Article Canadian Journal of Occupational Therapy

2015, Vol. 82(5) 307-315

DOI: 10.1177/0008417415577422

Enhancing student occupational ª CAOT 2015

Reprints and permission:
therapists’ client-centred counselling skills sagepub.com/journalsPermissions.nav
www.cjotrce.com

Rehausser les compétences en counseling centrées sur le client des

étudiants en ergothérapie

Pamela F. Wener, Carolyn O. Bergen, Lisa G. Diamond-Burchuk, Cynthia M. Yamamoto,

Alana E. Hosegood, and James D. Staley

Key words: Education; Occupational therapy; Patient-centered care.

Mots clés : ergothérapie; formation; soins centrés sur le client.

Abstract
Background. Client-centred practice is the cornerstone of the occupational therapy profession. However, there has been little
focus on how to teach students to be client-centred practitioners while engaged in counselling. Purpose. The purpose of
this study was to examine the impact of the use of a client-completed rating scale on student occupational therapists’
client-centred counselling skills. Method. A time-series design was used to measure the changes in students’ counselling skills
over time. Demographic information was collected prior to time one. An online questionnaire was administered after study
completion to explore students’ experiences of using the Session Rating Scale. Findings. The impact of using the Session
Rating Scale as a measure of students’ client-centred counselling skills performance significantly improved over time. Most
students valued using the rating scale and would recommend its use for future students. Implications. The process of
supporting students to learn how to engage clients in providing timely feedback and using this feedback to design treatment
sets the stage for integration and application of client-centred practice.

Abrégé
Description. La pratique centrée sur le client est la pierre angulaire de la profession d’ergothérapeute. Toutefois, on s’est peu
attardé à la façon d’enseigner aux étudiants comment être des praticiens centrés sur le client lorsqu’ils font du counseling. But. Le
but de cette étude était d’examiner l’impact de l’usage d’une échelle de cotation remplie par le client sur les compétences en
counseling centrées sur le client des étudiants en ergothérapie. Méthodologie. Un plan expérimental en série temporelle a
été utilisé pour mesurer les changements survenus dans les compétences en counseling des étudiants au fil du temps. Des
données démographiques ont été recueillies avant l’intervalle temporel un. Un questionnaire en ligne a été administré après
l’étude, afin d’explorer les expériences vécues par les étudiants face à l’usage de la Session Rating Scale. Résultats. L’impact
de l’usage de la Session Rating Scale en tant que mesure du rendement des étudiants face à l’utilisation de compétences en
counseling centrées sur le client est devenu plus important au fil du temps. La plupart des étudiants ont trouvé qu’il était utile
d’utiliser l’échelle de cotation et ils recommanderaient son usage aux futurs étudiants. Conséquences. Il est possible de
favoriser l’intégration et l’application de la pratique centrée sur le client en outillant les étudiants, afin qu’ils apprennent à
rehausser la participation des clients en donnant une rétroaction en temps opportun et en se servant de cette rétroaction
pour concevoir l’intervention.

Funding: This project was funded in part by the University of Manitoba, Centre for the Advancement of Teaching and Learning.

Corresponding author: Pamela Wener, Department of Occupational Therapy, College of Rehabilitation Sciences, Faculty of Health Sciences, University of
Manitoba, R125-771 McDermot Avenue, Winnipeg, MB, R3E 0T6, Canada. Telephone: 204-789-3456. E-mail: Pam.Wener@umanitoba.ca

