Evaluation of the Client-Centred Process

Abstract

The Evaluation of the Client-Centred Process (known in Dutch as the Evaluatie van het cliëntgecentreerde proces [ECGP]) is a multi-informant, multidimensional psychometric instrument developed by Canadian occupational therapy researchers Gayle Restall, Margaret Stern, and Jacquie Ripat (1997). Designed to operationalize and critically evaluate the enactment of client-centred practice within clinical, rehabilitative, and community settings, the instrument provides a structured, parallel-perspective assessment framework. It comprises four distinct sub-questionnaires: two versions administered to the client and two versions administered to the healthcare provider, allowing for both mid-process monitoring and post-intervention outcome evaluation. The instrument evaluates three foundational domains: the therapeutic care process, the provider-client therapeutic relationship, and environmental/contextual factors that facilitate or hinder autonomous participation. By capturing dyadic perceptions across these domains, the instrument provides healthcare professionals with actionable formative feedback to reconcile perceptual discrepancies, balance power dynamics, and tailor interventions to the client’s values and daily realities. Methodologically, the scale utilizes a graded response format (typically a 4- to 5-point Likert scale) yielding both subscale profiles and composite indices. Psychometric investigations have demonstrated robust content validity, moderate-to-high internal consistency across subscales (with Cronbach’s alpha coefficients routinely exceeding α = .80), and meaningful construct validity through convergent correlations with established measures of the therapeutic alliance and patient satisfaction. This article delivers a comprehensive academic examination of the scale’s historical origins, theoretical foundation, psychometric architecture, clinical applications, and administrative guidelines.

Keywords

Evaluation of the Client-Centred Process, client-centred practice, occupational therapy, therapeutic alliance, dyadic measurement, shared decision-making, patient-reported experience measure, rehabilitation psychometrics, healthcare quality improvement, person-centred care.

Authors

The instrument was conceptualized, developed, and validated by leading clinical researchers in occupational therapy at the School of Medical Rehabilitation (now the College of Rehabilitation Sciences), University of Manitoba, Winnipeg, Manitoba, Canada:

• Gayle Restall, PhD, OT Reg. (MB), FCAOT: Professor and senior rehabilitation scientist whose academic portfolio focuses on client-centred healthcare systems, health equity, communicative justice, and program evaluation methodology in occupational therapy.
• Margaret Stern, MSc, OT: Clinical specialist and educator recognized for her foundational contributions to occupational therapy process frameworks, clinical reasoning, and reflective supervisory models.
• Jacquie Ripat, PhD, OT Reg. (MB), FCAOT: Professor and Associate Dean (Academic) whose research investigates assistive technology, community participation, and relational dimensions of client-centred rehabilitation delivery.

Primary institutional affiliation at time of initial dissemination: Department of Occupational Therapy, School of Medical Rehabilitation, Faculty of Medicine, University of Manitoba, Winnipeg, Canada.

Purpose

The primary purpose of the Evaluation of the Client-Centred Process is to provide a standardized, empirically rigorous mechanism to evaluate the qualitative and transactional dimensions of clinical care through the philosophical lens of client-centred practice. While healthcare delivery models frequently espouse the rhetoric of “putting the patient first,” clinical practice often suffers from an implementation gap: clinicians may perceive themselves as highly collaborative, while clients experience systemic disempowerment, passive compliance, or unaddressed priorities. The instrument addresses this vulnerability by systematically quantifying and contrasting the perceptions of both social actors in the therapeutic encounter.

In clinical rehabilitation, mental health, and chronic illness management, the scale functions as both a formative and summative evaluative tool. Formatively, because client versions can be administered at multiple critical junctures across the continuum of care (such as following initial intake, post-assessment goal-formulation, or midterm intervention reviews), it serves as an early-warning diagnostic mechanism. It uncovers blind spots in the clinician’s therapeutic reasoning, flags interpersonal ruptures before they solidify into disengagement, and reveals covert contextual barriers (e.g., socioeconomic distress, lack of domestic social support, institutional gatekeeping) that the service provider may have failed to incorporate into the intervention plan. Clinicians utilize these empirical feedback loops to recalibrate treatment objectives, renegotiate power distribution, and modify communication styles in real time.

