Scandinavian Journal of Occupational Therapy
ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: https://www.tandfonline.com/loi/iocc20
Participatory citizenship: Critical perspectives on
client-centred occupational therapy
Hetty Fransen, Nick Pollard, Sarah Kantartzis & Inés Viana-Moldes
To cite this article: Hetty Fransen, Nick Pollard, Sarah Kantartzis & Inés Viana-Moldes (2015)
Participatory citizenship: Critical perspectives on client-centred occupational therapy, Scandinavian
Journal of Occupational Therapy, 22:4, 260-266, DOI: 10.3109/11038128.2015.1020338
To link to this article: https://doi.org/10.3109/11038128.2015.1020338
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Scandinavian Journal of Occupational Therapy. 2015; 22: 260–266
ORIGINAL ARTICLE
Participatory citizenship: Critical perspectives on client-centred
occupational therapy
HETTY FRANSEN1, NICK POLLARD2, SARAH KANTARTZIS3 & INÉS VIANA-MOLDES4
1
Department of Occupational Therapy, Ecole Supérieure des Sciences et Techniques de la Santé de Tunis, University of
Tunis El Manar, Tunis, Tunisia, 2Occupational Therapy, Faculty of Health and Wellbeing, Sheffield Hallam University,
Sheffield, UK, 3Division of Occupational Therapy and Arts Therapies, Queen Margaret University, Edinburgh, UK, and
4
Department of Health Sciences, Faculty of Health Sciences, University of A Coruña, La Coruna, Spain
Abstract
Background/aims: This article aims to discuss client-centred practice, the current dominant approach within occupational
therapy, in relation to participatory citizenship. Occupational therapists work within structures and policies that set boundaries
on their engagement with clients, while working with complex, multidimensional social realities. Methods: The authors present
a critical discussion shaped by their research, including a survey, discussions at workshops at international conferences, and
critical engagement with the literature on occupational therapy, occupation, and citizenship. Conclusion: A focus on citizenship
suggests reframing professional development based on the participation in public life of people as citizens of their society. While
occupational therapists often refer to clients in the context of communities, groups, families, and wider society, the term clientcentred practice typically represents a particular view of the individual and may sometimes be too limited in application for a
more systemic and societal approach. Significance: The authors question the individual focus which has, until recently, been
typical of client-centred occupational therapy. Placing citizenship at the core of intervention is a transformative process that
assumes all people are citizens and conceives of health as a collective issue, influencing the way we educate, do research, and
practise.
Key words: Collective, dis-citizenship, inequalities, professional development, participation, paradigms, occupational justice
Introduction
Client-centred practice underpins occupational
therapy, as stated by the World Federation of Occupational Therapists (1) and is frequently referred to in
core practice frameworks, primarily in Anglophone
countries. However, there are many different definitions of client and client-centred practice, as well as
tensions and contradictions between the theoretical
concept and the realities of practice. In the marketplace client relationships accompany a direct payment
for services. Neoliberalism suggests that the principal
way by which most clients are empowered is through
choosing how their money is spent with whichever
service provider. The phrase “client-centred” implies
an intent of the therapist towards the client without
defining that intent. In healthcare the client is “the
patient”, but the payment for treatment frequently
comes from the occupational therapist’s employer,
who may be another agency with an influence on
the outcomes for the client. Thus, client choices
may not be always evident in the situations in which
occupational therapists work. The term client is used
in many different healthcare systems in which the
access that people have to services varies greatly.
Many people cannot access services, such as occupational therapy, because they are impoverished, lack
entitlement for referral under their particular health
systems, or they live in locations where services are
not available. Working around this fragmented
Correspondence: Nick Pollard, Senior Lecturer, Occupational Therapy, Faculty of Health and Wellbeing, Robert Winston Building, Sheffield Hallam University,
11-19 Broomhall Road, Sheffield S10 2BP, UK. Tel: +44 114 2252416. E-mail: N.Pollard@shu.ac.uk
(Received 24 October 2014; accepted 12 February 2015)
ISSN 1103-8128 print/ISSN 1651-2014 online 2015 Informa Healthcare
DOI: 10.3109/11038128.2015.1020338
Participatory citizenship
network of client relations requires an imaginative
approach to what Rudman (2) suggests is a gap in
occupational therapy between intent and enactment.
