the entrance of his home, it is not that simple. We cognitive abilities, his insight with the disease, all this will
don’t have resources to deliver it.» Namita mentioned time: create a barrier.»
«…client-centred practice requires a lot of time…really In all the interviews the participants are discussing how
understanding the client’s needs, demands, setting, I don’t patients in an acute phase of a disease or injury have diffi-
think we have it [time] in this setup.» The participants said culties identifying possible functional problems. Namita
that it might be difficult to use a client-centred practice said: «In the acute phase nobody feels a need yet, it has not
because of time constraints if the patient gets discharged really hit them.» Manu explained it like this: «They don’t
fast and if the therapist’s case load is too big. Some of the know what their problem exactly is. They just know «I am
participants said that client-centred practice is more sui- not able to move my hand or leg.» … Even if you ask them,
table in the client’s own environment in a community they will say; «No, I don’t have a problem», or they’ll say: «My
health setup than in a hospital setup. Lakshmi said: wife is there to help me out right now». So only once they go
«Therapy is left at the hospital; it is not extended into his back, and they come as outpatient, that is the time when
actual living setup. So … if it is actually serving the purpose actually they say: «These are the problems, I have problem
in his real setup is not known to us most of the time.» Namita with eating» … That is the time they come with a functional
mentioned difficulties connected with a body-oriented problem. In such condition we’ll use client-centred practice.
system: «The patients themselves are very body-oriented, the Whereas in acute it’s very difficult.»

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They also argued how patients in an acute phase do not process. One reason they gave is that they use a medical
realise they have a chronic condition, they think they will treatment model where goals focus on performance areas
get cured either by traditional measures or by medicine. and treatment focuses on performance components.
Manu stated: «They feel that once they take medicine, after Lakshmi explained: «I think when we assess the patient we
10 - 15 days they’ll be fine. When they go back home they’ll be do [use a client-centred approach]. But when it comes to the
fine. ... they don’t see the problems which can occur in the treatment, we don’t. So when I am asking the patient what
future.» his problems are and all, I think, there is a touch of client-
Some of the participants pointed out that patients in an centred in it. … I think that the cycle of client-centred is not
acute phase have expectations that are not suitable for cli- complete. I feel it’s just at the assessment, and then the outco-
ent-centred practice. Praveen explained: «Acute phase, yes, me.»
even I would try to be a passive recipient … When somebody Namita partly agreed with the others: «as for goal we use
comes to the doctor or a therapist he expects them to know bet- it [client-centred approach]. Our goal is always for the cli-
ter about the disease and come with a solution.» Sherin said: ent». She also gave an example of how she can be client-
«Here the patients are more into things like «you give me a centred in the intervention when resources are available.
medicine» and «I need to get better».» One of her patients was interested in needlework, but had
The participants described how patients may have difficulties with her dexterity. Instead of using usual
vague expectations regarding therapy for different reasons. department activities, Namita used activities that matched
Sherin mentioned literacy: «Here in India most of the time the patient’s interest: «So with this particular patient I can
patients really don’t know what they need. … It may be say I was client-centred. Because the therapy was designed
because of understanding of words, literacy. So I think for a towards her interests.» Praveen said therapy is not client-
client-centred practice to be very effective, the patient should centred unless the client takes part in the decision making
have a good knowledge about their condition and should be process: «Why I say that I don’t give client-centred therapy is
educated.» because it is passively … it’s me who take the decision, it’s
Namita talked about education level: «Most of the pati- from my perspective. The patient is not involved actively in
ents we see are lower education class, they are also low socioe- the decision-making process. That’s why technically speaking I
conomic class. They are something like: «You tell me what to would not follow strictly the client-centred therapy.»