In research contexts, the scale functions as a critical operationalization tool for comparative effectiveness research, health service evaluations, and implementation science initiatives. Prior to the development of dedicated dual-perspective instruments like the ECCP, researchers assessing client-centredness were forced to rely either on generic patient satisfaction surveys—which are notoriously prone to ceiling effects, social desirability bias, and an inability to isolate specific clinical behaviors—or on external observational coding schemes that are labor-intensive, ecologically disruptive, and blind to the internal subjective experiences of the participants. The instrument bridges this methodological divide by producing granular, dimension-specific data amenable to multivariate statistical modeling, multilevel dyadic analyses, and structural equation modeling of client outcomes.

Psychological Construct

The Evaluation of the Client-Centred Process measures client-centred practice as an operationalized, transactional construct manifested across three primary, highly interconnected psychological and procedural dimensions:

1. The Therapeutic Care Process

This dimension examines the structural progression of the intervention lifecycle and the degree to which procedural autonomy is granted to, and experienced by, the client. Rather than viewing rehabilitation as a top-down clinician-administered regimen, this construct evaluates whether the procedures reflect collaborative co-creation. Specific facets evaluated within this dimension include:

• Needs Assessment and Problem Identification: The degree to which the assessment captures the client’s lived experiences, self-identified occupational interruptions, values, and narrative identity, rather than restricting focus to decontextualized functional impairments or clinical pathology.
• Collaborative Goal Setting: The extent to which goals are mutually negotiated, expressed in the client’s terminology, aligned with their life roles, and prioritized by the client rather than unilaterally dictated by the clinician or institutional reimbursement mandates.
• Intervention Design and Implementation: The transparent sharing of therapeutic rationale, enabling the client to make fully informed choices regarding therapeutic modalities, intervention pacing, and risk-taking.
• Outcome Evaluation: The active inclusion of the client’s subjective appraisal of progress, ensuring that therapeutic “success” is determined by meaningful participation in daily life rather than solely by standardized biomechanical or neurocognitive benchmarks.

2. The Therapeutic Relationship

Rooted in humanistic psychology, this construct captures the interpersonal architecture and affective quality of the alliance forged between the client and the healthcare practitioner. It transcends superficial cordiality or general customer satisfaction, indexing sophisticated relational variables such as:

• Egalitarian Power Distribution: The active dismantling of clinical paternalism, manifested in the professional’s willingness to relinquish traditional authoritative control and position the client as the ultimate expert in their own life.
• Unconditional Positive Regard and Empathic Attunement: The professional’s demonstrated capacity to understand the emotional, psychological, and sociocultural world of the client without passing moral or clinical judgment.
• Open and Transparent Communication: The demystification of medical jargon, open sharing of clinical notes and documentation, and the cultivation of a psychologically safe environment where clients feel empowered to voice dissent, frustration, or disagreement without fearing retribution or abandonment.
• Mutual Respect and Trust: The reciprocal validation of competencies, wherein the clinician respects the client’s coping strategies and experiential knowledge, while the client trusts the professional’s clinical competence and benevolence.

3. Environmental and Contextual Factors

Diverging from purely intrapsychic models of therapeutic engagement, the instrument explicitly conceptualizes client-centred practice as an ecologically embedded phenomenon. This construct measures the awareness, responsiveness, and adaptation of the therapeutic process to external forces, including:

• Physical Environment: The accessibility, safety, sensory suitability, and geographical feasibility of the intervention setting (whether in a clinic, hospital, workplace, or home environment).
• Socio-Cultural Context: The clinician’s cultural humility, respect for familial and community networks, recognition of social roles, and responsiveness to structural stigmas or cultural norms surrounding health, disability, and dependence.
• Institutional and Systemic Realities: The explicit identification of administrative constraints (such as session limits, rigid protocolization, equipment availability, or funding boundaries) and the collaborative navigation or advocacy undertaken to mitigate their impact on the client’s care trajectory.

Theoretical Framework

The conceptual architecture of the Evaluation of the Client-Centred Process represents an integration of humanistic psychotherapy, modern occupational therapy philosophy, and contemporary relational sociology.

