Beyond the Buzzwords: Client-Centred or Client-as-Partner?

1.0 Introduction

Rehabilitation outcomes are influenced not only by the type and quality of interventions provided but also by the nature of the clinical relationship between the rehabilitation professional and the client. Two conceptual approaches are often discussed in this context: client-centred care and the client-as-partner model. While these approaches share common goals of supporting client well-being and autonomy, they differ in their philosophical underpinnings, the balance of decision-making power, and the degree of shared responsibility. The decision of when to use one approach or the other is not straightforward. Instead, it requires an understanding of the client’s readiness, the safety of the context, and the goals of the rehabilitation process.

This article proposes that these two approaches exist on a continuum, with clinicians adjusting their stance based on the client’s capacity, preferences, and context. We integrate three key sources of guidance to explore this continuum: Wade’s theoretical contributions to rehabilitation, the Canadian Strategy for Patient-Oriented Research (SPOR) and Canadian Institutes of Health Research (CIHR) principles for patient engagement, and the River Model from psychotherapy training, which provides a metaphorical framework for understanding timing and level of intervention. Together, these sources form the basis for a decision-making model that helps clinicians determine when to adopt a primarily client-centred stance and when to transition toward full partnership.

2.0 Defining the Two Approaches

2.1 Client-Centred Care

Client-centred care in rehabilitation has its roots in occupational therapy and humanistic psychology, drawing heavily on the principles of respect for autonomy, empathy, and individualized goal setting (Law et al., 1995; Levack et al., 2011). Wade (2009, 2020) conceptualizes rehabilitation as a collaborative but clinician-led process in which interventions are tailored to the unique circumstances and goals of the individual. The clinician retains responsibility for structuring the process, ensuring safety, and guiding the client through evidence-based strategies. This approach recognizes that not all clients are ready or able to participate equally in decision-making at all times, and it safeguards against the risks of premature autonomy when the client’s physical, cognitive, or emotional capacity is limited.

Client-centred care is often essential in the early stages of rehabilitation or when a client is in crisis. By centring the client’s values and preferences, it fosters trust and rapport while protecting the client from undue pressure or decision-making burdens. However, critics have noted that client-centred care can inadvertently reinforce passivity if not paired with strategies to build engagement and self-efficacy (Leplege et al., 2007).

2.2 Client-as-Partner

The client-as-partner model extends beyond centring the client’s perspective to actively involving them in the design, delivery, and evaluation of their care. This approach is closely aligned with shared decision-making frameworks (Elwyn et al., 2012) and the SPOR definition of patient engagement, which describes meaningful and active collaboration in governance, priority-setting, conduct, and knowledge translation (Canadian Institutes of Health Research, 2019). In this model, the client assumes a co-author role in the rehabilitation process, sharing accountability for outcomes.

Partnership models have been associated with increased adherence, satisfaction, and long-term self-management (Bombard et al., 2018). They are particularly effective when clients have the knowledge, motivation, and stability to participate fully. However, full partnership is not always appropriate or feasible. Without adequate readiness or support, attempts at partnership can lead to frustration, confusion, or risk to the client.

3.0 Conceptual Continuum

Rather than viewing client-centred care and client-as-partner as mutually exclusive, it is more accurate to conceptualize them as points on a dynamic continuum. Clients may move back and forth along this continuum based on changes in capacity, health status, environmental demands, and rehabilitation goals. Clinicians must continuously assess where the client is on this continuum and adjust their stance accordingly.

Wade’s writings emphasize that rehabilitation should be both goal-directed and adaptive, responding to the evolving needs and abilities of the client (Wade, 2020). Similarly, the SPOR guiding principles of inclusiveness, mutual respect, co-building, and support imply that the clinician’s role is not static but responsive to context (Canadian Institutes of Health Research, 2019). This adaptability is at the heart of ethical rehabilitation practice, ensuring that care is safe, relevant, and empowering.

4.0 The River Model as a Timing Framework

The River Model, developed by Aronov and Brodsky (2009), is a metaphor-based framework for training psychotherapists in the skills of timing and intervention intensity. In this model, the therapist is conceptualized as a river guide, while the client is an active canoer navigating their river of life. The guide’s ultimate goal is to help the client develop the skills and confidence to navigate independently. The model distinguishes between moments when the guide should intervene more actively and moments when stepping back allows the client to take control.

