Client-centered therapy might be the answer in the era of managed care
Program works with patients who are reluctant participants
Rehab therapists commonly find that many of their patients are not actively engaged or interested in their therapy and interventions. In the past, there was always time to help the patient improve his or her attitude, especially when the patient had months as an inpatient to adjust to a physical disability or change.
Managed care trends and Medicare changes, however, have condensed the time therapists have to spend with patients, and that means each therapy session is laden with more goals and expectations. If clients are reluctant participants, there may not be enough time to achieve those goals.
"This is a fairly significant issue," says Pamalyn A. Johns, MS, OTR/L, an instructor of occupational therapy at the University of the Sciences in Philadelphia. "For the clients I’ve worked with, I would describe half of them as not being active participants in the process or not being very actively involved in taking the initiative in the process."
Johns recently participated in research that assessed improvements among spinal cord injury patients treated by occupational therapists with a client-centered intervention over a six- to eight-month period. The study found that the patients, all of whom were quadriplegic and about six months post-discharge from a rehab facility, showed some improvements in measures of quality of life, functional abilities, and community roles after the client-centered therapy.
A control group visited by nontherapeutic visitors did not show improvement, says Michelle E. Cohen, PhD, associate professor of occupational therapy and an experimental psychologist at Thomas Jefferson University in Philadelphia. Cohen was a co-investigator in the study, "Client-Centered Occupational Therapy for Individuals with Spinal Cord Injury."
Although the research had a limited group of participants (fewer than 30), its findings at least point to a trend that supports client-centered therapeutic approaches, Cohen says. "The people who received client-centered occupational therapy had a better outlook in terms of quality of life, and they improved."
The study also found that patients receiving the client-centered therapy were more successful in returning to the work and community roles they had before their injury, or they had developed new roles in which they could be involved with the community. "The social visitor group did not do that. They stopped working, and they did not maintain the community roles they had before," Cohen says.
In general, the research supports a therapy approach that focuses on patient instruction more than on outcome numbers, says Ruth Schemm, EdD, OTR/L, FAOTA, dean of health sciences at the University of the Sciences in Philadelphia. As Rehab Continuum Report went to press, Schemm and Johns were scheduled to speak about client-centered therapy at the annual conference of the American Occupational Therapy Association, held March 31-April 3 in Seattle. "We’re finding that therapists need to think about teaching and learning as part of service delivery for patients who are chronically disabled," she says. "Rather than do to the person, think about teaching them."
The client-centered approach, developed in the 1980s by Canadian occupational therapists, works from the assumption that clients know what they need and want from therapy and that the goals of therapy should be the client’s goals, Johns explains. (See related story, p. 55.)
"Therapists can’t actually change a client," Johns adds. "We can only provide an environment for patients to change themselves."
Assess your strategy
In client-centered therapy, for instance, therapists assess their teaching strategies, asking these sorts of questions:
• Are we breaking down tasks to the level that best suits a particular client?
• Are we providing clients with the structure they need?
• Are we using all the available avenues necessary for clients to learn the information?
• Are clients learning experientially, or are we providing support through written documentation or visual cues?
The client-centered model also requires therapists to think differently about patient goals during inpatient therapy, Johns suggests.
"Spinal cord injury is such a life-altering event that we’re looking at how much we can possibly do while a patient is in rehab," she explains. "It may be that in addition to focusing on patients’ goals, we will need patients to be independent, and we may need to help patients develop a sense of themselves."
That could be accomplished by helping patients develop skills in setting goals because they do not always know what they want from therapy, Johns says. For instance, a therapist might have to do a little detective work, digging into the patient’s life before the injury and finding out what was meaningful to the patient, and then incorporating those types of activities in the treatment plan. It also means that therapists should encourage patients to take a more active role in the therapeutic process. "Therapists need to use clinical reasoning to figure out where we need to go in the therapeutic process with that patient and then guide the patient to take a more proactive role in therapy," she says.
Schemm says helping patients find their new identities can be a key part of therapy because patients often don’t have an image of what they might become. "They don’t have their new self, the one who is the person with this handicap, so they are unable to think about themselves as a person who has lots of options because they are overwhelmed by what they have been through."
Therapists could help patients find a new self-image by providing them with role models and examples of achievements by other people who have disabilities. For instance, a therapist could show a spinal cord injured patient a videotape by the AXIS Dance Troupe of El Cerrito, CA. The troupe consists of people with spinal cord injuries.
"Now with rehab time cut so short, patients are almost disenfranchised from other patients who are further along in their rehab process and are getting back their lives," Schemm says.
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