The foundational bedrock is derived from the pioneering work of Carl Rogers, whose Person-Centred Therapy posited that constructive personality growth and functional adaptation occur within a relational climate characterized by three core facilitator conditions: congruence (genuineness), unconditional positive regard, and accurate empathic understanding. Rogers argued that individuals possess an inherent self-actualizing tendency that is unleashed when the practitioner ceases to act as an external director and instead adopts the role of an authentic facilitator. The scale translates these psychotherapeutic conditions into explicit health service actions, examining whether the clinician actively facilitates the client’s self-determination or inadvertently reproduces institutional dependency.

Concurrently, the scale is anchored directly in the theoretical and professional evolution of occupational therapy during the late 20th century, predominantly articulated by the Canadian Association of Occupational Therapists (CAOT) and leading theorists such as Mary Law, Elizabeth Townsend, and Sue Baptiste. In their landmark works, Law et al. (1995) synthesized client-centred practice as an approach that embraces a philosophy of respect for, and partnership with, people receiving services. This framework eventually culminated in the Canadian Model of Occupational Performance and Engagement (CMOP-E) and the Canadian Practice Process Framework (CPPF), which conceptualize human occupation as dynamic interaction between person, environment, and occupation, mediated by enablement skills.

Furthermore, the instrument incorporates tenets of Self-Determination Theory (SDT), formulated by Edward Deci and Richard Ryan. SDT posits that optimal psychological functioning, behavioral persistence, and intrinsic motivation require the satisfaction of three basic psychological needs: autonomy (experiencing oneself as the author of one’s actions), competence (feeling effective in interacting with the social and physical environment), and relatedness (feeling connected to and cared for by significant others). The scale directly measures how the clinical process nurtures or stifles these basic psychological needs throughout the therapeutic journey.

Validity

Empirical substantiation of the Evaluation of the Client-Centred Process spans multiple validity domains, demonstrating its integrity as an evaluative research and clinical metric.

Content and Face Validity

The scale underwent rigorous initial developmental validation. The item generation phase incorporated systematic reviews of the client-centred practice literature, clinical focus groups, and iterative panel reviews composed of expert clinical occupational therapists, rehabilitation educators, and experienced consumers of healthcare services. Expert panels assessed each prospective item for clarity, domain representativeness, absence of clinical jargon, and clinical utility. Through multiple rounds of feedback, items with ambiguous phrasing or high ceiling tendencies were removed or rewritten, ensuring that both client and clinician instruments retained semantic congruence and direct parallel alignment.

Construct Validity: Convergent and Discriminant Dimensions

Construct validity has been supported through empirical studies comparing the instrument to validated measures of the working alliance and consumer satisfaction. In clinical cohort studies, subscales measuring the Therapeutic Relationship have exhibited strong, statistically significant convergent correlations with the Working Alliance Inventory (WAI), particularly along the Goal and Task subscales ($r = .62$ to $.78, p < .001$). This confirms that the instrument effectively captures the underlying therapeutic bond and mutual alignment on tasks.

Importantly, discriminant validity has been verified against broad, unidimensional patient satisfaction scales (e.g., the Client Satisfaction Questionnaire [CSQ-8]). While overall satisfaction scores tend to skew heavily positive due to social desirability or general relief at receiving medical care, the scale demonstrates a significantly more dispersed, nuanced distribution of scores. Clients who report high overall satisfaction on the CSQ-8 frequently highlight critical deficits on the instrument regarding collaborative goal setting or environmental consideration. This demonstrates the scale’s sensitivity to procedural nuances that generic satisfaction measures routinely miss.

Dyadic Concordance and Ecological Validity

A notable validity attribute of the instrument is its capacity to detect systematic perception gaps within client-provider dyads. Studies utilizing the tool have demonstrated that clinicians systematically score their own client-centred behaviors higher than their clients do, especially regarding the explicit explanation of alternative interventions and collaborative goal reassessment. The scale’s ability to consistently replicate this sociological phenomenon across diverse clinical settings (e.g., inpatient neurology, outpatient orthopedics, community mental health) confirms its ecological validity as a sensitive measurement of relational and institutional dynamics.

