The dangerous shift in mental health: Are we clients or patients?

An excerpt from My Brother’s Keeper: The Untold Stories Behind the Business of Mental Health―and How to Stop the Abandonment of the Mentally Ill.

Throughout history, civilized societies have recognized the vulnerability and suffering of the ill and accordingly granted them special rights and protections, as well as a unique designation: “patient.” This is changing. In the 1990s, when I was involved in negotiating managed care contracts for a community mental health center, I was surprised when insurers insisted that contracts use the term “client;” “patient” would not be allowed. Why were they so insistent? How much does a name matter? As it turns out, a whole lot.

George Lakoff, Professor of Cognitive Science and Linguistics at UC Berkeley, describes how the words we use frame how we think about and act on important matters. As we shall see, referring to someone as a client rather than a patient profoundly shifts how we think about them, the rights and protections we offer them, and how we treat them. To this end, in service of the new economic paradigm, the health care industry sought to reframe patients as clients, and used similar mercantile terms to free themselves from the legal and ethical responsibilities historically associated with the care of patients.

Consistent with this shift, those seeking mental health care and addiction treatment are now most frequently referred to in business terms like client, customer, or consumer. The cynical use of these euphemisms was part of a deliberate effort to change the frame, as I found out in the negotiations for the community mental health center. Client brings to mind someone in need of a haircut, not someone facing illness. Paradoxically, this shift was actually promoted by a well-meaning humanistic movement in psychotherapy. Central to the doctor’s code of ethics is to put a patient’s needs above their own; not so with a businessperson selling their wares or services to a client. For example, it is standard business practice to sell a product to a client, but it is considered unethical for a doctor to do so to a patient. What was conceived as an empowering concept served instead as a linguistic Trojan Horse, bringing business interests into the treatment room, while stripping patients of rights and protections that had been accorded them since the time of Hippocrates.

Clientology

While health care corporations use commercial terms like client almost exclusively, it is only in psychotherapy and addiction treatment that clinicians themselves have embraced this term. I think this reflects the profound stigma with which our society views being a mental health “patient.” The first to popularize it was Carl Rogers, who pioneered “client-centered therapy” in the 1940s and ’50s. He chose this euphemism as an alternative to “patient” in an attempt to alter how those seeking therapy viewed themselves. With it he sought to foster a form of therapy that showed sufferers that they had within themselves the resources to figure out the answers to their troubles. Psychotherapists embraced this change for many reasons. Primarily, it served to distance them and their craft from the unpopular asylums, and from MD’s who treat the severely mentally ill, a way to attract paying “clients” to psychotherapy, avoiding any association to severely mentally ill “patients.” Rogers later recognized his error, admitting “the term client does have certain legal connotations which are unfortunate . . .” and abandoned its use, rebranding his treatment “person-centered therapy.”

Another influence came from social workers, whose core mission is to assist those seeking help from social service agencies, and appropriately refer to those they help in that context as clients. But working for the woefully underfunded CMHCs and other social service agencies was frustrating, and many social workers branched out into the practice of psychotherapy. Still, most continued to use the term they were trained to use, especially for those they helped with both social work and psychotherapy.

The rapidly growing numbers of women psychotherapists saw use of the term “client” as a feminist issue, a way to rectify the imbalance in power between (historically male) psychiatrists and psychologists and their (primarily female) patients. However, there are now roughly equal numbers of women and men practicing psychiatry, and women outnumber men in psychology (59 percent), social work (83 percent) and among MFTs (60 percent).

Some advocated the use of business terminology as a way of opening the practice of therapy to non-MD professionals. However, this idea is based on an erroneous assumption. A patient is one who receives care from any health care practitioner or healer. Midwives have patients, as do nurses, dentists, and oral hygienists. Physiotherapists have patients, why should psychotherapists have “clients”? Veterinarians have both patients and clients, the former being the one they treat, the latter the one who pays the bill.

Patient, client: What’s’ the difference?

The Merriam-Webster dictionary defines “patient” (noun) as “a person who receives medical care or treatment.” It derives from the Latin “pati,” meaning to undergo, bear, or sit with pain. It is related to the adjective “patient,” as in “to endure.” Whether the patient suffers from the pain of a broken bone or depression, the caregiver helps the person withstand, endure, or conquer their suffering. Its dual meaning is referred to in the Bible when Luke, the physician apostle, counsels, “In patience possess ye your souls.” (Luke 21:19. The Bible, King John Version.)

In contrast, “client” is defined as: “1: One that is under the protection of another: Dependent, 2: a: A person who engages the professional advice or services of another -a lawyer’s clients-, b: Customer – hotel client-, c: A person served by or utilizing the services of a social agency -a welfare client-.”

Client comes from the Latin “cliens” (plural “clientes””), meaning follower or retainer, related to “cluere”—to “listen, follow, or obey.” In today’s world, retail or service businesses have clients; the term is used interchangeably with consumer and customer. While there are analogies between clients and patients, notably that money changes hands in both, there are also crucial differences. One fundamental distinction is that a client pays for a product or service to defend them against problems in the external world. Thus, lawyers have clients, banks have clients, and social workers have clients, who help their client manage a specific external problem such as a legal threat, their financial affairs, or a lack of income or housing, respectively. Important tasks, to be sure, but what the term “client” leaves out that the term “patient” includes is the intimate bond dedicated to the avoidance and relief of internal suffering. While a client is passive, and provided with a service or product, a patient is a partner in treatment, which emphasizes and reinforces their strength as a person, rather than their weakness. At its core, “client” signifies the monetization of a relationship, whereas being a patient, at least as the relationship should be, is defined by empathy and collaboration, traits often absent in a financial transaction. For example, businesses themselves are frequently clients of other businesses, but they are never patients.

How did this view come to be in vogue? Its use, I think, sits at the core of therapists’ identity, their immersion in the world of the suffering, and how society marginalizes the notion of mental suffering. Client sanitizes the shame associated with mental suffering, but reinforces the distinction between who is suffering and who is providing the service. And, as we shall see, referring to people as clients only makes this inequality greater by contractually limiting rights and protections.