Yet citizenship presents similar theoretical and
practical issues to client-centredness. Participatory
citizenship may be defined as: “Participation in civil
society, community and/or political life, characterised
by mutual respect and non-violence and in accordance with human rights and democracy” ((3), p. 12).
Within Europe, where the authors’ investigations have
primarily been centred, there are diverse conceptions
of citizenship. These are linked to historical and
cultural factors as well as to considerable inequalities
in opportunity, wealth, and health. This combination
of diverse political, social, and cultural traditions and
very different health systems generates many positions. Therefore, while citizenship is a significant issue
for occupational therapy in order to promote and
ensure participation in occupation and sustainable
health, the relationship is complex and the actions
undertaken will depend on context. Furthermore,
there may be perspectives where a focus on citizenship
as part of an ideological component of Western
democracy needs critical investigation before it might
be recognized as being beneficial or useful. For
example, some individuals might perceive basic health
promotion and survival as more immediate than
citizenship rights.
Occupational therapists work within policies and
structures that set boundaries on their engagement
with clients (4,5), who are often, because of their
stigmatized status as others (6), in situations of inequity. Inequity results from a combination of social and
economic factors such as poverty and lack of access to
education. These produce combined effects across
communities and amongst individuals, but also
restrict access to health through occupation by the
operation of unequal status (7). Therefore, it has been
argued that occupational therapists should act for
social and political changes based on the principles
of occupational justice (8). These social differences
realized through occupational injustices require the
profession to develop a transformative and critical
position around the conception of client-centred
practice from the perspective of citizenship.
The authors are engaged in the exploration of the
relationship between occupation, occupational therapy, and citizenship related to their work in a project
group of the European Network of Occupational
Therapy in Higher Education (ENOTHE). This
Citizenship Group, whose members have varying
viewpoints arising from the countries in which they
work and from which they originate (Fransen: Tunisia/Netherlands; Kantartzis: UK/Greece; Pollard:
UK; Viana-Moldes: Spain/Brazil), was established
to explore the position of occupational therapy
261
research, education, and practice in relation to
citizenship as a response to the European Year of
Citizens in 2013. They prepared a statement on
citizenship (9), conducted a survey, and held several
workshops at international conferences incorporating
discussions with practitioners, educators, and students. The current discussion is built upon these
data and shaped by a critical engagement with the
literature on citizenship.
Defining client-centred practice and
citizenship
Client-centred practice
Client-centred practice emerged in the second part of
the twentieth century as a reaction to the dominant
prescriptive medical model on cure. Carl Rogers
(1902–1987), known as the creator of client-centred
therapy, rejected the negative view of human behaviour: “In my earlier professional years I was asking the
question: How can I treat to cure, or change this
person? Now I would phrase this question in this way:
How can I provide a relationship which this person
may use for his own personal growth?” ((10), p. 32).
Rogers recognized that clients have the power and
motivation to help themselves and can be given
responsibility to solve their own problems. Taking a
humanist, non-directive approach, therapists focused
on concerns as expressed by the client, understanding
and explaining their human behaviour and mental
processes. This approach was centred on the individuality of people and on the qualities that can positively
fulfil their lives.
During the 1980s client-centred principles were
embraced in occupational therapy as being concordant with those of the profession (11,12). A number
of elements are seen to influence the successful implementation of client-centred practice, with the aim to
enable clients to participate in their valued occupations. These include respect and value for the client,
his/heir identity, and his/her subjective experiences,
and the facilitation of mutual dialogue and partnership between the client and the therapist, to enable the
client to participate and collaborate in therapy.
“Enabling” is the term used for describing therapy
that uses participatory, empowerment-oriented
approaches ((13), p. 77).