do». Most of the time we say they are passive recipients … Through the interviews they discussed different ways of
First of all they are not so demanding, and sometimes it is dif- using this approach depending on the context and the
ficult for them to comprehend when we ask them what they patient. Namita said she uses client-centred practice with
wish. … in fact they say everything is fine.» educated patients who are able to communicate. In these
Lakshmi added: «They just see us as another doctor. They cases she would explain the therapy to the patient and ask
just say, «I have pain, I have this, I have that. So for the pati- about his view. «That is when I’m client-centred, right, I’m
ent to understand what the therapist is capable of doing is asking his wish, but that is not possible every time. For educa-
necessary.» ted patients I can explain.» Further she said: «We are almost
Another challenge the participants identified was that a variety to client-centred.» Manu gave an example of how
patients in India tend to have a lack of motivation to beco- he would approach a patient with a low education-level:
me independent. Namita explained: «In India there is «People who are very poor and illiterate, they’ll like; «Okay,
someone to help you anyway. We don’t even mind taking help; no, we don’t want [therapy]». And their understanding will
it’s a part of our culture. In fact if the mother doesn’t help, she also be very poor. So in that condition we’ll use more of, we
feels bad. If we don’t help, we feel guilty.» Sandeep declared only say: «If you do this, you’ll get better».» This is how
that «the patient plays the sick role». Sachin said that pati- Sandeep said he would meet patients with difficulties
ents accept their condition and their dependence on identifying problems: «...therapist has to find out the pro-
others very fast; «I have to live with it, it’s fortunate or blem as well as the solutions. So automatically the client-cen-
unfortunate this thing.» tred is not there. … Their complaints will be few … The
Several of the participants talked about a connection decision will finally be taken by the therapist.» Some of the
between client-centred practice and independence. Padma other participants indicated that they can still be client-
stated: «If the patient doesn’t have that motivation to be inde- centred by using repeated probing and questioning, as
pendent, we don’t have any role for the patient, we motivate Sherin said: «...we need to really look into and have an on-
that issue, that’s where we start from then.» Lakshmi, in ans- sight evaluation, how he’s doing it and asking him ‘do you
wer to this, asked: «If there is no need for that [independen- think it’s a problem?» and if he says «yes», then we should
ce] in the patient, then how do we use client-centred?» address it. So it’s indirect.»
Namita revealed a different opinion to this: «According to In cases where the patient is not motivated for therapy
client-centred practice you’re supposed to accept that.» Lakshmi explained how they do it: «…convincing the pati-
ent that it is important to be independent, that he can be
The participants’ description of how they use independent and that this is going to facilitate his quality of
client-centred practice life and his sense of wellbeing in life. So getting the patient to
The participants discussed how they use parts of a client- understand that, and then look into what he really aims at in
centred approach in therapy. Some of them stated that life. … If they are motivated we automatically can use client-
they use it in goal setting, but not in the rest of the therapy centred, but if they are going to accept the fact that «yes, my

44 Ergoterapeuten 03.12
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wife is going to do this for me, or my husband will do this for
me», then, I think we start with facilitating the need to be
independent, and then getting to address his needs.»
Sachin explained that in the prescription from the phy-
sician the focus is on body components in a terminology
the patient does not understand: «Please mobilize and
improve their [patients] ranges.» Further he said: «...what he
[the patient] understands is: On day one he could not eat,
after ten days he still cannot eat. This is the language that he
understands. So we keep juggling between these two tracks.»
Sandeep gave an example where the patient’s goal was to
ride a bike (performance area) but the focus in therapy ses-
sions became increased wrist extension (performance com-
ponent). Padma pointed out: «You have to explain to the
clients that this will help them in their performance areas.
You have to explain them, it’s not visible.»

Discussion
It is evident from the results that the participants’ definiti-
on of client-centred practice contains many of the same
components as Sumsion’s (2000) definition. They mentio-
ned collaboration and negotiation between the therapist
and the client, informed decision, client’s active participa-
tion and the importance of prioritising client’s needs and
values in goal setting. This indicates a common knowledge
base when it comes to client-centred practice.
