The Relationship Between Client-Centered Goal-Setting and Treatment Outcomes Shifting definitions of health and well-being, prompted by the World Health Organization's International Classification of Functioning (2001), have stimulated changes in traditional clinician-client relationships in rehabilitation. Among these changes, in keeping with the concept of client-centered care, is a trend toward more collaborative goal-setting and joint determination of intervention plans. ... Article
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Article  |   April 01, 2012
The Relationship Between Client-Centered Goal-Setting and Treatment Outcomes
Author Affiliations & Notes
  • Jennifer L. Womack
    Division of Occupational Science and Occupational Therapy, Department of Allied Health Sciences at the University of North Carolina, Chapel Hill, NC
  • Jennifer L. Womack, MA MS OTR/L, is Clinical Associate Professor, Division of Occupational Science and Occupational Therapy, Department of Allied Health Sciences at the University of North Carolina, Chapel Hill, NC. Her clinical and research interests focus on community-based and client-centered practice, community mobility, and neurorehabilitation.
    Jennifer L. Womack, MA MS OTR/L, is Clinical Associate Professor, Division of Occupational Science and Occupational Therapy, Department of Allied Health Sciences at the University of North Carolina, Chapel Hill, NC. Her clinical and research interests focus on community-based and client-centered practice, community mobility, and neurorehabilitation.×
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Hearing Disorders / Special Populations / International & Global / Language Disorders / Aphasia / Articles
Article   |   April 01, 2012
The Relationship Between Client-Centered Goal-Setting and Treatment Outcomes
SIG 2 Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, April 2012, Vol. 22, 28-35. doi:10.1044/nnsld22.1.28
SIG 2 Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, April 2012, Vol. 22, 28-35. doi:10.1044/nnsld22.1.28

Shifting definitions of health and well-being, prompted by the World Health Organization's International Classification of Functioning (2001), have stimulated changes in traditional clinician-client relationships in rehabilitation. Among these changes, in keeping with the concept of client-centered care, is a trend toward more collaborative goal-setting and joint determination of intervention plans. Evidence suggests that supporting clients' autonomy in prioritizing personally meaningful goals leads to increased engagement in intervention, less emotional anxiety about the rehabilitation process, and improved treatment outcomes. Supporting people with aphasia in a process of collaborative goal formulation may also serve to alter treatment priorities so that they address more relevant communication challenges embedded in post-rehabilitation life.

In the early 2000s, the World Health Organization (WHO) set a standard for conceptualizing health as encompassing factors beyond the body with its dissemination of the International Classification of Functioning, Disability and Health (ICF; WHO, 2001). The ICF is largely credited for the current reorganization of health care around biopsychosocial concerns as opposed to the traditional medical model and has been officially adopted by numerous health-care entities to structure care practices. One of the core domains of the ICF model is the concept of participation (WHO, 2001).
Within the process of rehabilitation, participation is often conceptualized as the ultimate outcome of therapeutic interventions (American Occupational Therapy Association, 2008) or what the client will do after successful involvement in therapy. The focus of this paper is the concept of participation of therapy clients—and clients with aphasia in particular—in determining rehabilitation goals and collaborating to prioritize intervention strategies. First, I present general evidence pointing to the positive relationship between client participation in goal-setting and attainment of those goals. Next, I explore the role of rehabilitation professionals in supporting client autonomy as a core feature of client-centered practice. Finally, I outline the importance of collaborative goal-setting and intervention planning as both means and ends to support life participation for people with aphasia. Throughout this paper, the term rehabilitation clinicians is inclusive of occupational therapists (OTs), physical therapists (PTs), and speech-language pathologists unless otherwise specified.