Downloaded from cjo.sagepub.com at University of Sussex Library on May 24, 2016

308
C
lient-centred practice is foundational to occupational
therapy and has been a focus of study and discussion
for over 30 years (e.g., Department of National Health
and Welfare & Canadian Association of Occupational Thera-
pists [CAOT], 1983; Townsend et al., 2013). Recent national
and provincial continuing competency documents highlight the
importance of client-centred practice, requiring occupational
therapists to be competent client-centred practitioners (see
Association of Canadian Occupational Therapy Regulatory
Organizations, 2011; College of Occupational Therapists of
Manitoba, 2013).
Beginning in mid-1990s, occupational therapy scholars
have recognized the need for a clear definition of client-
centred practice (e.g., Law, Baptiste, & Mills, 1995). Identifying
and articulating the dimensions of client-centredness have been
integral in evaluating this occupational therapy approach to cli-
ent care. Law et al. (1995) argued that client-centred practice
within the therapist–client relationship involves respect, partner-
ship, recognition of autonomy, and client choice. The concepts
of equal partnership (Egan, 1997; Law et al., 1995; McColl &
Pranger, 1994; Sumsion, 1999a, 1999b, 2000; Waters, 1995) and
of the sharing of power within the therapeutic relationship
(Law, 1998; CAOT, 2002) have been similarly emphasized.
More recently, Sumsion (2006) and Sumsion and Law (2006)
highlighted empowerment as another aspect of client-centred
practice. According to these authors, when the therapist is
client-centred and the power differential is diminished between
the client and the therapist, the client may feel empowered and the
therapeutic relationship may be enhanced.
While the definition of client-centred practice has evolved
over time, the centrality of the therapeutic relationship has been
consistent. Tickle-Degnen (2002) discussed therapist–client
interactions in occupational therapy as being similar to the
concept of the therapeutic alliance seen in the context of psy-
chotherapy and at the very core of client-centred practice.
Tickle-Degnen argued that occupational therapists should incor-
porate client-centred principles into everyday practice when
developing rapport and building a working alliance with clients.
Indeed, occupational therapists may feel most prepared to apply
client-centred approaches in the context of the one-to-one ther-
apeutic relationship. Restall and Ripat (2008) found that occupa-
tional therapists were more comfortable implementing client-
centred strategies at the level of the client–therapist relationship
in comparison to broader environmental levels, such as the prac-
tice setting, community organizing or coalition advocacy, and
political action. Palmadottir (2006) argued that the therapeutic
relationship is ‘‘one of the most important tools in occupational
therapy’’ (p. 400) and that occupational therapists are in a unique
position to develop effective therapeutic relationships with their
clients due to the often personal and informal nature of occupa-
tional therapy services.
Similar to occupational therapists, clients receiving ser-
vices agree that the therapeutic relationship is critical to
client-centred practice. Corring and Cook (1999) explored the
meaning of client-centredness from the perspective of mental
health consumers and found that feeling valued and being
Canadian Journal of Occupational Therapy Downloaded from cjo.sagepub.com at University of Sussex Library on May 24, 2016
Wener et al.
treated as a human being were the most essential components
of client-centred care. Study participants described client-
centred care by discussing interpersonal experiences, focusing
on the relationship between themselves and various service
providers. Blank (2004) looked at how adult clients receiving
community mental health services viewed their relationships
with occupational therapists. Study participants identified
client-centred skills, including an open posture, warmth, respect,
trust, and empathy, as promoting positive client-therapist rela-
tionships. Similar to Corring and Cook, Blank highlighted the
client–therapist relationship as central to the client’s experience
of occupational therapy. Taken together, these authors suggest
that the therapeutic relationship is a key interface where client-
centred strategies may be enacted in daily practice.
Accordingly, it is not surprising that most Canadian univer-
sity occupational therapy programs expect students to gain
knowledge and skills to facilitate client-centred therapeutic rela-
tionships. For example, the University of Manitoba occupational
therapy program is based on six key concepts including client-
centred practice (MOT Program Committee, 2011), while the
Master of Science Occupational Therapy Program (2014) at
Queen’s University includes a client-centred approach as one
aspect of the program’s therapeutic values. Over the course of
occupational therapy education programs, academic and field-
work instructors aim to teach students how to develop a client-
centred relationship with clients. However, to date, minimal
research has explored how students learn to facilitate these
client-centred therapeutic relationships.
Coates and Crist (2004) studied the development of pro-
fessional behaviours, including client-centredness, among
student occupational therapists across a 12-week fieldwork
placement. Students were videotaped administering the
Canadian Occupational Performance Measure at the begin-
ning and end of placement to examine changes in observable
client-centred behaviours over time. These researchers found
that at placement completion students demonstrated
increased client-centred behaviours (as defined in their
study), including defining performance deficits and desired
outcomes with the client, empowering the client, encoura-
ging resource utilization, encouraging decision making, and
when appropriate, using the client’s style of coping. This
study suggested that the use of client-centred assessment tools
has merit in teaching client-centred behaviours to student occu-
pational therapists. Jamieson et al. (2006) created and evaluated
an experiential learning opportunity with a focus on the develop-
ment of empathy through increased understanding of the lived
experience and coexistence of health and disability. These
authors concluded that the students developed empathy consis-
tent with the principles of client-centred practice. In a recent
study, Ripat, Wener, and Dobinson (2013) explored how student
