William is a 40 year old man, with a 20 year history of schizophrenia. During that time, William has lived in and out of hospital, but has had little contact with his family. William expresses considerable anxiety and nervousness about community living and community participation. He has recently been hospitalized for an acute episode, where he discontinued his medication and quickly became delusional and paranoid. He is now ready for discharge to a supervised boarding home in the community. He has been referred to OT for assessment.
The first issue that must be addressed in conducting the COPM, and by extension any client-centred therapy, with someone like William is the legitimacy of the client’s perspective despite his mental illness. Most readers will read this sentence and say to themselves that, of course, they always consider the client’s perspective as legitimate. However the client-centred approach upon which the COPM is based requires much more than that we intellectually state our enlightenment on this score. It requires that the client’s perspective carry the final authority in the therapeutic relationship. Thus if William states that he has a problem that the therapist does not observe or consider important, it must still appear on the therapeutic agenda. Perhaps even more challenging, if William states that he does not have a problem, even though the therapist observes evidence of the problem, the problem does not appear on the therapeutic agenda. This is the true test of the client-centred approach. It is easy to be client-centred when therapist and client agree. Where the therapeutic relationship is truly tested is where there is disagreement. Typically the institutional power structure favours the therapist, and his or her perspective wins out, since issues like discharge and access to other benefits and services hinge on the therapist’s assessment. However the client-centred relationship overturns the power structure and systematically favours the client’s perspective. The COPM is one of the few measures that permits the application of the client-centred approach at the assessment stage. It is a constant challenge to practice from a client-centred perspective in a system, and in fact in a world, that honours medical-scientific credentials and expertise. It is particularly challenging when issues of client safety and risk come into play. In these cases, it is important that a reliable assessment of competency is undertaken, and that assumptions not simply be made about competence.
A second issue in using the COPM with someone like William is the ability to readily identify problems. In some instances, individuals may not be able to enumerate or express specific problems in response to a question. The future may look so threatening and overwhelming that a therapeutic process may be necessary in order to help an individual get to the stage where he or she is able to identify problems. Occupational therapy may be involved in activities, simulations, discussions or outings that assist the individual to begin to conceptualize the demands of his or her life, together with the potential pitfalls and obstacles.