Goal Achievement and Involvement of the Client in Goal-Setting
Across the spectrum of health care, but particularly in the context of re/habilitation programs, goal-setting is a ubiquitous practice that guides intervention, but also serves as an indicator of success in the therapeutic process. Blackmer (2000) contends that goals can be evaluated as outcome criteria for rehabilitative programs not only in the traditional manner—considering whether or not discrete goals were met in the course of intervention—but also in terms of whether or not they reflect the priorities of the client and address participation as a whole. While acknowledging that the process of goal-setting often represents an ethical conflict for the health-care provider, in that beneficence toward the client is juxtaposed against the desire to support client autonomy, Blackmer suggests that as clients move through a health-care continuum, part of their journey should be to engage in goal-setting with progressively more autonomy (2000). There is no indication that the rehabilitation professional should relinquish involvement in the goal-setting process, but that increasing collaboration with clients has benefits for the intended outcomes of treatment as well as for the individual client.
The practice of collaborative goal-setting between clients and clinicians has been linked to increased gains in functional outcomes (Nair, 2003; Ponte-Allan & Giles, 1999; Randall & McEwen, 2000), improved ability on the part of the client to recall goals (Kristensen, Persson, Nygren, Boll, & Matzen, 2011), decreased anxiety about the future (Bloom et al., 2006), empowerment toward participating in the treatment process (Lane, 2000), and the expansion of goals beyond bodily functions into realms of social and community participation (Engin & Pretorius, 2008). Despite the evidence that collaborative goal-setting appears advantageous to treatment outcomes as well as the client's well-being, clients appear to be differentially incorporated into collaborative goal-setting based on personal factors such as age, gender, diagnosis, and type of health-care setting.
Maitra and Erway (2006) interviewed 30 clients and their OTs in 11 different long-term rehabilitative care situations regarding their perceived involvement in setting goals for their therapy program. Typically, clients who were younger, male, and in more acute rehabilitation settings reported a higher incidence of having collaborated with their therapists to set goals. In addition, the OTs noted that the tendency of the client to relinquish decision-making, difficulty communicating with the client, and a facility's lack of emphasis on client-centered care were all factors that discouraged them from emphasizing collaborative goal-setting. Regardless of these challenges, the interviewers found clients across all age groups and facilities reported with 90% frequency that having the opportunity to collaborate in setting goals for their own rehabilitation program was crucial to their participation (Maitra & Erway, 2006).
Clients with chronic and complex health conditions also appear vulnerable to decreased involvement in determining their own treatment goals. Huntington and Gilmour (2001) argue that this lack of involvement is partly due to a gradual acceptance of the dominance of medical expertise in addressing chronic conditions, which leads to a devaluing of the clients' own knowledge about their experiences. Cardol et al. (2002) studied responses regarding perceived participation across five different diagnostic groups among 126 community-dwelling persons in the Netherlands. Individuals with stroke, rheumatoid arthritis, and fibromyalgia reported more severe restrictions in participation, whereas individuals with more slowly progressing neuromuscular diseases reported fewer perceived restrictions. It is interesting to note, however, the more salient issue appears not to be identifying those life roles which are perceived as most restricted, but the emotional distress that interviewees reported when unable to autonomously identify problems most critical in their own lives. In other words, items rated as most severely restricted for these participants did not always match with items rated as their most pressing life problems. Across the board, respondents reported a need for more emotional support in recognizing the discrepancy both within and beyond the rehabilitation process.
Cardol, de Jong, and Ward (2002) addressed mis-identification of client priorities in the actual rehabilitation process, noting that ultimately the concept of participation, as defined in the ICF (WHO, 2001), necessitates comparison of a person with a disability to a person without, forcing the use of normative criteria to define disadvantages that may or may not be perceived by the individual (Cardol et al., 2002). These authors introduce the concept of autonomy into the rehabilitation process as a partner to participation, arguing that it adds a personal perspective lacking in the broader construct. In other words, the concept of autonomy acknowledges that one person's handicap is not necessarily the same as that of another and moves the rehabilitation process toward a more truly client-centered focus. At a pragmatic level, this autonomy-supportive approach includes opportunities for clients to participate in decisions about rehabilitation goals and processes, as well as ask for emotional support and more directive guidance when needed.
