A COPE exercise at the Kumudini Hospital in Bangladesh used this approach to help staff appreciate the clients' perspective on services (see Approaches to Quality Improvement for a description of the COPE approach to quality improvement). Hospital staff answered the question: "What would you expect if you or a member of your family came to a family planning clinic for services?" Putting themselves in the clients' position, staff members could define quality concretely as a clean, comfortable, well-equipped facility; flexible scheduling; prompt, effective care with minimal discomfort or pain; a full range of services and choice of methods; clear, concise, accurate information; competent, courteous staff; privacy; and confidentiality (23).

A client orientation is especially crucial to counseling because counseling provides the foundation for informed choice, which is a hallmark of good quality of care in family planning. Many providers think that they know what is best for clients because they have more expertise, more education, or higher social class than the clients. They may doubt clients' ability to make wise choices (318, 337). Therefore, many providers control counseling sessions; they ask all the questions and give directions. They do not encourage clients to participate (1, 190, 310, 332). As a result, providers do not learn enough about clients' situations to advise them well, and clients may not learn enough to make appropriate decisions (189, 257). Some clients may simply agree to whatever the provider suggests.

In contrast, client-centered counseling calls for providers to respect each client's knowledge of her or his own situation and to use their professional expertise to help the client make well-informed decisions. Providers encourage each client to talk about her or his concerns. For example, in the 6-step GATHER approach to family planning counseling, the second step is to ask the client about her or his needs, wishes, and circumstances (303). This information permits providers to recommend practices, behavior, and methods that are safe, appropriate, and feasible for that individual. Providers personalize information and instructions so clients can relate them to their own lives (190, 303, 310).

Client-centered counseling has proved more satisfying for both clients and providers in family planning and other health settings (31, 304). It also has improved compliance and continuation rates (1, 86, 342, 401). Client-centered counseling has improved outcomes among patients with chronic health conditions, both by objective measures such as blood pressure, blood sugar, and relief of symptoms and by subjective measures such as patients' evaluations of their own health (140, 182).