Key elements of the River Model translate effectively into rehabilitation contexts:

• Pre-embarkation checklist: Assessing whether both clinician and client are prepared for the journey. This aligns with readiness assessments for partnership in rehabilitation.
• Lifejacket: Establishing safety nets, such as emergency plans or support systems, before granting greater independence.
• The Wedge: Making minimal, precise interventions that preserve the client’s opportunity to lead, a principle consistent with partnership.
• Shovel: Digging deeper into important issues but pacing the depth to avoid overwhelming the client.
• Bombs and Sandbags: Addressing urgent threats to safety or therapeutic progress, which may require a shift toward more directive client-centred care.
• Fog Banks: Recognizing times when it may be beneficial to let the client find their own way, while being ready to offer direction if necessary.
• Islands: Identifying points where therapy may pause or transition, leaving space for the client to return when ready.

By focusing on timing and intervention level, the River Model provides a structured way for clinicians to decide when to maintain a primarily client-centred stance and when to move toward partnership. It supports the thesis that an ongoing assessment of readiness, safety, and therapeutic goals best guides the choice between these approaches.

5.0 Canadian SPOR/CIHR Guidance

The Canadian Institutes of Health Research (CIHR), through its Strategy for Patient-Oriented Research (SPOR), provides a national framework for patient engagement in health research and service development. SPOR defines patient engagement as “meaningful and active collaboration in governance, priority setting, conducting research and knowledge translation” (Canadian Institutes of Health Research, 2019, para. 1). While initially designed for research contexts, these principles are directly applicable to clinical rehabilitation practice.

The four SPOR guiding principles are:

1. Inclusiveness – Recognizing the diversity of patient perspectives and ensuring that different voices are heard.
2. Support – Providing the resources, training, and environment necessary for engagement.
3. Mutual respect – Valuing all contributions and acknowledging the expertise of both clients and clinicians.
4. Co-building – Working together from the beginning to identify problems, develop solutions, and evaluate outcomes.

In a rehabilitation setting, these principles can help clinicians decide when to move from a client-centred approach toward a client-as-partner model. For example, mutual respect and co-building require a degree of equality in the relationship that is only possible when the client is ready and able to engage in shared decision-making. Inclusiveness and support may be addressed in both models, but full partnership requires active participation in all stages of care.

The River Model’s emphasis on readiness and timing aligns well with SPOR’s principle of co-building. A client may begin their rehabilitation journey in a primarily client-centred model that prioritizes support and inclusiveness. As readiness increases, the clinician can shift toward partnership, ensuring that mutual respect and co-building are realized in practical ways.

6.0 Clinical Vignettes

Vignette 1: Passive or Overwhelmed Client

Maria, a 52-year-old recovering from a severe traumatic brain injury, begins outpatient rehabilitation with significant cognitive fatigue and reduced insight into her deficits. Her therapist, recognizing the “Bombs” in the River Model (Aronov & Brodsky, 2009), adopts a client-centred approach. Safety measures are established (Lifejacket), goals are simplified, and the therapist makes precise, directive interventions to prevent overwhelm. Partnership is deferred until Maria demonstrates sustained attention and comprehension during sessions.

Vignette 2: Ready and Engaged Client

Liam, a 34-year-old with an incomplete spinal cord injury, has regained physical stability and is motivated to return to work. The therapist uses the Wedge principle to make minimal, targeted suggestions, allowing Liam to take the lead in problem-solving. Occasional “Fog Banks” arise when planning for accessibility modifications, during which the therapist refrains from immediate direction, allowing Liam to explore options. This reflects a client-as-partner stance grounded in shared decision-making and co-design.

Vignette 3: System-Level Partnership

A provincial rehabilitation network convenes a planning committee to redesign its outpatient programs. Two former clients are included as full members from the outset, consistent with SPOR’s co-building principle. These client partners help shape service priorities, contribute to accessibility planning, and co-author a public-facing progress report. Here, the client-as-partner role is extended beyond individual care into the governance and policy domain.

