Here’s a brief look at client-centered therapy
Check out these strategies for using the method
Let’s face it: Functional improvement measurements (FIM) and other ways to quantify goal achievements do not exactly contribute to a better relationship between therapists and patients. It’s up to the therapists to bridge the gap between data collecting and patient care with their own enthusiasm and coaxing methods. But even the most determined therapist could find goals still unmet if a patient is not interested in the process.
Recently, researchers have found that if therapists engage in a client-centered therapeutic approach, they might have better cooperation from their more reluctant clients.
"Client-centered therapy is not about having the client make all the decisions, but about taking the client’s ideas and moving forward with them in a client-centered surrounding," says Michelle E. Cohen, PhD, associate professor of occupational therapy and an experimental psychologist at Thomas Jefferson University in Philadelphia.
The therapeutic model uses adult learning principles and creates an atmosphere in which therapists lead the way through teaching patients strategies for improving their lives and gaining independence, explains Ruth Schemm, EdD, OTR/L, FAOTA, dean of health sciences at the University of the Sciences in Philadelphia.
Therapists often look for big changes in their patients and sometimes ignore the small accomplishments that have occurred, says Pamalyn A. Johns, MS, OTR/L, instructor of occupational therapy at the University of the Sciences. "We had a therapist who wanted a patient to work on finding equipment, and the therapist asked the patient to call five different vendors about equipment," she says. "Between visits, the patient only made one phone call, and the therapist was disappointed instead of being pleased the patient at least made one phone call."
It’s possible that rehab therapists are setting their expectations too high, which leads to disappointment, instead of reinforcing positive behaviors, even small ones, Johns adds.
It might help if rehab facilities incorporated the client-centered approach into their team strategy, although it’s a different model than the medical model typically used, Johns says. "Therapists working in a rehab center that’s heavily based on the medical rehab model are not going to be able to be 100% committed to the client-centered approach, but they can incorporate principles and components of it into their practice."
It’s a good idea to do so, because once patients leave rehab, their coping strategies and emotional balance change, she says. "What we can do is help them feel confident so that they have the skills to do what they need to do."
Johns offers these strategies for incorporating a client-centered approach in a rehab setting:
• Incorporate the patient’s goals in the treatment plan.
Therapists should ask patients what their goals are, help them develop goals, then incorporated them into treatment planning, Johns says. Some research suggests that while occupational therapists ask clients about their goals for treatment, they often only minimally reflect them in the intervention goals, she notes. For example, a patient might be worried about how to take care of a child or return to work. But the therapist’s goals might be to teach the patient self-care and home management. If the therapist ignores the patient’s concerns and attempts to convince the patient to focus on self-care issues, it may not work because the client is too preoccupied with other goals.
"You may have to compromise so that the client can hear that you are paying attention to the client’s concerns that going back to work or taking care of the child is important," Johns says. "Then you can address those concerns while addressing the skills the client needs to learn."
• Investigate the patient’s history.
Sometimes patients are not able to articulate their goals or what’s important in their lives. Therapists shouldn’t assume that means they can skip the client’s goals and move on to the therapy goals. Instead, therapists should do some investigative work to find out what was important to the patient before the injury. "Find out what are their values, their leisure activities, and what things had meaning for them, and then try to incorporate those into the therapeutic process," Johns explains. "This may help to give patients a vision of where they’re going in the future."
• Be aware of patient-therapist control issues.
Control is an important issue to rehab patients because they often have very little control in their lives. They have to follow rules set by the facility, and their injuries have further limited their ability to act on their own volition.
"People need to at least feel they have control, even if it’s an illusion of control over their lives," Johns says. "So try to be collaborative with them on treatment planning and what they do in therapy." For example, therapists could include patients in the process of scheduling goals, she suggests. "Or even if you can structure it, try to let the patient guide or direct the therapeutic process," she adds. "Try to remember these are folks we don’t want to be passive after they leave therapy, because if they are passive, they might not be as successful as they possibly could be."
• Assess patient activities in terms of building confidence.
This is one of the most important strategies because it can make the difference between an enthusiastic patient and one who acts defeated during therapeutic interventions. "Look at the activities you’re choosing to do with the client," Johns says. "Have you broken down the tasks in such a way that it promotes confidence?"
Therapists try to provide patients with challenges that promote success, but they sometimes lose sight of the possibility that patients need smaller activities and goals to help them feel more confident in the process. Without smaller goals, they might feel too pressured for outcomes.
For example, Johns worked with one spinal cord injury patient who had not left the block at his house except to see his doctor. "So when I first started working with him, I really wanted him to take a bus downtown and go to the movies because that was a prior leisure activity he had engaged in," she says. She visited the young man a few times after making this suggestion, and each time he came up with an excuse about why he hadn’t gone to the movies. Finally, Johns realized she had set the goal too high. Taking a bus and attending a public theater was too threatening an activity to this man, who still had not adjusted to being in a wheelchair and being viewed as a disabled person.
So she adjusted her goal to a smaller step first. She suggested he and his girlfriend go to a nearby park and have a picnic. This goal had the added benefit of reinforcing his relationship with his girlfriend, and it gave him an opportunity to be out in public around strangers.
"What was interesting about that experience was that when they were on their way to the picnic site, the man said he could feel people looking at him, and he felt uncomfortable," Johns recalls. "But when he left the park after having the picnic, he said people didn’t pay any attention to him."
The patient probably was acutely aware of the stares when he first ventured out in public. But once he became used to it, he forgot to look, and even if people stared at him, he didn’t notice it as much, Johns surmises. "For him that was a turning point, because after this park visit he started to circle around his neighborhood. Eventually, we started to be able to talk about his going downtown and talk about recreational events for people who are disabled."
Need More Information?
Michelle E. Cohen, PhD, Associate Professor of Occupational Therapy, Experimental Psychologist, Thomas Jefferson University, 130 S. Ninth St., Suite 810, Philadelphia, PA 19107. Telephone: (215) 503-0121.
Pamalyn A. Johns, MS, OTR/L, Instructor of Occupational Therapy, University of the Sciences in Philadelphia, 600 S. 43rd St., Philadelphia, PA 19104. Telephone: (215) 596-8493. E-mail: [email protected].
Ruth Schemm, EdD, OTR/L, FAOTA, Dean of Health Sciences, University of the Sciences in Philadelphia, 600 S. 43rd St., Philadelphia, PA 19104. Telephone: (215) 596-8767. E-mail: [email protected].
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