According to the participants in this project, there are
many factors that can influence the ability to use client- Oda Pettersen making splints.
centred practice:
a Practice context such as type of clinical setting, the
structure of the health services, working within a body see patients’ problems from two different angles (Matting-
oriented system, resources and time. Duggan (2005), ly 1994). This is similar to findings in this project, where
Maitra and Erway (2006), Mortenson and Dyck the participants explained that from a medical point of
(2006), Sumsion (2004), Sumsion and Smyth (2000), view they are seeing performance components, whilst
Wilkins et al. (2001) and Wressle and Samuelsson from a client-centred point of view they are focusing on
(2004) all mention different factors related to the con- performance areas. The participants suggested that wor-
text that have an impact on client-centred practice. The king in the community in the patient’s own environment
participants also described factors related to the client: would make it easier to recognise the patient’s performan-
b Client’s condition such as cognition and insight, ce problems for the patient as well as for the therapist.
c client’s difficulties seeing performance problems, Participants described inpatients in an acute phase as
d client’s expectations such as expectations to get well fast having difficulties identifying functional problems. This is
or to be cured, either by the therapist or by medicine, similar to findings in Maitra and Erways’ (2006) study,
and where patients in hospitals had difficulties participating in
e client’s lack of motivation to become independent. the goal setting process. Falardeau and Durand (2002)
Chen et al. (2002), Maitra and Erway (2006), Sumsion observed the therapist’s power as stronger than the client’s;
(2004), Wilkins et al. (2001) and Yang et al. (2006) all the client’s role being passive, and the therapist’s being the
found barriers for application of a client-centred appro- expert role in a medical model. The way the participants
ach at the level of the client in their studies. in this project described patients taking the sick role, being
passive recipients and having expectations that the thera-
In this project the aim was particularly to look at client- pist would cure them, can this way be seen partly as the
centred practice in a medically oriented setting within an result of a medically oriented system. They say that even
Indian cultural context. The following discussion will the patients consider their condition from a medical point
focus on these aspects. of view. The participants find working client-centred in a
medically-oriented setting difficult. They try to use the cli-
Juggling between two tracks ent-centred approach as much as possible, but end up
Within a medical model the emphasis is on illness while in using only elements of it. As Falardeau and Durand
client-centred practice the focus is on occupational perfor- (2002) say, a medical model and a client-centred approach
mance (Falardeau & Durand 2002). Juggling between the- can be seen as contrasts in many ways. This may indicate
se two tracks means that occupational therapists have to that the use of a client-centred approach the way it is defi-

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ned by Sumsion (2000) in this type of medical setting, mutual learning and a common understanding regarding
may be an unrealistic expectation. This is supported by solutions in the client-therapist relationship (Levasseur &
Duggan (2005) who suggests that applying an ideal client- Carrier 2010). These elements are important requirements
centred practice might not be attainable in an institutional for client-centred practice as described by Sumsion and
setting. Wilkins et al. (2001) stated that occupational the- Law (2006). Therefore to reflect on the patient’s level of
rapists should find ways to work client-centred with all cli- health literacy and give information that the patient
ents. Considering the above, there may be a need for a understands can be considered important when applying a
customised version of client-centred practice so that occu- client-centred approach to practice. This is supported by
pational therapists in medically oriented settings do not Levasseur and Carrier (2010), who suggest that in order to
constantly have to strive for something that may not be enable the client to understand health information, reha-
achievable. bilitation professionals need to consider their client’s level
of health literacy. They also state that a low level of health
Cultural impacts literacy is a wide-spread problem in western countries.
Lim and Iwama (2006) explain that Asian clients’ lack of Health literacy may therefore be a relevant element to con-
initiative and passive behaviour may be due to a culture sider when using a client-centred approach not only in
where stillness in «being» is more valued than actively India, but also in other parts of the world.