occupational therapists develop client-centredness—or the atti-
tude or belief in being client-centred—throughout their educa-
tional program and into their first years of practice. These
authors discuss several themes important to the client-centred
development of students, such as internalizing client-
centredness, relationship building, the academic/practice
Canadian Journal of Occupational Therapy 82(5)
discrepancy, and the subsequent difficulty students experience in
bridging this gap (Ripat et al., 2013).
Some authors have challenged the profession’s espoused
commitment to client-centred practice. In particular, Hammell
(2013b) has underscored the lack of consideration of the client
perspective in what constitutes client-centred practice often
found in occupational therapy research and practice evaluations.
Duncan et al. (2003) suggest that measurement tools, such as the
Session Rating Scale (SRS; Johnson, Miller, & Duncan, 2000),
may be used by clinicians to ensure that counselling sessions
meet the client’s needs as perceived by the client, thus incorpor-
ating a key aspect of a client-centred approach. As a brief global
measure of the therapeutic alliance with ease of both administra-
tion and interpretation of results (Campbell & Hemsley, 2009),
the SRS presents interesting possibilities for teaching occupa-
tional therapy students the skills to foster client-centred relation-
ships with simulated or situational clients.
University of Manitoba’s Counselling Curriculum
Master of occupational therapy students at the University of
Manitoba are taught client-centred counselling skills. Although
there are many types of counselling, Manitoba’s occupational
therapy program emphasizes the development of generic coun-
selling skills with particular emphasis on strengthening the
therapeutic relationship with the client. As part of this process,
1st-year master of occupational therapy (MOT1) students are
taught basic interviewing and communication skills using both
didactic and experiential teaching methods.
Building on the 1st-year curriculum, 2nd-year (MOT2)
students use the textbook Counseling and Therapy Skills (Mar-
tin, 2011) as the basis for learning evocative empathy. Evoca-
tive empathy is defined as counselling where the therapist
conveys understanding of the intellectual and experiential
aspects of an interaction in such a way that the individual feels
his or her intended message is understood (Martin, 2011). The
evocative empathy approach focuses on building a therapeutic
relationship, more specifically, a personal bond characterized
by warmth, acceptance, and empathy. Using this approach, the
client perspective is deeply valued throughout the counselling
process. Therapeutic responses are considered good only inso-
far as the client feels understood and is viewed on equal terms
with the therapist as both leader and follower in therapy (Mar-
tin, 2011). Evocative empathy is taught within this program
because it combines foundational principles of the occupa-
tional therapy client-centred approach (see Law et al., 1995;
Restall, Ripat, & Stern, 2003; Sumison & Law, 2006) with
evidence-based practice (see Law & MacDermid, 2008).
Evocative empathy is taught to MOT2 students while will-
ing MOT1 students who provide written consent have the oppor-
tunity to gain firsthand experience in being a client. To recognize
that MOT1 students are not seeking counselling but rather are
volunteering to engage in counselling sessions for learning pur-
poses, the MOT1 student is referred to as a situational client.
Although the counselling is provided in the context of a learning
experience, MOT1 students bring real issues to their counselling
Downloaded from cjo.sagepub.com at University of Sussex Library on May 24, 2016
309
sessions. Both MOT1 and MOT2 students are taught about the
limitations of participating in these four counselling sessions and
take part in an in-depth discussion of possible topics for counsel-
ling, such as work–life balance, transitioning from undergradu-
ate studies to the occupational therapy program, and moving
away from home. Each situational client is paired with a MOT2
student who is learning evocative empathy. MOT2 students pre-
pare for this learning experience by reading the Martin (2011)
textbook and engaging with their instructor about the pragma-
tics and parameters of the counselling experience. After attend-
ing several classes on evocative empathy, the MOT2 students
write an examination of their theoretical understanding of key
concepts and research evidence for the method. Following these
preparatory steps, the MOT2 students begin their counselling
sessions with the MOT1 situational clients. Instructors provide
group supervision meetings in between and following all four
counselling sessions to assist students in completing their coun-
selling sessions.
Study Purpose
Learning evocative empathy in this way teaches the MOT2
students to focus on the whether the client feels heard or under-
stood. However, specific instruction was lacking on how to
include the client as a participating partner in shaping counsel-
ling sessions. Thus, a process was needed for eliciting in-the-
moment client feedback to better guide the MOT2 students in
their efforts to meet the self-perceived needs of their clients. The
purpose of this study was to explore the utility of the client-
completed SRS (Johnson et al., 2000) as part of an experiential
counselling exercise in teaching client-centred communication
skills to student occupational therapists. We were also interested
in understanding the students’ perceptions of using the SRS,
including the perceived impact on the student’s professional rea-
soning, client-centredness, evidence-informed practice, reflec-
tion, and counselling skills. The guiding research question
was, How does using an intervention tool over the course of four
counselling sessions impact MOT2 students’ performance of
client-centred behaviours?
Method
Study Design
As the focus of this study was to explore MOT2 students’ client-
centred counselling over four counselling sessions, a time-series
design as described by Portney and Watkins (2009) was used.
More specifically, we explored how using the SRS over time
impacted the students’ learning of client-centred counselling
skills. A demographic questionnaire was used prior to Time 1
to gather information about the MOT1 and MOT2 study partici-
pants, and an online questionnaire was administered after the last
counselling session to collect the MOT 1 and MOT 2 students’
opinions regarding use of the SRS in this learning experience.
