T

he idea of client-centered therapy has become

Client-Centered more common over the past 20 years due to a
number of social influences. The prevalence uf
Assessment chronic disease has increased the need for persons to
take responsibility for their own health. The sophistica-
tion of, and access to, health care information have made
Nancy Pollock for more critical cunsumerism amung the public. As a
result, the idea of health is changing for many people,
with concerns over quality of life and life-style. Definitions
Key Words: independent living skills (human of health have moved from a medical mudel cuncept of
activities) • motivation. planning process, the absence of disease, through the World Health Organi-
occupational therapy zatiun's definition including complete physical, mental,
and social well-being, to more of an emphasis on func-
tion, in which health may be viewed as the potential or
capacity to achieve preferred goals or perform certain
When occupational therapists assess function or occu- functions (Calnan, 1987). The latter idea is central to
pational performance, they must consider each per- occupational therapy. The foundations of our profession
son's unique needs and abilities, as well as the envi- rest on functional activity and its relationship to health.
ronmental and social factors that may be aJlectlng the In examining functional activity, occupational ther-
clients' performance. Therefore, occupational thera- apy is concerned with occupational performance. Reed
pists must use evaluation tools that are individualized and Sanderson (1980) described occupational perform-
and sensitive to the clients' varying needs and situa- ance as the activities carried out by the client in the areas
tions. One approach to individualized evaluation is of self-care, productivity, and leisure, influenced byenvi-
the use of a client-centered process ofsetting goals and
ronmental and societal factors. Performance is predicated
assessing change. This paper describes the develop-
ment qj'a methodology for a client-centered assess- on the interaction of the person's mental, physical, socio-
ment currently being used In Canada, the Canadian cultural, and spiritual performance components. It is also
Occupational Peljormance Measure (COPM). The related to individual roles and role expectations and de-
conceptual model, administration and scoring proce- velopmental stage. It stands to reason, then, that occupa-
dures, and preliminary feedback to the COPM are tional performance is unique to the person; one person's
described. occupational performance needs and abilities will not be
the same as any other person's. Yet, in assessing occupa-
tional performance, occupational therapists often use
measurement tools that are not individualized or sensi-
tive to varying needs and situations. A review of the litera-
ture shows that few assessments include the environment
or social role expectations in their assessment uf occupa-
tional performance (Pollock et al., 1990).
In addition to the content of assessments, we need
to be concerned with process. Almost without exception,
clients are interviewed or observed for testing purposes,
but the scores for clients' performance are assigned by
the tester. Is the tester in the best position to judge
whether a client's occupational performance is adaptive
or maladaptive? Is the tester so familiar with that client's
enVironment, life-style, and the demands placed on the
client that the tester can make that judgment? As in the
case of the Sickness Impact Profile (Bergner, Bobbin,
Carter, & Gilson, 1981), can a panel of experts be used to
determine that a problem in family interactions is worth
three times as many scale points as a problem in ambula-
tion? I suggest that if we use a truly client-centered ap-
Nancy Pollock, MSc. OT(C). is Assistant Clinical Professor,
proach, then we cannot.
McMaster University, and Research Manager, Occupational
The use of rater judgment in scoring assessments
Therapy, Checioke-McMaster Hospitals, PO Box 2000, Hamil-
ton, Ontario L8N 3Z5.
may only reinforce the passivity of clients and the sense of
the professional as the answer to the problem. If the
This article was accepted/or publication Nuuember .24, 199.2. person is no longer the problem definer, it is unlikely that