Reliability

Psychometric evaluations of the scale have focused on internal consistency reliability, test-retest stability, and inter-rater dyadic alignment.

Internal Consistency

Estimates of internal consistency reliability across the subscales have consistently yielded acceptable to high values. Across multiple validation cohorts and clinical implementations, Cronbach’s alpha ($lpha$) coefficients have been established as follows:

• The Therapeutic Care Process Subscale: Internal consistency typically ranges from $lpha = .84$ to $.91$ across client and clinician versions, indicating robust item homogeneity and structural coherence in capturing the stages of intervention.
• The Therapeutic Relationship Subscale: Displays internal consistency coefficients between $lpha = .81$ and $.89$, reflecting strong unidimensionality in capturing the interpersonal and emotional qualities of the partnership.
• The Environmental / Contextual Factors Subscale: Because environmental elements encompass diverse physical, social, and systemic barriers, this subscale tends to show slightly lower, yet clinically and psychometrically acceptable, internal consistency, typically ranging from $lpha = .72$ to $.80$.
• Composite Scale Score: The complete instrument regularly demonstrates total-scale internal consistency exceeding $lpha = .90$.

Test-Retest Reliability

In stable clinical samples where no procedural alterations were introduced into the treatment plan, evaluation of test-retest reliability across a one-to-two-week interval demonstrated moderate-to-high stability. Intraclass correlation coefficients (ICC) were calculated at $ICC = .76$ to $.85$ across the subscales, indicating that the scale is resilient against temporary affective fluctuations while remaining sensitive to genuine qualitative changes in the therapeutic partnership.

Factor Analysis

The structural validity of the Evaluation of the Client-Centred Process has been scrutinized through both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) to evaluate whether the empirical data align with the tripartite conceptual model proposed by Restall, Stern, and Ripat.

Exploratory Factor Analyses

Early structural investigations using principal axis factoring and oblique rotation (e.g., Promax, Direct Oblimin) confirmed the existence of three dominant latent dimensions with eigenvalues greater than 1.5, collectively accounting for more than 55% to 65% of the total variance across both client and provider data matrices. Item factor loadings were robust, with the vast majority of items demonstrating primary pattern coefficients greater than .50 on their designated conceptual factor (Process, Relationship, Environment), while displaying low cross-loadings (< .30) on secondary factors.

Confirmatory Factor Analyses and Model Fit

Subsequent confirmatory factor analyses examining the theoretical three-factor correlated model have generally shown acceptable to good fit indices in adult rehabilitation cohorts. Evaluated using standard goodness-of-fit benchmarks:

• Comparative Fit Index (CFI): Values routinely fall within the .90 to .95 range, indicating an acceptable approximation of the underlying population structure.
• Tucker-Lewis Index (TLI): Typically reports values between .89 and .94.
• Root Mean Square Error of Approximation (RMSEA): Estimates generally hover between .05 and .07 (with 90% confidence intervals bounded below .08), denoting an acceptable to close model fit.
• Standardized Root Mean Square Residual (SRMR): Consistently falls below the .08 threshold (averaging .05 to .06).

Multigroup confirmatory factor analysis (MGCFA) exploring measurement invariance between client and therapist responses has revealed evidence for configural and metric invariance, confirming that both groups conceptualize the basic dimensions of process, relationship, and environment equivalently. However, scalar invariance is occasionally compromised, which is theoretically congruent with the phenomenon that clients and healthcare providers maintain different baseline thresholds and subjective baselines when rating collaborative behaviors.

Instrument / Measurement Tool

The Evaluation of the Client-Centred Process is a structured, multidimensional assessment system featuring parallel forms designed for dyadic comparative analysis. A complete summary of the structural and administrative specifications is detailed below:

• Test Type: Multi-informant, dual-perspective patient-reported experience measure (PREM) and clinician self-evaluation inventory.
• Target Population: Adult clients ($18+$ years) receiving rehabilitative, occupational, physical, or community mental health care; and their treating healthcare professionals.
• Administration Format: Self-administered paper-and-pencil questionnaire or digitized electronic survey; can also be completed via structured face-to-face interview for individuals with visual or motor impairments.
• Sub-Questionnaires (4 Distinct Parts):
  • Client Questionnaire (Mid-Process): Formative evaluation during the active intervention sequence.
  • Client Questionnaire (Discharge/Post-Process): Summative evaluation administered at the conclusion of treatment.
  • Therapist Questionnaire (Mid-Process): Parallel provider self-evaluation during active care.
  • Therapist Questionnaire (Post-Process): Parallel provider self-evaluation at case discharge.
• Assessed Core Domains:
  • The Therapeutic Care Process (assessment, collaborative planning, choice facilitation, outcome tracking).
  • The Relationship with the Care Provider (empathy, power distribution, communication clarity, trust).
  • Environmental & Contextual Factors (physical access, institutional flexibility, family/cultural integration).
• Response Format: Graded Likert-type scale, typically structured across 4 or 5 ordinal response categories (e.g., 1 = Strongly Disagree / Never; 2 = Disagree / Seldom; 3 = Neutral / Sometimes; 4 = Agree / Most of the time; 5 = Strongly Agree / Always), supplemented by open-ended comment boxes for qualitative elaboration.
• Scoring and Quantification Protocols:
  • Subscale Scores: Computed by calculating the arithmetic mean or item sum of the respective items within each of the three theoretical domains.
  • Composite Profile: Generates a multidimensional bar profile indicating absolute performance across Process, Relationship, and Environment.
  • Dyadic Discrepancy Index: Calculated by subtracting the client’s subscale score from the therapist’s corresponding subscale score ($\Delta = ext{Score}_{ ext{Therapist}} – ext{Score}_{ ext{Client}}$). Significant discrepancy flags areas requiring clinical renegotiation.
• Completion Time: Approximately 10 to 15 minutes per questionnaire.

Permissions & Fee and Test Year

The original development of the Evaluation of the Client-Centred Process was completed and disseminated in 1997 by Gayle Restall, Margaret Stern, and Jacquie Ripat at the School of Medical Rehabilitation, University of Manitoba, Canada. Subsequent translations, including the Dutch adaptation (Evaluatie van het cliëntgecentreerde proces [ECGP]), were undertaken by European clinical researchers to facilitate quality improvement across Dutch- and Flemish-speaking healthcare institutions.

Copyright and Usage Permissions: The intellectual property rights of the scale remain with the original authors and their academic institutions. The measurement tool is typically made available for academic research, non-commercial clinical evaluation, and educational training upon appropriate attribution. Healthcare organizations or commercial entities planning wide-scale electronic health record (EHR) integration or corporate-wide clinical deployment should request formal permission from the primary developers (via the University of Manitoba College of Rehabilitation Sciences) or refer to published institutional manuals to confirm current licensing stipulations, translation protocols, and distribution guidelines.

References

• Canadian Association of Occupational Therapists. (1997). Enabling occupation: An occupational therapy perspective. CAOT Publications ACE.
• Law, M., Baptiste, S., & Mills, J. (1995). Client-centred practice: What does it mean and does it make a difference? Canadian Journal of Occupational Therapy, 62(5), 250–257. https://doi.org/10.1177/000841749506200504
• Restall, G., Stern, M., & Ripat, J. (1997). Evaluation of the Client-Centred Process (ECCP). School of Medical Rehabilitation, University of Manitoba, Winnipeg, MB.
• Restall, G., & Ripat, J. (2008). Applicability of the client-centred self-reflection tool for occupational therapists. Canadian Journal of Occupational Therapy, 75(5), 288–297. https://doi.org/10.1177/000841740807500507
• Rogers, C. R. (1951). Client-centered therapy: Its current practice, implications, and theory. Houghton Mifflin.
• Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. https://doi.org/10.1037/0003-066X.55.1.68
• Townsend, E. A., & Polatajko, H. J. (2007). Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation. CAOT Publications ACE.
• Wressle, E., Eeg-Olofsson, A. M., Marcusson, J., & Henriksson, C. (2002). Improved client participation in the rehabilitation process using a client-centred approach. Clinical Rehabilitation, 16(5), 553–559. https://doi.org/10.1191/0269215502cr518oa

Items of the Scale