Ethical approval for this study was received from the Uni-
versity of Manitoba Health Research Ethics Board. The course
Revue canadienne d’ergothérapie
310
coordinator, course instructors, and the first author (PW) were
not aware of which students provided consent; as well, partici-
pants could withdraw consent at any time during the study.
Participants
At the beginning of the 2012–2013 academic year, a course
instructor met with MOT1 and MOT2 students to provide an
orientation to the electronic version of the SRS. MOT1 students
who assumed a situational client role were assigned to work with
MOT2 students who assumed a counsellor role. MOT2 students
were given the option to take on more than one situational client
if he or she sought additional counselling experience. Inclusion
in the study was based on the pair of students’ willingness to
consent to participate in the project evaluation. All participating
MOT2 students had previous experience as a client or as a situa-
tional client receiving counselling from a student in the previous
academic year. This requirement was intended to ensure the
MOT2 students (i.e., counsellors in training) had an experience
to reflect upon to better understand the position of vulnerability
and trust that may be assumed by the situational client. A max-
imum of 50 students are enrolled each year in each cohort. A
total of 42 MOT1 and 41 MOT2 students agreed to participate
in this study representing 42 counsellor–situational client pairs.
Instruments
SRS. The SRS (Johnson et al., 2000) is a brief four-subscale
instrument with four independent subscale scores designed to
gather client feedback about a counselling session. The measure
provides information about the client’s perception of the quality
of the therapeutic relationship and is used by the counsellor to
identify client/counsellor therapeutic alliance problems that may
occur throughout therapy (Campbell & Hemsley, 2009). When
used in clinical practice, the client completes the SRS at the end
of each counselling session. The counsellor reviews the client’s
answers then uses the information gathered in the SRS to tailor
his or her approach in a way that better meets the needs and
expectations of individual clients.
The SRS comprises four subscales: Relationship, Goals and
Topics, Approach or Method, and Overall. Each subscale is
depicted as a 10-cm-long visual analogue scale, for which the
client provides a rating with negative responses on the left and
positive responses on the right (Duncan et al., 2003). In the Rela-
tionship subscale, the client rates his or her perception of the cli-
ent–therapist relationship on a continuum from ‘‘I did not feel
heard, understood, and respected’’ to ‘‘I felt heard, understood,
and respected.’’ The second subscale looks at the level of agree-
ment between therapist and client regarding the goals and topics
of the session as viewed by the client. The goals and topics are
evaluated on a continuum from ‘‘We did not work or talk about
what I wanted to work on or talk about’’ to ‘‘We worked on or
talked about what I wanted to work on or talk about.’’ The
Approach or Method subscale looks at the goodness of fit
between the therapist’s approach to the session and what the
client is looking for, ranging from ‘‘The therapist’s approach
Canadian Journal of Occupational Therapy Downloaded from cjo.sagepub.com at University of Sussex Library on May 24, 2016
Wener et al.
is not a good fit for me’’ to ‘‘The therapist’s approach is a good
fit for me.’’ Finally, the Overall subscale is more generally
designed to gain insight into the level of confidence the client
has that therapy will be beneficial (Duncan et al., 2003). The
client is asked to rate the session on a continuum from ‘‘There
was something missing in the session today’’ to ‘‘Overall,
today’s session was right for me.’’ Taken together, these sub-
scales reflect the major components upon which the therapeutic
alliance is built (Duncan et al., 2003). The total score is calcu-
lated by summing the four subscales (Duncan et al., 2003).
In the present study, the SRS subscales were used as indi-
cators of client-centredness as they conceptually overlap with
the construct. The dimensions of respect, client choice, and
engagement in decision making are described as key aspects
of client-centredness in the literature (see CAOT, 2002; Law
et al., 1995; Rebeiro, 2000). Other important characteristics
of client-centredness include partnership, as explored by Sum-
sion (1999a, 1999b, 2000), and power sharing (see CAOT,
2002; Law et al., 1995). Furthermore, the SRS was selected
because it has good psychometric properties. The SRS has
moderate test–retest reliability, high internal consistency, mod-
erate concurrent validity, and it has demonstrated the ability to
capture improvements in the therapeutic alliance as perceived
by the client in therapy sessions (Duncan et al., 2003). SRS data
were collected at the end of each of the four sessions. To gather
information about student learning and improvement of skills
over time, the SRS data from each student were reviewed and
ratings were compared longitudinally, student by student.
All data were collected in MyOutcomes, a web-based out-
come tracking tool used by clinicians providing psychotherapy
services. The program offers secure online tracking of client
progress in therapy using the SRS along with various resources
(Health Factors Canada, 2013).
Online questionnaires. To describe the participant
group, the first and last author developed MOT1 and MOT2
questionnaires to gather demographic information, including
sex, age, educational background, and previous exposure to
counselling roles. Both questionnaires also included questions
about the students’ perceptions of using the SRS, including rec-
ommendations for future students. The MOT2 questionnaire fur-
ther asked students about the perceived impact of this process on
the development of professional reasoning, client-centredness,
evidence-informed practice, reflection, and counselling skills.
Depending on the nature of the question, responses were indi-
cated in yes/no format or on a 4-point Likert scale ranging from
strongly agree to strongly disagree.
Data Collection
This research project required students to participate in four
counselling sessions as either a situational client (MOT1 stu-
dent) or counsellor (MOT2 student). MOT2 students were
divided into two groups of 25 students each (this number
comprises total enrolled) and assigned a course instructor
who provided group supervision throughout the counselling
Canadian Journal of Occupational Therapy 82(5) 311