298 April 1993, Volume 47, Number 4

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 he or she will be the problem solver either. This disparity areas in daily functioning. \Xfhen a client is unable to
can reduce the client's self-determination and sense of identi~r problem areas (e. g., when the client is a young
control over health, often leading to what may appear as child or a person with dementia), a caregiver may re-
noncompliance. If the therapy goals are set by the client spond to the measure. The COPM considers the impor-
through a process of client-centered assessment, the po- tance, to the client, of the occupational performance
tential for active participation is enhanced areas, as well as the client's satisfaction with present per-
How then can we help clients to define their occupa- formance. The measure takes into account client roles
tional performance problems This paper presents a and role expectations and, in focusing on the client's own
'
methodology for client-centered assessment currently be- environment, ensures the relevance of the problem to the
ing used by occupational therapists in Canada. client. It can be used to measure client outcome with
different objectives for treatment, including develop-
ment, maintenance or restoration of function, and pre-
Development of the Measure
vention of change. During the assessment process, the
The Canadian N;sociation of Occupational Therapists measure will help engage the client from the beginning of
(CAOT), in collaboration with Health and Welfare Can- the occupational therapy experience and increase client
ada, has developed a conceptual model and guidelines for involvement in the therapeutiC process. The COPM sup-
the client-centered practice of occupational therapy (De- ports the notion that clients are responsible for their
partment of National Health and Welfare [DNHW] & health and their own therapeutic process. It permits the
CAOT, 1983). This occupational performance model is therapist and client to identify and deal with life span
based on the belief that the person is a fundamental part issues and permits the evolution of the use of purposeful
of the therapeutic process, and describes a person's oc- tasks and actiVities.
cupational performance as a balance of performance in
three areas: self-care, productiVity, and leisure.
Administration and Scoring of the COPM
This model was accompanied by assessment and in-
tervention guidelines for the client-centered praetice of The COPM is a five-step process based on a semi-
occupational therapy (DNHW & CAOT, 1983; 1986). Sub- struCtured interview conducted by the therapist tOgether
sequently, a third collaborative task force focused on the with the client or caregiver or both. The ftve steps are
outcome measures in occupational therapy in Canada problem deftnition, problem weighting, scoring, reas-
(DNHW & CAOT, 1987). sessment, and follow-up.
The third task force used the occupational perform- Step I. Problem definitiOn. In this step, the occupa-
ance model to investigate current outcome measures of tional therapist interviews the client or caregivers or both
self-care, productivity, and leisure. The task force recom- to determine whether they are haVing any problems in
mended that work go forwanJ "to develop tool(s) specifi- occupational performance. For each performance area,
cally for occupational therapy and testing (of this tOol) the therapist asks the client if he or she needs to, wants
should assess the degree to which it captures the impor- to, or is expected to perform these activities If the answer
tant contributions of occupational therapy" (DNHW & to any of these three questions is yes, the client is asked if
CAOT, 1987, p. 39). The result of this work is the Canadi- he or she can perform, does perform, and is satisfied with
an Occupational Performance Measure (COPM), an out- hmv he or she performs these activities. When the client
come measure designed to be used by occupational identifies a need as well as an inability to perform an
therapists to assess client outcome in the areas of self- aetivitv satisfactorily, this performance area is identified
care, productivity, and leisure The COPM identifies prob- as a problem. If the client does not identify a need or
lem areas in occupational performance, assists in goal expectation to perform, this area would not be addressed
setting, and measures changes in occupational perform- further. Activities in each area of self-care (e.g., dressing,
ance over the course of therapy. mobility), productivity (e.g., school, paid work), and lei-
The COPM reflects the philosophy of the model of sure (eg., socialiation, hobbies) are discussed.
occupational performance. It incorporates roles and role Step 2. Problem weighting. Once the specific prob-
expectations within the client's environment. It considers lem areas have been identified, the client is asked to rate
the importance of the skill or activity to the client through the importance to her or him of each of the identified
a semi-structured interview approach. activities on a scale of 1 to 10 with the anchor points being
The advantages of thiS individualized measure are "not important at aJl" and "extremely important."
that it is client centered, is generic (that is, not diagnosis Step 3· Scoring On the basis of the importance rat-
specific), and crosses developmental stages. N; well, such ing from Step 2, the five most urgent problems are identi-
an individualized measure can be used with a physically fiec\. The client is then asked to rate his or her ability to
dependent client to evaluate her or his control ovel- the perform the specified activities and his or her satisfaction
environmen t. with that performance on scales of 1 to 10. The ratings of
The COPM measures the client-identified problem abilitv and satisfaction are each multiplied by the impor-