«doing». The way the participants described patients
taking the sick role and being passive recipients, this can Conclusion
also be seen as a result of cultural factors. Chen et al. We used a qualitative method to explore the applicability
(2002) also mention this phenomenon in their study. In of client-centred practice in a medically-oriented setting in
addition to this the participants described that some pati- an Indian cultural context. By interviewing nine Indian
ents do not have the drive to be independent. This is simi- occupational therapists, we found that they define client-
lar to the findings in Yang et al. (2006). The participants centred practice in a similar way to Sumsion (2000). They
explained that this is because of a culture where the family find practicing this approach challenging, due to many
helps out when the person falls ill. In western parts of the factors. Despite these challenges they try to use client-cen-
world independence is considered a central concept in tred practice as much as possible, but end up using only
rehabilitation (Tamaru, McColl & Yamasaki 2007). The elements of it. Through our discussion we suggest that
participants raised the question of how to be client-cen- there is a need for further research to investigate the rele-
tred when the patient does not want to become indepen- vance of health literacy in client-centred practice, to find
dent. Awaad (2003) says that western oriented models in an appropriate way of using client-centred practice in
OT need to be adjusted to better suit patients from non- medically oriented settings, and to explore the use of cli-
western cultures, and that the goal for rehabilitation could ent-centred practice in non-western contexts. This may
focus on interdependence as well as independence. This contribute to enhance the quality of OT services and cli-
indicates a need for further research on client-centred ent-centred practice. q
practice as an approach in non-western OT settings. This
may benefit occupational therapists and patients in non-
western countries as well as in a growing multicultural References
context in western countries. American OT Association (2010). OT Code of Ethics and Ethics
Standards. Bethesda USA: AOTA
Health literacy Awaad, T. (2003). Culture, Cultural Competency and OT: A Review
of the Literature. British Journal of OT, 66(8): 356-362
Part of Sumsion’s (2000) definition of client-centred prac- Berg, B.L. (2009). Qualitative research methods for the social sciences
tice is that the therapist «enables the client to make informed (7th ed.). Boston, USA: Pearson Education Inc.
decisions». Sumsion and Law (2006) say that clients must Chen, Y., Rodger, S. & Polatajko, H. (2002). Experiences with the
be given sufficient information to be able to take control COPM and client-centred practice in adult neurorehabilitation in
and participate in a partnership with the therapist. The Taiwan. OT International, 9(3): 167-184
participants described how patients with a low education College of Occupational Therapists (2010). Code of Ethics and
Professional Conduct. London: COT
level and belonging to a low socioeconomic class have dif-
Duggan, R. (2005). Reflection as a means to foster client-centred
ficulties understanding such information. They also practice. Canadian Journal of OT, 72(2): 103-112
expressed difficulties in facilitating patients to come up Falardeau, M. & Durand, M.J. (2002). Negotiation-centred versus
with their problems. Health literacy is defined as «the abi- client-centred: Which approach should be used? Canadian Journal
lity to access, understand, evaluate and communicate infor- of OT, 69(3): 135-142
mation as a way to promote, maintain and improve health in Hasselkus, B.R. (2002). The Meaning of Everyday Occupation. New
a variety of settings across the life-course» (Rootman & Jersey: SLACK Incorporated
Høgskolen i Oslo (2010). Fagplan for bachelorstudiet i ergoterapi:
Gordon-El-Bihbety 2008 cited in Levasseur & Carrier
Kull 2008-11. Høgskolen i Oslo: Avdeling for helsefag
2010, p. 757). Patients’ difficulties understanding infor- Kang, D.H., Yoo, E.Y., Chung, B.I., Jung, M.I., Chang, K.Y. & Jeon, H.S.
mation given by the occupational therapist and patients’ (2008). The application of client-centred OT for Korean children
difficulties expressing their needs, can be related to the with developmental disabilities. OT International, 15(4): 253-268
aspects of understanding and communicating information Kvale, S. & Brinkmann, S. (2009). Interviews: Learning the craft of
in health literacy. Health literacy fosters partnership, Qualitative Research Interviewing. Los Angeles: SAGE

46 Ergoterapeuten 03.12
 faglig
Larsen, A.K. (2008). En enklere metode: Veiledning I samfunnsviten-
skapelig forskningsmetode. Bergen: Fagbokforlaget
Levasseur, M. & Carrier, A. (2010). Do rehabilitation professionals
need to consider their clients’ health literacy for effective practi-
ce? Clinical Rehabilitation, 24: 756-765
Lim, K.H. (2008). Working in a transcultural context. In: J. Creek & L.