process to prepare the MOT2 students for each counselling 9.8

session. Group supervision was provided prior to and after all
sessions and included, instruction on evocative empathy the-
ory, role-play exercises of counselling scenarios, and review
of each student’s counselling sessions, including the initial
SRS scores. The research assistant created student code num-
bers for each pair of MOT1 and MOT2 students and regis-
tered the MOT2 students in the MyOutcomes program prior
to the first counselling session. Student code numbers
ensured confidentiality and anonymity of the pair of MOT1
and MOT2 students on the MyOutcomes program. Although
the instructor could access MyOutcomes for the 25 students
under their supervision, they did not have access to the stu-
dent codes and therefore could not identify any individual
student. Only the individual pair of MOT1 and MOT2 stu-
dents could identify each other.
At the end of each of the four counselling sessions, the
client (MOT1 student) submitted his or her completed SRS
to the MyOutcomes website. All MOT2 students were
expected to review and reflect upon the SRS scores of the pre-
vious sessions prior to the beginning of the subsequent coun-
selling session with an aim to provide an improved ‘‘fit’’ for
the upcoming session. Within the group supervision meetings,
MOT2 students and instructors discussed the SRS scores and
how the MOT2 student counsellors could adjust their counsel-
ling style in a way that was responsive to the MOT1 student-
client feedback. At the end of all the counselling sessions, the
research assistant collected each MOT1 and MOT2 student
pair’s SRS data from MyOutcomes and exported them to an
Excel worksheet.
Following the completion of all four counselling sessions,
the research assistant e-mailed the MOT1 and MOT2 students a
link to access the online questionnaires. The questionnaires
were designed to take approximately 15 minutes to complete,
and a 2-week time frame was provided. A reminder e-mail was
sent out 2 days before the deadline.
Data Analysis
Student pairs for whom there were incomplete SRS data (i.e., if
SRS scores were missing for any of the four sessions) were
removed, and only data from consenting students were
included in the data analysis. Scores on the four subscales and
the total score of the SRS were analyzed across the four time
periods using a repeated-measures ANOVA with time as the
within-subject factor. Corrections were applied to the p values
to control for multiple comparisons. The level of statistical sig-
nificance was set at p < .05, and the data were analyzed using
SPSS (Version 14.0).
Data collected from the online questionnaires were sum-
marized using SurveyMonkey software, which yields anon-
ymized aggregated data. Both MOT1 and MOT2 student
questionnaire responses were analyzed using descriptive statis-
tics and summary. The course coordinator and course instructors
did not have access to any identifying information throughout
the data analysis process.
9.6
9.4
9.2
9
8.8
8.6
8.4
8.2
8
7.8
Time 1 Time 2 Time 3 Time 4
Relationship Approach or Method
Goals and Topics Overall
Figure 1. Session Rating Scale scores in four subscales (Relationships,
Approach or Method, Goals and Topics, Overall) across four counsel-
ling sessions.
Results
SRS Subscale Scores
Data were retrieved from 32 pairs of students consisting of one
MOT2 counsellor and one MOT1 situational client. As MOT2
students were given the option to take on more than one situa-
tional client, the final sample size consisted of 32 MOT1
students and 31 MOT2 students.
The repeated-measures ANOVA comparing scores on the
four subscales and the total score adjusting for multiple compar-
isons using the Bonferroni correction indicated a statistically
significant increase in scores across the four time periods for
each of the dependent measures: Relationships, F(3) ¼ 6.10,
p ¼ .015; Goals and Topics, F(3) ¼ 5.86, p ¼ .009; Approach
or Method, F(3) ¼ 15.13, p ¼ .002; Overall, F(3) ¼ 12.39,
p ¼ .003; total score, F(3) ¼ 17.67, p ¼ .001 (see Figure 1).
On average, the MOT1 students rated the first session as a
‘‘fair alliance’’ between the MOT2 counsellor and the MOT1 cli-
ent. As seen in Figure 1, the greatest increase in scores on the
dependent measures occurred from Time 1 to Time 2 and from
Time 2 to Time 3 with only minimal change from Time 3 to
Time 4. This pattern was confirmed by tests of within-subjects
contrasts that indicated a significant linear relationship across the
four time periods (Relationships, p ¼ .005; Goals and Topics,
p ¼ .001; Approach or Methods, p ¼ .000; Overall, p ¼ .000;
total score, p ¼ .000).
Questionnaire
Percentages indicating question responses were reported as
favourable or unfavourable by collapsing the response categories
of strongly agree with agree and strongly disagree with disagree.