Citizenship
Many definitions of citizenship exist; the perspective
adopted here concerns full participation in society. In
the statement “Citizenship: Exploring the contribution of occupational therapy” (9) the authors defined
citizenship as follows:
262
H. Fransen et al.
Table I. Citizenship, occupation, and occupational therapy: Key
issues.
Partnerships:
The complex and multidimensional processes of citizenship involve
many social actors, and need to be approached from a kaleidoscopic
perspective. This calls for collaborative approaches and
interdisciplinary/transdisciplinary work
Physical, social, and virtual spaces in which to practise citizenship:
Citizenship takes place through a large number of social
institutions, for example those providing employment, education,
and legal regulation. Equity of access (accessibility) and equity of
engagement in the processes of these institutions needs to be
ensured. These spaces also promote opportunities for people to
share experiences of life with others, in work, leisure, play, intimacy,
and creativity
Participatory citizenship as a way of being in the world with others:
Citizenship is expressed through occupation with others in a social
context, and is challenged by inequality, discrimination, and other
forms of exclusion or privilege. Empowering citizenship includes:
having a voice and being listened to, self-power, decision-making,
having control or gaining further control, being free, independence,
being capable of fighting for rights, and being recognized and
respected as equal citizens and human beings with a contribution
to make
Citizenship, in the widest sense, is both a right and a
responsibility to participate with others in the cultural, social and economic life and in the public
affairs of society. With such a participatory or active
concept of citizenship it becomes an educational
and negotiated process as well as a regulatory and
legal task. It invites people to consider each other as
equals, as fellow citizens, and facilitating citizenship
as a mutually shared interdependent responsibility.
Citizenship enhances civic participation and fosters
social cohesion in a time of increasing social and
cultural diversity ((9), p. 1).
This concept of participatory citizenship is supported by various European citizenship models,
including liberal, communitarian, civic republican,
and critical citizenship models, and its activities range
from informal social interaction, civic engagement,
and protest activities to conventional politics (3).
Participatory citizenship extends beyond merely political actions such as voting in elections, including
participation in everyday social and cultural life,
and is interconnected with the concepts of human
and occupational rights.
Such a conceptualization places citizenship not just
as the formal, static status of an individual, but also as
a practice, a dynamic and contested process within the
larger community (14). This suggests, by an association with practice, that the inclusion or the exclusion
of individuals from the status of citizenship is something that is arbitrated at the local contextual level,
as much as it might be ordained through the structures of power. The consequences of such arbitration
are experienced in terms of personal identity and
belonging, access to resources and facilities, and
the experience of personhood and of freedom, that
is, the components of agency in the social world. As
Devlin and Pothier ((14), p. 2) suggest, “because
many persons with disabilities are denied formal
and/or substantive citizenship, they are assigned to
the status of ‘dis-citizen’, a form of citizenship-minus,
a disabling citizenship”.
Thus, the starting point of our reflection is participation in contemporary society through occupation,
in response to “dis-citizenship”. For occupational
therapists, the expression of citizenship through occupation is central. Key issues to consider are: partnerships and collaborative approaches; the spaces in
which to practise citizenship; and participatory citizenship as a way of being-in-the-world with others
(see Table I) (9).
The promotion of participatory citizenship includes
essential action and respectful concern for those people restricted not only in access to the community, but
also to the processes of citizenship, including social
recognition, having a voice and being listened to, and
equitable participation in discussion, decisionmaking, conflict resolution, and power (7). This
influences the nature of multiple relationships including that of the therapist and “client” as fellow citizens
and fellow participants in the construction of their
shared world (15).
Paradigms and worldviews influencing
occupational practice today
Client-centred practice (as it emerged from the work
of Rogers) (16) is based on theoretical underpinnings
that are centred on the individual. It is based in a
paradigm that focuses on the development of individual potential with commitment to social values and
cultural norms. The training of health workers, such
as occupational therapists, is typically based on the
capacity to perceive the needs and the ability level of
the individual (17). More recently, client-centred
practice has also been applied in situations where
occupational therapists are working with families,
communities, populations, and even institutions.