Lougher (Ed), OT and Mental Health (4th ed., p.251-274).
Edinburgh: Elsevier Limited
Lim, K.H. & Iwama, M.K. (2006). Emerging models – an Asian per-
spective: The Kava (River) Model. In: E. Duncan (Ed.), Foundations
for Practice in OT (p.161-189). Edinburgh: Elsevier Limited
Maitra, K.K. & Erway, F. (2006). Perceptions of Client-Centered
Practice in Occupational Therapists and Their Clients. American
Journal of OT, 60: 298-310
Mattingly, C. (1994). OT as a Two-Body Practice. The body as a
Machine. In: C. Mattingly & M.H. Fleming, Clinical Reasoning:
Forms of Inquiry in a Therapeutic Practice (p.37-63). Philadelphia:
F.A. Davis Company
Mattingly, C. (1994). OT as a Two-Body Practice. The Lived Body.
In: C. Mattingly & M.H. Fleming, Clinical Reasoning: Forms of Inquiry
in a Therapeutic Practice (p.64-93). Philadelphia: F.A. Davis
Company
Moore, N. (2006). How to do research: A practical guide to designing
and managing research projects (3rd ed.). London: Facet
Publishing
Mortenson, W.B. & Dyck, I. (2006). Power and client-centred prac-
tice: An insider exploration of occupational therapists’ experien-
ces. Canadian Journal of OT, 73(5): 261-271
Norsk Ergoterapeutforbund (2006). Ergoterapeutenes samfunns-
kontrakt – yrkesrolle og etiske retningslinjer. Oslo: Norsk
Ergoterapeutforbund
Parker, D. (2006). The client-centred frame of reference. In: E.
Duncan (Ed.), Foundations for Practice in OT (4th ed., p.193-215).
Edinburgh: Elsevier
Rogers, C.R. (1939). The clinical treatment of the problem child.
Boston: Houghton Mifflin
Rootman, I. & Gordon-El-Bihbety, D. (2008). A vision for a health
literate Canada. Report of the Expert Panel of Health Literacy.
Ottawa: Canadian Public Health Association.
Sumsion, T. (1999). A Study to Determine a British OT Definition of
Client-Centred Practice. British Journal of OT, 62(2): 52-58
Sumsion, T. (2000). A Revised OT Definition of Client-Centred
Practice. British Journal of OT, 63(7): 304-309
Sumsion, T. (2004). Pursuing the Client’s Goals Really Paid Off.
British Journal of OT, 67(1): 2-9
Sumsion, T. & Law, M. (2006). A review of evidence on the concep-
tual elements informing client-centred practice. The Canadian
Journal of OT, 73(3): 153-162
Sumsion, T. & Smyth, G. (2000). Barriers to client-centredness and
their resolution. The Canadian Journal of OT, 67(1): 15-21
Tamaru, A., McColl, M.A. & Yamasaki, S. (2007). Understanding
«Independence»: Perspectives of occupational therapists.
Disability and Rehabilitation, 29(13): 1021-1033
Wilkins, S., Pollock, N., Rochon, S. & Law, M. (2001) Implementing
client-centred practice: Why is it so difficult to do? The Canadian
Journal of OT, 68(2): 70-79
World Health Organization (1986). The Ottawa Charter for Health
Promotion. Retrieved May 9th 2011 from:
[Link]
wa/en/
Wressle, E. & Samuelsson, K. (2004). Barriers and Bridges to Client-
centred OT in Sweden. Scandinavian Journal of OT, 11: 12-16
Yang, S., Shek, M.P., Tsunaka, M. & Lim, H.B. (2006). Cultural influ-
ences on OT practice in Singapore: A pilot study. OT International,
13(3): 176-192

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