When clients are provided support in assessing their own problem areas and identifying goals, there is evidence that treatment outcomes are enhanced. Wressle and colleagues compared experimental and control groups totaling 210 clients across two different Swedish rehabilitation systems comprising geriatric, home, and stroke care teams (Wressle, Eeg-Olofsson, Marcusson, & Henriksson, 2002). Participants were randomly assigned to a group upon admission to the rehabilitation program. All participants received a standard initial evaluation from both OTs and PTs, using identical tools in both systems. Participants in the experimental group were also interviewed by OTs using the Canadian Occupational Performance Measure (COPM, 3rd ed.; Law et al., 1998), a semi-structured tool designed to elicit clients' identification and prioritization of problems. Participants in the control group were not interviewed using the COPM. The COPM asks clients to identify deficits associated with self-care, leisure, and work/productivity and then rank those problems according to current performance, perceived satisfaction with that level of performance, and importance of the issue. This tool stems from a Canadian model of client-centered care that speaks to the need to involve clients in identifying problem areas, formulating goals, and prioritizing intervention strategies (Law, Baptiste, & Mills, 1995).
In the results of the Wressle et al. study (2002), clients in the intervention group (who were interviewed using the COPM) not only indicated they had been actively engaged in the goal-setting process, but also recalled specific rehabilitation goals 2–4 weeks post-discharge, a phenomenon not encountered with the control group. Clients in the control group reported only vague notions of their rehabilitation goals and more frequently mentioned interventions than goals, even when asked about the latter. The authors noted passivity in the responses of the control group; these participants often reported friendliness from the therapy staff and trusted that they would make the right decisions regarding their care (2002). An even more striking result is that the intervention group retained higher scores on the standard initial evaluation 2–4 weeks post-discharge and reported greater success with managing desired household and community tasks than did participants in the control group, despite both groups being similar in terms of functional abilities assessed at the time they completed their rehabilitation programs. These results reinforce those of an earlier study by Ponte-Allan and Giles (1999), in which stroke clients who participated in setting their own goals in an acute rehabilitation setting scored higher on assessments of functional independence conducted by independent evaluators than did a group of similar clients whose goals were determined by the rehabilitation staff.
The studies cited above appear to provide an overwhelmingly positive response to involving rehabilitation clients in the goal-setting process. Why, then, do we even need research to point this out? Why is it not standard practice to center clients as the experts in their own lives and support their autonomy in directing their rehabilitation? One clue lies in a study by Le Granse, Kinebanian, and Josephsson (2006) in which it became clear that although rehabilitation clinicians state the importance of client involvement in prioritizing goals, these same clinicians cite numerous barriers to enacting client-directed goal-setting and few methods by which they can increase client autonomy. Institutional, procedural, and client factors were all cited by the clinicians in this study as barriers to involving clients in goal-setting. Though it is true that different practice contexts lend themselves more or less to client-centered care, and personal and diagnostic factors of all clients require different levels of autonomy support, rehabilitation professionals play an important role in creating opportunities for client-driven goals—a role that we discuss in the next section.
Rehabilitation Professionals Supporting Autonomy
Whereas much has been written about the role of the physician in influencing, guiding, and, in some cases, overtly controlling the direction of goals and intervention (Alexander, Hearld, Mittler, & Harvey, 2011; Charles, Whelan, & Gafni, 1999; Goodyear-Smith & Buetow, 2001; Lieber, Kim, & Volk, 2011), less has been studied about the role of rehabilitation clinicians in determining the nature of goals and treatment priorities. Studies reviewed for this article often addressed ways to motivate clients or “remind” them of their goals (LeQuerica, Donnell, & Tate, 2009; Maclean, Pound, Wolfe, & Rudd, 2000) and less frequently spoke to the power dynamics between professional and client (Peoples, Satink, & Steultjens, 2011). Rehabilitation clinicians influence both the goals and outcomes of therapy not necessarily by asserting power verbally, but through the power of our actions.