Paradigms are used in science to refer to a theoretical framework, sometimes used more loosely to
describe the prevailing view of things. These belief
systems are usually seen as “the way things really are”
by the groups holding them, and they become the
taken-for-granted way of making sense of the world
(18). Paradigms in occupational therapy are based
onand connected to the paradigms and worldviews
ofsociety, and are influenced by the exchange of
underpinning ideas from economics, politics, and
education, as well as health sciences. Askew and
Participatory citizenship
Carnell (19) developed a fourfold classification of
paradigms or ideologies – liberatory, social justice,
client-centred, and functionalist – based on a matrix
that maps beliefs and knowledge with the role of
education in society. These four ideologies have
also influenced the historical and contemporary practices of occupational therapy, as part of the broader
beliefs and concepts concerning health and the way
professionals should practise and society should
deliver services. Within this classification (19),
client-centred and functionalist paradigms tend to
work towards the intrinsic axis of social regulation.
However, the concept of citizenship belongs to a
different paradigm, that of social justice, which,
together with the liberatory paradigm, works along
the extrinsic axis of radical change.
While the client-centred paradigm focuses on individual potential, abilities, and perceived needs, the
functionalist paradigm tends to be mechanistic,
focused on learning how to do rather than reflecting
on why things are done. These paradigms are intrinsic
because they provide a focus that does not look
beyond the task, and their effect is to atomize rather
than contextualize practice. However, in the liberatory view, individual change is a prerequisite for
change in society, a wider and extrinsic focus,
reflected in the skills of the health worker for reflection
and the analysis of experience, particularly in relation
to the person’s lived experience of inequality. The
social justice paradigm goes further in encouraging
responsibility for changing society, and where the
development of social awareness and skills in the
professional potentially enables the critical analysis
of social injustice in society (15,20). Rather than
assuming that social issues such as inequality are
inevitable, the social justice tradition makes them
the focus of investigation and action. One of the
leading figures in this tradition is Paulo Freire, generally known as the father of empowerment. He
emphasizes dialogue (involving respect and working
with each other) and informed action (developing
consciousness and hope, in order to have the power
to transform daily reality), in order to change the
social and political structures that perpetuate inequality and injustice (21).
Therefore, it becomes necessary to question the
assumption that occupational therapy is naturally
client-centred. A second assumption to be questioned
is that the possibilities for fulfilment are intrinsic to
every individual in his/her unique reality. A number of
authors have contributed to this debate with discussions of how medical dominance, market-driven
economies, insurance, laws, and political conditions
influence the successful implementation of clientcentred practice and may overrule good intentions
(12,13). However, as in Mortenson and Dyck’s study
263
(22), structural issues are more often considered as
issues influencing the possibility of client-centred
practice, rather than as a need to question such
practice as the only possible approach.
A third assumption relates to client-centred practice as it has extended its focus from the individual to
the family and the community. However, it should be
questioned whether this is a suitable paradigm for
social change such as health promotion or community
development (23,24). Models of practice which focus
on individuals and their occupations may not be
appropriate for understanding the cultural dynamics
of collective occupation and may be too limited to
guide practice addressing issues of participation
in community and inclusive citizenship. From a
paradigmatic point of view, the knowledge base of
client-centred practice is related to a subjective and
individual perspective, whereas a community or society approach asks for an appreciation of the social
dynamics based on an extrinsic and sociological
context. Many authors from South America and
Africa have described their practice (including
education and research) grounded in a social and
transformative approach (15,20,21,25,26) and not
within client-centredness.
A fourth assumption, linked to the previous ones, is
based in a worldview that places the individual at the
centre, with the responsibility and the potential to
pursue change and to develop his/her abilities to the
fullest. However, not all persons and communities
have this view of life. Alternative views may place the
person embedded in his/her relationship with others,
including the therapeutic relationship, both in the
present and through time, and not separated from
the world around him/her (27). Such a view may
influence the therapeutic relationship, its responsibility, and its directionality.