Downloaded from cjo.sagepub.com at University of Sussex Library on May 24, 2016 Revue canadienne d’ergothérapie
312
Table 1
Characteristics of Participating Master of Occupational Therapy Students
Participating students
Characteristic MOT1a (%) MOT2b (%)
Undergraduate major
Psychology 44.4
Kinesiology 22.2
Other 33.3
Undergraduate minor
Psychology 30.4
Sociology 21.7
Other 47.8
Previous counsellor experience
Yes 19.2
No 80.8
Previous counsellee experience
Yes 33.3
No 66.7
Note. MOT1 ¼ 1st-year master of occupational therapy students; MOT2 ¼
2nd-year master of occupational therapy students.
a
n ¼ 27. bn ¼ 36.
Percentages were also reported as a proportion of the total number
of participants who responded to each individual question.
MOT1 student questionnaire. A total of 30 MOT1 stu-
dents accessed the survey, and 27 consented to participate in the
online questionnaire through SurveyMonkey. Three declined
participation and did not complete the remainder of the question-
naire. The demographic characteristics of participating MOT1
students are outlined in Table 1. The majority of respondents
were female (96.2%) and between the ages of 20 and 25 years
(59.3%). Psychology and kinesiology were the most frequently
indicated undergraduate degrees, with a total of 19 students hav-
ing completed a major or minor in psychology as an undergrad-
uate student. When asked about past experience as either a
counsellor or counsellee, 33.3% reported having previously seen
a counsellor and 19.2% claimed previous experience in the coun-
sellor role. Finally, MOT1 students had favourable responses to
the SRS, with 76.0% of students indicating that completion of
the SRS after each session was beneficial and 88.0% recom-
mending use of the SRS with future students.
MOT2 student questionnaire. A total of 36 MOT2
students consented to complete the online questionnaire
through SurveyMonkey. The demographic characteristics of
participating students are outlined in Table 1. Similar to the
MOT1 participant pool, MOT2 students were predominantly
female (97.2%) and within the age range of 20 to 25 years
(77.8%). Psychology was the most common undergraduate
degree, followed by sociology. All MOT2 students had expe-
rience as a counselling client or participated as a situational
client as an MOT1 student prior to assuming the therapist role.
Thirty-five of the 36 students indicated participation as a
situational client in the previous academic year, and while
41.7% indicated prior experience as a counsellee, relatively
Canadian Journal of Occupational Therapy Downloaded from cjo.sagepub.com at University of Sussex Library on May 24, 2016
Wener et al.
few (8.3%) claimed previous experience in the counsellor
role.
Overall, the MOT2 student participants found it valuable
to see the results of the SRS after each session (86.9%), with
most of the MOT2 students recommending use of the SRS with
future students (88.9%). The majority of students also found
the process to be client-centred (80.6%) and evidence-
57.1
informed (88.9%). However, views regarding the impact on the
42.9 development of reflection and professional reasoning skills
were less favourable. While 63.8% found the process to
27.6 enhance reflection skills, fewer (61.1%) agreed that the process
31.0 supported development of professional reasoning skills.
41.4
8.3
91.7 Discussion
41.7 In this study, we examined the impact of using the SRS client
58.3 feedback measure during counselling on the client-centred
approach of student occupational therapists. The SRS appears
to be a useful tool to enhance the ability of student occupational
therapists to develop client-centred relationships, goals and
topics, approach and method, and overall therapeutic alliances
with their situational clients. Key indicators of the student
counsellors’ client-centred approach were situational clients’
reports that they were heard, respected, and understood; that
the counselling sessions focused on situational clients’ priori-
ties; that the counsellors’ approach fit the situational client; and
that the overall session was right for the situational client.
The beginning of therapy is a critical phase for the client–
therapist relationship in which the therapeutic alliance is
thought to be determined, most likely peaking during Session
3 (Eaton, Abeles, & Gutfreund, 1988). If a therapeutic alli-
ance is not established during the early stages of therapy,
early termination and a lack of therapeutic effectiveness are
major concerns (Horvath & Luborsky, 1993). Recognizing the
importance of this critical alliance phase, in this study, MOT2
students met with peers and course instructors in a small
group setting of 13 students to discuss initial scores and stra-
tegies for student therapists to adapt their counselling style in
a way that was responsive to client feedback. Central to the
group supervision was a process where all students and the
instructors engaged in problem solving with each student
counsellor with an aim to better meet the self-perceived needs
of their situational clients. The most significant changes
reported by the MOT2 students on all four scales of the SRS
occurred between Times 1 and 2 and between Times 2 and 3.
There was no significant change following Time 3. Thus, the
findings are consistent with existing literature on the course of
the therapeutic alliance.
The educational backgrounds of the participating students
may have influenced the relatively high SRS scores obtained at
Time 1 in all four subscales. Although no formal analysis was
conducted to explore the impact of educational background on
the characteristics of participating MOT students, familiarity
with the area of psychology at the undergraduate level may
have better prepared the students for assuming the roles of a
Canadian Journal of Occupational Therapy 82(5)
situational client and counsellor. Future research may examine
whether a relationship exists between educational background
and the scores obtained on the SRS. Overall, high SRS scores
across the four counselling sessions may have reflected the
level of confidence participating students had in applying
client-centred communication skills within the client–therapist
relationship. Consistent with Restall and Ripat (2008), in the
present study, student occupational therapists valued and felt
comfortable using the SRS as a means of reflecting upon and
then implementing client-centred strategies within the micro-
environment of the therapeutic relationship.
Still other factors may have contributed to the high scores
found across the four sessions. MOT1 students may have been
influenced by power dynamics in the relatively small student
community and thus felt uncomfortable rating MOT2 students
poorly. MOT1 students may also have been more inclined to
rate the MOT2 counsellors favourably out of the desire to sup-
port fellow students and as a result of empathy, knowing that
they would be in the counsellor position in the coming aca-
demic year. Topping (1998, 2005) discussed many advantages
of peer assessment in higher education. However, he also
described that students may not want to accept the responsibil-
ity of assessing peers in small cohesive groups and that power
differences can inhibit or constrain peer assessment.
Developing a client-centred approach requires that thera-
pists are able to develop a therapeutic relationship with their
clients as perceived by their clients. Hammell (2013a) argued
that Canadian conceptions of client-centredness have been
changed over time to reflect a hierarchical relationship between
client and therapist in which the expert therapist—with key
enablement skills—bestows the tools for engagement in occu-
pation upon a nonexpert client recipient. In closing the gap