One way in which rehabilitation clinicians enact power is through the use of assessments that focus on impairments and subsequently lead to related interventions. Writing specifically about speech-language pathology for aphasia, Kagan and colleagues (Kagan et al., 2008) note that interventions flow from the type of information gained in assessment, and “if we measure number of word output per minute, then that is what we also deliver in intervention” (p. 270). This approach risks sacrificing the opportunity to address participation-level goals in favor of ostensibly more measurable impairment-level outcomes. Likewise, assessments in occupational therapy that focus only on components of self-care tasks or physical therapy assessments aimed solely at determining the efficiency of gait patterns or walking distance may also fail to capture meaningful life change.
Another way in which rehabilitation professionals control opportunities for clients to be involved in directing their own care reflects opinions held about professional roles. Le Granse and colleagues (Le Granse et al., 2006) noted that OTs in their study viewed their primary role as providing information about the relative feasibility of and risks inherent in goals expressed by clients, rather than as facilitators of goal-setting opportunities. Daniëls, Winding, and Borell (2002) interviewed clinicians who reported they had difficulty when clients in neurological rehabilitation reached a plateau in their progress. At this point, the clinicians often switched to adaptive versus remedial strategies, even when they worried that the client would disagree with the change in focus. In this case, the clinicians viewed their expertise in shifting the treatment focus as a responsibility that took precedence over the client's wishes.
At times, the direction of therapeutic intervention appears unknown to the client, even when clinicians believe they are making decisions in the client's best interest. OTs working in long-term care indicated in interviews that they embraced principles of client-centered care, but clients interviewed by the same investigators indicated they were unaware of attempts described by the therapists to engage them actively in the rehabilitation process (Maitra & Erway, 2006). When the same therapists were informed of the clients' perspectives, they cited barriers to enacting client-centered care, including the inability to engage clients with decreased cognitive abilities in goal-setting; the interference of high productivity demands; difficulty with clients who are passive, unmotivated, or unable to express their goals verbally; and work climates where the clients' personal goals are not the priority of the health-care team.
Similar barriers to those identified in the Maitra and Erway study (2006) were also invoked by PTs in another study: The PTs identified opportunities to engage clients in goal-setting and intervention decisions, but did not facilitate those opportunities due to perceptions of professional responsibility to take charge of the decisions (Baker, Marshak, Rice, & Zimmerman, 2001). The clients of those PTs, however, reported to investigators that they were unaware of the information being used to make decisions about their care and would like to participate more in setting their rehabilitation goals. Baker and colleagues concluded that client participation models are not common in physical therapy settings and education for both therapists and clients would be necessary to move toward inclusive client-centered care practices.
A transition toward rehabilitation professionals being more adept at supporting participation and relative levels of autonomy in goal-setting and intervention planning requires not only a shift in professional paradigms, but also a transformation of the patterns of behavior clients have been taught (Lane, 2000). In other words, it is not just up to the rehabilitation professional to relinquish some power in decision-making, but also up to the client to seize it. As Pimentel (2008) noted, the opportunity and responsibility to formulate goals is foreign to most clients, and we cannot expect that they automatically know how to proceed. It can be argued that this is particularly true for clients with aphasia, for whom it is often considered more expedient to assume or ask significant others to identify preferences rather than take the time to resolve communication challenges. The final section of this paper addresses issues specific to collaborating with clients with aphasia in setting goals and determining priorities for treatment.