Critical issues and dilemmas
The enactment of the principles of citizenship from an
occupational perspective presents challenges to the
profession of occupational therapy and has considerable implications for client-centred practice. Consequently the concept of citizenship raises dilemmas,
ethical issues, and problems of education and of
practice for the occupational therapist.
Client-centred practice and dis-citizenship
The assumptions and paradigmatic perspectives
described lead us to deconstruct the dominant
influences on professional roles underpinning clientcentred practice, in favour of considerations embedded
in perspectives of participatory citizenship. Addressing
inequalities, professional power relationships, and
264
H. Fransen et al.
occupational justice requires a transformative approach,
questioning the social order beyond the individual’s
occupational performance. The transformative paradigm provides such a framework for examining
assumptions that explicitly address issues of power
and occupational justice (28). The objective becomes
participation of all citizens, including dis-citizens.
Examination of forms of dis-citizenship requires an
exploration of processes of access and exclusion (29).
We need to consider what makes a citizen belong, and
to consider the rights and responsibilities associated
with these, for example for people with disabilities.
Siebers (30) argues that people with disabilities are
often regarded as separate from the rest of humanity.
This separation presents a challenge to the utopian
perspective of Rawls (31), because the exclusions of
people with disabilities are revealed as social constructions. In turn, exclusions can often be internalized as
negative personal identifications, as Goffman (6) suggests. Forms of disability can be manifest as concrete
physical differences that act as a constraint upon
social identity; they are issues that cannot be altered
by the theory of social constructionism, and that are
beyond current medicine or other therapeutic interventions. As Siebers (30) notes, because humans
differ in size and shape, many features of their social
environment exclude them from the social possibilities and the physical spaces of Rawls’ shared, wellordered society. These exclusions become aspects of
individual and group identity. Until a principle of
fairness and justice is politically enacted, excluded
citizens will protest from the basis of identity politics
that challenge concepts of well-orderedness. As a
consequence, perhaps few disability theorists would
use client-centred terminology. Although people with
disabilities have coined the term “nothing about us,
without us”, an identity based on experiences of
exclusion does not suggest a conformity to centrally
held values, rather it suggests that that identity has
components constructed outside and not within the
system that serves the majority.
Partnership approaches
It might be argued that client-centred practice has
many similarities to the presentation of citizenship in
this paper (see Table I). Partnership and collaboration, a participatory approach, and empowerment are
mentioned as being at the core of client-centred
practice, as they are at the core of citizenship
approaches. However, these words express different
concepts in each approach. Partnership, in clientcentred practice, focuses on the relationship between
the client and the therapist, with the aim to enable
clients to participate in their valued occupations.
Related to participatory citizenship, collaborative
partnerships point to cross-sectorial collaborations for
effective and sustainable solutions, in order to tackle
complex and multidimensional health, social, and
development issues. Partnership may be described
as an ongoing working relationship where risks and
benefits are shared (32), even if in reality this may be
difficult to achieve. The assumption underpinning
this partnership approach is that comprehensive
and widespread cross-sector collaboration is needed
to make sustainable development initiatives imaginative, coherent, and integrated enough to tackle the
most intractable problems, such as poverty, exclusion,
and marginalization. Even within the person–therapist relationship such a partnership approach
acknowledges both persons as primarily citizens living
within complex and interrelated worlds.
Participation and occupation
The importance of participation in the occupational
therapy process inevitably requires critical consideration. Participation is a social process that can range
from empowerment to forced participation, exploitation, and manipulation (33). These complexities have
not been adequately considered in occupational definitions of participation. It is possible that a person
may experience multiple patterns of interdependence,
mutual dependence, and concurrent forms of social
participation depending on the contexts through
which he/she moves and transacts his/her relationships. As discussed earlier, the concepts of participation and partnership need to be explored and our
occupational knowledge base and competences
broadened to the systematic and societal level of
cross-sectorial collaboration.