The American Juunwl or OccupmwlICd Themp.1' 299

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 tance rating to determine a ba-'ieJine ~('ure. The impur- Through this process the true priorities of the clients
tance rating acts as a weighting factUl" through this multi- hecame evident; these priorities often differed from the
plication. The possible range of scores is fmm I to laO for therapists' initial ideas Clients' insight into their abilities
satisfaction and 1 tu ] 00 for performance for each proh- and difficulties in occupational perf(lrmance frequently
lem identified The scores are aelded to create an overall increased through the assessment process. Some clients
summarive score that is divided by the number of rated have commented that they appreciated the feeling of
activities, yielding a score that can be used for compari- being in control of the process of prohlem identification.
sons acro-'i-'i time and across clients. There are two scores, Some concerns have been raised about the appropri-
one for performance and one for satisfaction. ate timing of the use of the COPM. It will serve well as an
The client and therapist mu~t then decide on the initial assessment, but the client may lack the insight to be
goal of treatment. If the goal is to develop or restore able to respond to the COPM early in the therapeutic
function, one would expect an increase in performance or process, so it may be advantageous to do the COPM later.
satisfaction scores or both. If the goal is maintenance or With some clients, it may be necessary to usc caregivers
prevention, no change in performance score may be the as pro>.')! respondents, and may therefore raise the ques-
desired outcome. tion of who is the real client. Our experience has shown
To understand the reasons for performance prob- that it is possihle to use the COPM with families as re-
lems, to set short-term objectives, and to plan therapy, spondents, but more difficult, particularly when judging
the therapist may need to asse-'iS performance compo- the importance of the activity on behalf of the client.
nents contributing to the client's difficulties in the identi- We have completed the pilot testing of the COPM
fied problem areas. Such as~essments, although not the and have initiated stuclies to examine the reliability, valid-
primary outcome of occupational therapy, assist the ity, and responsiveness of the measure. We welcome
therapist in evaluating causes of dysfunction and pl,mning comments from users of the measure and encourage oth-
an appropriate intervention to achieve the goal identified ers to do research on the COPM.
by the client The therapist may need to observe the client
performing certain tasks, to use standardized tests to
Summary
evaluate skill areas, to assess the client's environment, or
to use any number of other approaches to understand the The COPM is an individualized measure designed to as-
client's problem-'i and plan treatment The COPM is not sess client-identified problem areas in daily functioning. It
meant to replace other a-'isessments; it is meant to focu-'i considers the importance of the actiVity to the client, as
on occupational performance prohlems and to operation- well as his or her satisfaction with performance of those
alize a client-centered approach. activities. The COPM takes into account client roles and
Step 4. Reassessmenl. This step follows the interven- role expectations and, in focusing on the client's environ-
tion process. The therapist again asks the client or care- ment, ensures the relevance of the identified problem
giver to rate his or her abilities and satisfaction with per- areas. The COPM supports the notion that client-'i arc
formance in the activities identified as problems in Step 2. re-'iponsible for their health and their own therapeutic
These ratings arc multiplied by the original importance process. It stands as one example of client-centered as-
ratings, summed, and divided to calculate the change sessment. •
seen in the client over time. This process enables the
client and therapist to have a concrete image of changes Acknowledgmen tS
that have occurred during the therapy process. I acknowledge the other members of the COPM Research
Step 5 Follow-up. The purpose of this step is to plan Group: Macv Law. ,\ISc Sue Baptiste, \IHSc. Anne CarswelJ-
for treatment continuation, follow-up, or discharge. With Opzoomel', PhD. MaryAnn McColl, PhD. and ]-iclene Polmajko, PhI).
a new COPM form, the therapist asks the client or care- The COPM is available from the Canadian Association of Occu-
pational Therapists, 110 Eglinton Avenue West, Third Floor,
giver the six questions used in Step 1 to decide whether Toronto, Omario M4R 1A.}
occupational performance problems remain or whether This manuscript is based on a papec presented at the S)'m-
new difficulties have emerged over time. The client and posium 077 N/easurement and Assessment. Directionsfor Fu-
therapist then decide on the best course of action as in ture Reseanh in Occupational Tberapy at the University of
Illinois at Chicago, Octo[)el- 16-18, 1991. The symposium was
the first use of the measure.
jointly sponsored by the American Occupational Therapy Asso-
Pilot testing of the COPM has been completed with ciation, the Amel'icCin Occurational Therapy Foundation, and
approximately 200 clients in different centers across Can- the Occupational Therapy Center for Resemch and Measure-
ada. Feedback from both therapists and clients has been ment at the University of l\Iinois at Chicago.
positive, reporting that the COPM was easy to administer
and took 20 to 40 min. The format and rating scales were References
clear and easy to emplo)l. Most therapists believed that Bergner, M., Bobbitt, R. A, Carter, \'1/. B, & Gilson, B. S.
the COPM provided a useful framework for their initial (1981). The Sickness Impact Profile: Development and final
assessment of all areas of occupational performance. revision of a health statuS measure. Medical em'e. 19, 787-805.

300 Ilpr!1 1993, Vulume 47. Number 4

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 Calnan, IV!. (1987). Health and illness London: Tavistock. Department of National Health and Welfare and Canadian
Depanment of Nationaillealth and Welfare and Canadian Association of Occupational Thc['apists. (1987). Toward out-
Associatirm of Occupational Therapists. (1983). Guidelines/or come measures in occupational/herap)! (H39-114/1987£). Ot-
the client-centered practice of occupational /hempv (1139- tawa, ON: Department of National Health and Welfare.
33/1983£). Ottawa, ON: Depanment of National Health and Pollock, N., Baptiste, S., Law, M., McColl, M. A., Opzoomer,
Welfare. A., &. Polatajko, H. (1990). Occupational perfmmance measmes:
Department of National Health and Welfare and Canadian A [-eview based on the guidelines for the client-centered practice
Association of Occupational Therapists (1986). Interuention of occupational therapy. Canadian Journal of Occupational
gUidelines .lor tIJe client-cen/ered practice of occupational TIJerapl', 57. 77-En
therapy (H39-100/1986£). Ottawa, ON: Department of National Reed, K., & Sanderson, S. R. (1980). Concepts ofoccupa-
Health and Welfare. tional therapy Baltimore, MD: Williams & Wilkins.

/he Alllericol/l .I()/.Ir!W/ ur OCCIIPOli()I/{// /her(/pJ' 301

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