Participation in Goal-Setting and Outcomes for Clients With Aphasia
Nätterlund (2010) interviewed people with aphasia (PWA) who had been discharged from rehabilitation programs. The results revealed that although these clients initially felt emotionally supported and encouraged as they worked on therapy goals, they often had an incomplete picture of what was occurring and misunderstood information provided to them during the process. Following discharge, they reported feeling a lack of support from the health-care system in which they had been clients, which intensified their sense of social isolation even when family and friends remained supportive. Social isolation and exclusion is one of the most commonly cited experiences of PWA (Cruice, Worrall, Hickson, & Murison, 2003; Parr, 2007), but perhaps unexpected in the context of the health-care environment.
Health-care professionals who are not directly trained in supportive communication techniques for PWA often report feelings of inadequacy, anxiety, and even fear when attempting to provide care to aphasic clients, and stroke survivors with aphasia subsequently relate that they are frequently excluded from not only decisions but also discussions about their own lives during health-care encounters (Parr, Pound, & Hewitt, 2006). Even when rehabilitation professionals are well-versed in communication techniques, such as is the case with speech-language pathologists, they may also fall into the pattern of focusing too narrowly on goals for recovering language skills versus goals that address the consequences of living with aphasia (Dalemans, de Witte, Wade, & van den Heuvel, 2009).
Kagan and colleagues (2008) set out to determine a systematic way in which real-life meaningful outcomes of aphasia therapy can be prioritized in clinical settings. The resulting Living With Aphasia: Framework for Outcome Measurement (A-FROM) includes concepts from both the ICF (WHO, 2001) and the Canadian Disability Creation Process (Noreau, Fougeyrollas, & Vincent, 2002), which emphasize the concepts of participation and social construction of disability, respectively. Kagan and colleagues (2008) recommend that aphasia therapy move away from a focus on remediation of impairments to a focus on meaningful life, characterized as increased participation in life roles or changes in life habits. In order to realize this shift in intention, rehabilitation professionals must listen to the client as the source of what constitutes meaningful life change and expand intervention to include significant others.
If the above principles and approaches are enacted within rehabilitation programs, it is likely that the goals expressed by PWA may be quite different from those determined by their rehabilitation clinicians. In Pimentel's (2008) example of a clinic that shifted to a client-centered model of goal-setting, clients consistently established goals that involved social interaction rather than individualistic pursuits. Harris and Eng (2004) also reported that community-dwelling stroke survivors whom they interviewed prioritized interactive leisure goals over the self-care goals predicted for them by rehabilitation professionals. This theme of social interaction is consistent with the findings of Dalemans and colleagues—that the quality of engagement with important others is paramount for PWA (Dalemans et al., 2010); the diaries kept by PWA in their study are replete with desires to remain socially engaged with others despite the difficulties posed by communication deficits. In order for rehabilitation clinicians to facilitate the ability of PWA to reveal these goals, it is essential they implement innovative assessment and goal-setting procedures, such as those outlined in the other papers in this issue.
Conclusion
A client-centered approach to rehabilitation, which is in keeping with current concepts of health, well-being, and disability rights, necessitates that clinicians and clients engage in collaborative goal-setting and that clients' priorities for intervention are heard, respected, and heeded. This participatory model requires that rehabilitation clinicians assume roles that are less authoritative and more oriented toward supporting autonomy than deciding priorities on behalf of the client. The potential exists for increased work satisfaction for the clinicians as well as improved goal attainment for the clients. Clients with aphasia may be particularly likely to benefit from opportunities to participate actively in collaborative goal-setting, in that the facilitation of autonomy within the rehabilitation setting serves as a model for later social interaction. As Paul Berger so eloquently states in his account of 20 years of living with aphasia:

I believe I am proof that patients with aphasia can successfully translate and integrate skills learned in clinical aphasia rehabilitation sessions into functional communications to live independently and participate fully in the community through a patient-centered approach that incorporates intensive, individualized home-based activities and tools with goals that are meaningful to the patient and a treatment plan that provides skills aimed to achieve these goals. (Berger & Mensh, 2011, p. 291)

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The 19 individual SIG Perspectives publications have been relaunched as the new, all-in-one Perspectives of the ASHA Special Interest Groups.