7.0 Decision Tables

Table 1 – When Each Approach is Needed or Preferred

Clinical Context	Recommended Approach	River Model Element	Ethical Justification
Low capacity or high safety risk	Client-centred	Lifejacket, Bombs	Protects from harm, ensures safety before autonomy
Emerging readiness with moderate support needs	Gradual shift	Wedge, Shovel	Builds self-efficacy while maintaining safety
High readiness, strong engagement	Client-as-partner	Wedge, Fog Banks	Maximizes autonomy and shared responsibility
Service or research co-design	Client-as-partner	Islands (re-entry when needed)	Equity in decision-making aligns with SPOR principles

Table 2 – Mapping SPOR Principles to Clinical Relationship Decisions

SPOR Principle	Client-Centred Application	Client-as-Partner Application
Inclusiveness	The clinician ensures diverse client perspectives are acknowledged in care planning.	Clients proactively represent their perspectives and help shape care and program design.
Support	The clinician provides education, resources, and emotional support to prepare for engagement.	Clinician and client share responsibility for maintaining supports that enable sustained engagement.
Mutual Respect	Clinician values client experiences and preferences in decision-making	Both parties recognize and apply their expertise equally in care planning and execution
Co-building	The clinician incorporates the client’s input when setting goals and making care decisions.	Client and clinician jointly develop, implement, and evaluate plans, extending to service-level initiatives.

 

8.0 Guidelines for Clinicians

Based on the integration of Wade’s theoretical work, SPOR/CIHR guidance, and the River Model, the following guidelines can help rehabilitation clinicians determine when to remain in a client-centred stance and when to move toward full partnership:

1. Assess readiness early and often
   Use structured and informal assessments to determine the client’s cognitive, emotional, and physical capacity for shared decision-making (Levack et al., 2015). Reassess as circumstances change.
2. Match intervention to need, not habit
   Avoid defaulting to either full partnership or full clinician control. Use the River Model’s “Pre-embarkation Checklist” to evaluate fit and readiness before shifting approach (Aronov & Brodsky, 2009).
3. Prioritize safety before autonomy
   In situations with significant safety concerns, adopt a client-centred approach with strong protective measures (Lifejacket, Bombs) before allowing greater independence (Wade, 2020).
4. Use minimal and precise interventions
   Apply the Wedge principle to preserve the client’s opportunity to lead while ensuring therapeutic progress. This is particularly important during transition phases between models.
5. Align with SPOR principles
   Maintain inclusiveness, mutual respect, co-building, and support regardless of stance. Partnership is most effective when these principles are operationalized in everyday clinical decisions (Canadian Institutes of Health Research, 2019).
6. Document the rationale for stance shifts
   Note in the clinical record why the relationship stance was maintained or changed, including readiness indicators, safety concerns, and client preferences.

9.0 Discussion

The findings from integrating these three frameworks, Wade’s rehabilitation philosophy, SPOR/CIHR principles, and the River Model, support a dynamic approach to clinical relationship management. This approach recognizes that client-centred care and client-as-partner are not fixed categories but fluid roles that shift over time in response to the client’s readiness, the clinical context, and broader systemic factors.

Wade’s work emphasizes that effective rehabilitation is both individualized and adaptive, requiring clinicians to tailor interventions to the evolving needs of the client (Wade, 2020). This adaptability mirrors the River Model’s focus on timing and intervention level, offering practical tools for deciding when to act and when to step back (Aronov & Brodsky, 2009). SPOR/CIHR’s principles reinforce that partnership should be meaningful and supported, with co-building as a goal when clients have the capacity and resources to engage (Canadian Institutes of Health Research, 2019).

From an ethical perspective, this continuum-based approach aligns with the principles of beneficence, autonomy, and justice (Beauchamp & Childress, 2019). Beneficence is maintained by providing the appropriate level of guidance to ensure safety and optimize outcomes. Autonomy is promoted by moving toward partnership when clients are ready, and justice is upheld by ensuring equitable opportunities for engagement across diverse client populations.

The River Model’s metaphors are particularly valuable for training and reflective practice. They provide a shared language for supervisors and clinicians to discuss complex decisions about stance, timing, and intensity of intervention. For example, “Bombs” and “Fog Banks” offer an accessible way to conceptualize moments requiring either decisive clinician control or deliberate non-intervention. These metaphors are not merely illustrative; they function as decision-making heuristics that can be embedded into everyday practice.

10.0 Conclusion

Knowing when to be client-centred and when to transition to a client-as-partner model is a critical skill in rehabilitation practice. This decision should be guided by ongoing assessments of readiness, safety, and therapeutic goals, rather than by static allegiance to a single model. The River Model provides a structured, metaphor-driven framework for making these timing decisions. Wade’s work supplies the theoretical foundation for adaptability, and SPOR/CIHR principles offer a system-level vision of meaningful partnership.

By integrating these three perspectives, clinicians can move fluidly along the continuum between client-centred and client-as-partner approaches, ensuring that care is responsive, safe, and empowering. This dynamic approach not only improves clinical outcomes but also aligns with broader movements toward patient engagement and shared decision-making in Canadian health care.

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