between occupational therapy rhetoric and practice, she calls
for a shift away from a focus on therapist skill and power
toward a more relationship-focused approach, grounded in an
authentic posture of respect for clients and their unique knowl-
edge and expertise. The present study aimed to address this
notion by teaching students how to apply evocative empathy,
the ability to communicate understanding as perceived by the
client (Martin, 2011), and then to use a tool to guide student
therapists to focus on the client’s perception of the relationship.
The use of Martin’s (2011) evocative empathy combined with
the SRS appeared to facilitate the ability of the student occu-
pational therapists to engage with their situational clients in
partnerships characterized by the client-centred characteris-
tics—respect, recognition of autonomy, choice, and acknowl-
edgment of client knowledge and expertise—described by
Law et al. (1995).
Finally, this educational experience aimed at developing
client-centredness may come at an optimal time in the educa-
tional careers of these occupational therapy students. The focus
for MOT1 students tends to be on internalizing client-
centredness, the academic/practice discrepancy, and relation-
ship building, while the MOT2 students, who are also focused
on the academic/practice discrepancy, begin to attend to
issues of power and control (Ripat et al., 2013). Thus, at the
Downloaded from cjo.sagepub.com at University of Sussex Library on May 24, 2016
313
beginning of their 2nd year of the occupational therapy pro-
gram, the MOT2 students may be primed to incorporate tools,
such as evocative empathy and the SRS, that further develop
their client-centredness by helping them to resolve the differ-
ences between the academic and practice environments while
addressing the issue of power and control. Ripat, Wener,
Dobinson, and Yamamoto (2014) further explored students’
client-centredness with a more in-depth focus on internalizing
client-centredness. These authors reported that during the 2nd
year of the 2-year program, students understand client-
centredness to be a professional value and begin to view them-
selves as client-centred practitioners. Thus, MOT2 students may
be ready and well prepared to use a tool such as the SRS.
Equipping student occupational therapists with the tools
and providing an opportunity to develop client-centred partner-
ships early on in their professional careers may represent a
viable action step in promoting the move from rhetoric to real-
ity in client-centred occupational therapy practice. If utilized
across a practice setting, the SRS may have the potential to
encourage the adoption of client-centred approaches at the
meso level as well as impact more broadly the environments
in which occupational therapists work. Future studies may
explore the application of evocative empathy and the SRS to
developing therapist–client relationships in clinical practice.
Similar studies in clinical environments may enable practicing
occupational therapists to become increasingly more client-
centred and allow them to monitor their client-centredness
through ongoing client feedback.
Study Limitations
This research reports the results of a study of one cohort of
master of occupational therapy students at one Canadian uni-
versity, and therefore the results cannot be generalized to other
groups of students, nor can they be generalized to therapists
working with clients in clinical practice. This research project
reported the changes in students’ client-centredness at the same
time that they were engaged in experiential learning about
counselling theory and skills. However, the study did not mea-
sure the sustainability of these skills beyond 3 months.
Conclusion
The purpose of this study was to examine the impact of the use
of a client-completed rating scale on student occupational
therapists’ client-centred counselling skills. The findings sug-
gest that the use of the SRS in concert with instructor-led group
supervision allowed these students to significantly improve
their ability to deliver client-centred counselling to their situa-
tional clients over the course of the first three counselling ses-
sions, which was maintained for the final counselling session.
Students in this study valued giving and receiving feedback
when learning to develop client-centred counselling skills, and
the majority recommended use of the SRS with future student
occupational therapists. The high SRS scores achieved by these
Revue canadienne d’ergothérapie
314
student occupational therapists demonstrate that they were able
to establish a therapeutic alliance within the four counselling
sessions. These high scores, as well as student opinions, sup-
port continued use of the SRS as a means of teaching client-
centred counselling skills to these entry-level master’s occupa-
tional therapy students. Use of a client-centred feedback mea-
sure as part of an experiential learning opportunity can play a
facilitative role in the development of students’ client-centred
counselling skills.
Key Messages
 Provided with the opportunity, knowledge, and tools, stu-
dents can significantly increase their client-centred coun-
selling skills over time.
 Students, acting as client or therapist, found that the Session
Rating Scale was a valuable tool for guiding the client-
centred process from both the client’s and therapist’s
perspectives.
 An experiential learning opportunity for students to
improve their client-centred counselling skills involves a
tool for recording a client’s perspectives of being heard,
respected, and understood; the degree to which the counsel-
ling session focuses on a client’s priorities; the fit of the
counselling approach to the client; and the client’s overall
impression of the session.
Acknowledgements
We would like to acknowledge the previous work of Allison Norrie
who was one of the research assistants for this project and our collea-
gue, Jacquie Ripat, PhD, OT Reg. (MB), who reviewed the manuscript
and provided very helpful suggestions.
References
Association of Canadian Occupational Therapy Regulatory Organiza-
tions. (2011). Essential competencies of practice for occupational
therapists in Canada (3rd ed.). Toronto, ON: Author.
Blank, A. (2004). Clients’ experience of partnership with occupational
therapists in community mental health. British Journal of Occupa-
tional Therapy, 67, 118–124. doi: 10.1177/030802260406700304
Campbell, A., & Hemsley, S. (2009). Outcome Rating Scale and Ses-
sion Rating Scale in psychological practice: Clinical utility of
ultra-brief measures. Clinical Psychologist, 13, 1–9. doi:10.1080/
13284200802676391
Canadian Association of Occupational Therapists. (2002). Enabling
occupation: An occupational therapy perspective (Rev. ed.).
Ottawa, ON: CAOT Publications ACE.
Coates, G. L. F., & Crist, P. A. (2004). Brief or new: Professional
development of fieldwork students. Occupational adaptation, clin-
ical reasoning, and client-centeredness. Occupational Therapy in
Health Care, 18(1/2), 39–47. doi:10.1080/J003v18n01_05
Canadian Journal of Occupational Therapy Downloaded from cjo.sagepub.com at University of Sussex Library on May 24, 2016
Wener et al.
College of Occupational Therapists of Manitoba. (2013). Self-
assessment tool for occupational therapists in Manitoba: Clinical
practice. Retrieved from http://cotm.ca/upload/COTM_SA_-_
Clinical_2013_EXTENDED.pdf
Corring, D., & Cook, J. (1999). Client-centred care means that I am a
valued human being. Canadian Journal of Occupational Therapy,
66, 71–82. doi: 10.1177/000841749906600203
Department of National Health and Welfare & Canadian Association
of Occupational Therapists. (1983). Guidelines for the client-