The authors also recognize the need for occupational therapy and occupational science to conceptualize the occupational nature of active citizenship,
located as a practice in the interconnectedness of
the individual and the larger community. Participation and citizenship are dialectical constructions with
a dynamic relationship in their impact on health that
depends on social determinants (34). The health
system itself, as an institution, contributes to this
dynamic through its own part in the production of
health inequities (7,34).
Action, public spaces, and the experience of living
together
Action is an important concept in the occupational
therapy goal of facilitating participation in everyday
occupations. The ultimate ideal of a citizenship perspective is full participation for all, in all the diverse
occupations offered within public spaces. This
Participatory citizenship
includes consideration of educational, health, administrative, and work institutions, the regulations and
policy that govern the activities that can or should take
place within them, and the relationships that are so
constructed. Arendt (35) discussed action as the coming together of people based on their equality and
plurality, and the power that emerges from this coming
together to create and sustain the common or public
world. The importance of this public world has been
emphasized as the place where the previously unnoticed can act and be heard, and have voice and visibility,
claiming both the space for and entry to political life
(36). At the same time the public world often operates a
meritocracy and makes minor assumptions regarding
inclusion and equality, which prevent those who are
overlooked from participating, for example nonattendance might be the result of inaccessibility rather
than lack of interest. A combination of such exclusions
can render the invisible more invisible, and promote
greater inequality.
People differ in their needs, wants, and abilities,
including their capacity to live alongside others. Citizenship is not only about rights but also about how
individual duties are related to collective responsibility
in the society to which a person belongs, individual and
collective decisions concerning social participation and
transformation, and the extent to which these decisions
are made operational through governance. The tensions in how people relate to others can be seen in the
intentionality of collective relationships on a continuum between liberating and oppressive relationships
(37). The collective, through informal networks of daily
occupation, can not only exclude on the basis of social
norms regarding acceptable behaviour according to
gender, age, and nationality, but also regarding perceived threats to the interests of the dominant members
of the community (38). Everyone is, at all times, a
participating citizen but the quality of participation
varies depending on how individuals are perceived
by others within the broader social collective.
Reframing professional development
There is growing insight into the potential of
occupation as an essential and enriching part of the
establishment and development of inclusive societies.
The awakening of consciousness and focus on
restricted participation, limited citizenship, and social
exclusion is congruent with the awakening of occupational justice in the field of occupational science and
occupational therapy, and the debate about reengaging with the profession’s roots in social justice
(39). Occupational injustice is regarded as a social
condition rather than a psychological state inhibiting
individual potential to meet aspirations. It entails a
rights-based approach to intervention, with a focus on
265
the concepts of power, participation, and a redistributive paradigm to guide practice. Justice becomes
more than an implicit foundation of occupational
therapy as merely client-centred: it is made explicit,
central to the profession’s development of appropriate
social approaches that address both individual and
community needs.
The recognition that the participation of people in
public life as citizens of their society is constructed
and shaped by social, political, cultural, economic,
and racial/ethnic values indicates the importance of
power and privilege as social determinants. Occupational therapy and occupational science, in order to
develop effective approaches towards overcoming
barriers to participatory citizenship, could develop
occupational indicators of health and full citizenship.
These could be, for example, around the ideas of
autonomy, interdependence, participation, and partnerships, which are contained in some ideas of clientcentred practice and of citizenship. These concepts
appear significant for the critical dialogues that will
shape future directions and challenges for the profession, and look beyond an individual rights-based
approach to tackling the sense of belonging to a
common future. A robust understanding of underpinning worldviews and paradigms will serve occupational therapy to reinterpret its existing knowledge
and philosophy, and reposition itself with renewed
emphasis.
The authors consider occupational therapy as a set
of practices that are part of the public space. A public
space involves a coming together of diverse people to
initiate and develop action in the common world.
Participatory citizenship implies the active involvement of citizens, including all people, in the life,
activity, and decision-making of their communities,
to be interconnected and shaping their world and
future together. Rather than as clients, or as subjects
who are the objects of a client-centred health practice,
these diverse people are conceived as citizens and
health as a collective issue. This is a transformative
process that will influence the way we educate, do
research, and practise.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
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