For almost 20 years, occupational therapists have advocated client-centered practice. Yet client-centered practice is fraught with tensions that arise outside the practice of individual occupational therapists. This paper is guided by two questions: What produces professional tensions in client-centered practice? and What understanding and change might be generated using institutional ethnography? The sociological theory and method of institutional ethnography are described using data from an ongoing investigation of mental health services as a social institution. Illustrated are the research aim, research questions, and institutional analysis that distinguish institutional ethnography from conventional ethnography. Two professional tensions are associated with attempts to fulfill client-centered practice in mental health. One is that of working at cross-purposes with the prevailing hierarchical structure; the other tension is that of being celebrated yet subordinated in the medical and management hierarchies of health services. Although client-centered practice is difficult to do, the authors recommend institutional ethnography as a research approach to generate understanding and transformation of the context and practice of occupational therapy.