centred practice of occupational therapy (Cat. No. H39-33/
1983E). Ottawa, ON: Department of National Health and Welfare.
Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds,
L. R., Brown, J., & Johnson, L. D. (2003). The Session Rating
Scale: Preliminary psychometric properties of a ‘‘working’’ alli-
ance measure. Journal of Brief Therapy, 3(1), 3–12.
Eaton, T. T., Abeles, N., & Gutfreund, M. J. (1988). Therapeutic alli-
ance and outcome: Impact of treatment length and pretreatment
symptomatology. Psychotherapy: Theory, Research, Practice,
Training, 25, 536–542.
Egan, G. (1997). Skilled helper: A problem-management approach to
helping (6th ed.). Pacific Grove, CA: Brooks/Cole.
Hammell, K. W. (2013a). Client-centred occupational therapy in
Canada: Refocusing on core values. Canadian Journal of Occupa-
tional Therapy, 80, 141–149. doi: 10.1177/0008417413497906
Hammell, K. W. (2013b). Client-centred practice in occupational
therapy: Critical reflections. Scandinavian Journal of Occupa-
tional Therapy, 20, 174–181. doi: 10.3109/11038128.2012.
75203
Health Factors Canada. (2013). Clinical practice: Art vs. science vs.
business. Retrieved from http://info.myoutcomes.com/Learn-
More-MyOutcomes-Online-Brochure
Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic
alliance in psychotherapy. Journal of Consulting and Clinical
Psychology, 61, 561–573. doi: 10.1037//0022-006X.61.4.561
Jamieson, M., Krupa, T., O’Riordan, A., O’Connor, D., Paterson, M.,
Ball, C., & Wilcox, S. (2006). Developing empathy as a foundation
of client-centred practice: Evaluation of a university curriculum
initiative. Canadian Journal of Occupational Therapy, 73, 76–
85. doi: 10.2182/cjot.05.0008
Johnson, L. D., Miller, S. D., & Duncan, B. L. (2000). The Session
Rating Scale 3.0. Chicago, IL: Author.
Law M. (Ed.). (1998). Client-centered occupational therapy. Thoro-
fare, NJ: Slack.
Law, M., Baptiste, S., & Mills, J. (1995). Client-centred practice:
What does it mean and does it make a difference? Canadian Jour-
nal of Occupational Therapy, 62, 250–257. doi: 10.1177/
000841749506200504
Law, M., & MacDermid, J. (Eds.). (2008). Evidence-based rehabilita-
tion: A guide to practice (2nd ed.). Thorofare, NJ: Slack.
Martin, D. G. (2011). Counseling and therapy skills (3rd ed.). Long
Grove, IL: Waveland.
Master of Science Occupational Therapy Program. (2014). Handbook
2014–2015. Kingston, ON: Queen’s University. Retrieved March
16, 2015, from http://rehab.queensu.ca/storage/files/The%20
complete%20Online%20OT%20Handbook%20-%202014-2015_
22August2014.pdf
Canadian Journal of Occupational Therapy 82(5)
McColl, M. A., & Pranger, T. (1994). Theory and practice in the occu-
pational therapy guidelines for client-centred practice. Canadian
Journal of Occupational Therapy, 61, 250–259. doi: 10.1177/
000841749406100505
MOT Program Committee. (2011). Master of occupational therapy
program guide. Winnipeg, MB: University of Manitoba. Retrieved
February 11, 2015, from http://umanitoba.ca/medrehab/media/ot_
program_guide.pdf
Palmadottir, G. (2006). Client–therapist relationships: Experiences
of occupational therapy clients in rehabilitation. British Journal of Occu-
pational Therapy, 69, 394–401. doi:10.1177/030802260606900902
Portney, L. G., & Watkins, M. P. (2009). Foundations of clinical
research: Applications to practice (3rd ed.). Upper Saddle River,
NJ: Prentice Hall.
Rebeiro, K. L. (2000). Client perspectives on occupational therapy
practice: Are we truly client-centred? Canadian Journal of Occu-
pational Therapy, 67, 7–14. doi: 10.1177/000841740006700103
Restall, G., & Ripat, J. (2008). Applicability and clinical utility of the
client-centred strategies framework. Canadian Journal of Occupa-
tional Therapy, 75, 288–300. doi:10.1177/000841740807500512
Restall, G., Ripat, J., & Stern, M. (2003). A framework of strategies
for client-centred practice. Canadian Journal of Occupational
Therapy, 70, 103–112. doi: 10.1177/000841740307000206
Ripat, J., Wener, P., & Dobinson, K. (2013). The development of
client-centredness in student occupational therapists. British
Journal of Occupational Therapy, 76, 217–224. doi: 10.4276/
030802213X13679275042681
Ripat, J., Wener, P., Dobinson, K., & Yamamoto, C. (2014). Interna-
lizing client-centredness in occupational therapy students. Journal
of Research in Interprofessional Practice and Education, 4(2).
Retrieved from http://www.jripe.org/index.php/journal/article/
view/173/101
Sumsion T. (Ed.). (1999a). Client-centred practice in occupational
therapy. Edinburgh, UK: Churchill Livingstone.
Sumsion, T. (1999b). A study to determine a British occupational ther-
apy definition of client-centred practice. British Journal of Occu-
pational Therapy, 62, 52–58. doi:10.1177/030802269906200202
Sumsion, T. (2000). A revised occupational therapy definition of
client-centred practice. British Journal of Occupational Therapy,
63, 304–309. doi:10.1177/030802260006300702
Sumsion, T. (2006). Client-centred practice in occupational therapy:
A guide to implementation. (2nd ed.). Philadelphia, PA: Churchill
Livingstone.
Sumison, T., & Law, M. (2006). A review of evidence on the con-
ceptual elements informing client-centred practice. Canadian
Journal of Occupational Therapy, 73, 153–162. doi: 10.1177/
000841740607300303
Tickle-Degnen, L. (2002). Client-centered practice, therapeutic
relationship, and the use of research evidence. American
Downloaded from cjo.sagepub.com at University of Sussex Library on May 24, 2016
315
Journal of Occupational Therapy, 56, 470–474. doi:10.5014/
ajot.56.4.470
Topping, K. (1998). Peer assessment between students in colleges and
universities. Review of Educational Research, 68, 249–276. doi:10.
3102/00346543068003249
Topping, K. (2005). Trends in peer learning, Educational Psychology:
An International Journal of Experimental Educational Psychol-
ogy, 25, 631–645. doi:10.1080/01443410500345172
Townsend, E. A., Beagan, B., Kumas-Tan, Z., Versnel, J., Iwama, M.,
Landry, J., . . . Brown, J. (2013). Enabling: Occupational therapy’s
core competency. In E. A. Townsend & H. J. Polatajko , Enabling
occupation II: Advancing an occupational therapy vision for
health, well-being, and justice through occupation (2nd ed.,
pp. 87–133). Ottawa, ON: CAOT Publications ACE.
Waters, D. (1995). Recovering from a depressive episode using
the Canadian occupational performance measure. Canadian
Journal of Occupational Therapy, 62, 278–282. doi: 10.1177/
000841749506200507
Author Biographies
Pamela F. Wener, MEd, OT Reg. (MB), is Associate Professor,
Department of Occupational Therapy, College of Rehabilitation
Sciences, Faculty of Health Sciences, and a doctoral candidate,
Individual Interdisciplinary Program, Faculty of Graduate
Studies, University of Manitoba, Winnipeg, MB, Canada.
Carolyn O. Bergen, MA, OT Reg. (MB), MAMFT, is
Instructor, Department of Occupational Therapy, College of
Rehabilitation Sciences, Faculty of Health Sciences, Winnipeg,
MB, Canada.
Lisa G. Diamond-Burchuk, BMR(OT), OT Reg. (MB), is
Instructor, Department of Occupational Therapy, College of
Rehabilitation Sciences, Faculty of Health Sciences, Winnipeg,
MB, Canada.
Cynthia M. Yamamoto, MOT, OT Reg. (MB), is Occupational
Therapist, Gaining Resources Our Way (G.R.O.W. Inc.), and
Research Assistant, Department of Occupational Therapy,
College of Rehabilitation Sciences, Faculty of Health
Sciences, Winnipeg, MB, Canada.
Alana E. Hosegood, MOT, OT Reg. (MB), is Occupational
Therapist, Winnipeg Regional Health Authority Program for
Assertive Community Treatment, Winnipeg, MB, Canada.
James D. Staley, MA, is Statistical Consultant, Office of
Clinical Research, St. Boniface General Hospital, Winnipeg,
MB, Canada.
Revue canadienne d’ergothérapie