Originally posted on http://sacramentovalleypsychologist.com/
It’s an unspoken rule that we don’t treat patients in psychotherapy; we work with clients. For many, the word patient is old-fashioned – even taboo. There was a time when I felt shocked (shocked!) whenever I heard someone refer to his or her clients as “patients.” “Don’t you know that we don’t call them that anymore?” I’d think to myself.
Although Carl Rogers’ influential book, Client-Centered Therapy, was first published in 1951, the shift away from the word patient really caught steam in latter decades of the 20th Century. For many, the word client has come to represent a more progressive, humanistic, and egalitarian view of the therapeutic relationship (Joseph, 2010). Indeed, many of the changes surrounding the use of this term are positive. However, I have increasingly felt that the term “client” simply doesn’t fit. When I opened my own practice, I decided to buck convention by switching to “patient.” Here’s why:
1. Accuracy: The meaning of the word patient is more in line with what we do as therapists. The Latin root means “one who is suffering.” Unlike client, which more specifically means customer (Hoofnagle, 2008), for centuries the word patient has unambiguously described someone who is the recipient of special care designed to ease suffering and restore wellness. As Jonathan Shedler (2006) notes, it is somewhat ironic that “many people have come to associate the mercantile rather than the medical metaphor with greater compassion and humanity.”
2. Responsibility: Not only does the word patient more accurately describe the purpose of therapy (to ease suffering and restore wellness), but using it has important implications regarding responsibility. To my mind, our level of responsibility is more accurately characterized by the doctor-patient relationship than the professional-client relationship. We do not simply provide a set of professional services. We are responsible for healing those in our care. The people we see need help. In some cases, they literally place their lives in our hands. Moreover, a significant power differential exists within the therapeutic relationship, and that power requires a high level of responsibility. We are responsible for hospitalizing the suicidal person, determining the extent of reality testing in the psychotic person, and responding therapeutically to the provocations of the personality disordered person. Moreover, we are entrusted with the most intimate details of people’s lives. This enhanced power and responsibility is reflected in laws against sexual relationships between therapists and those in their care. You can scour the law books, but won’t find similar statutes against sex between hairdressers, accountants, or fitness trainers and their clients.
3. Intimacy: The level of intimacy in the therapeutic relationship exceeds that conveyed by the word client. We meet with people in their darkest hours, discuss their deepest secrets, and deal directly with aspects of the individual that are most vulnerable to mistreatment. By virtue of this level of interaction, profoundly intimate relationships are routinely established between therapists and those in their care. We become objects of hope and longing – attachment figures of immense importance to those with whom we work. And our patients require much from us in return. The media frequently portrays therapists as remote and stoic, but real therapists agonize over the counter-transference pulls they feel in response to their patients. They toil inside and out of the treatment room to understand how best to help. They remain present and available in the face of tremendous emotional suffering. They reach deeply within themselves, looking directly at their own pain in order to understand the pain of another. This is not something you would ask of your financial advisor.
4. Trust: The term patient is more conducive to establishing trust than the word client. Implicit in this term are important elements without which the therapeutic relationship could not progress. In a paper examining the implications of replacing patient with client, Raphael and Emmerson (1991) emphasize the importance of the patient role. While our ultimate goals may be to promote autonomy, maturity, and self-actualization, many people must first be allowed to regress within the safety of the therapy relationship before they can move forward in a healthy way. The role of “patient” is well-established in the popular mind. It effortlessly promotes a kind of regressed openness to the care and knowledge of the healing figure. It implicitly gives permission to the patient to be, well, a patient.
Despite these points, there is something to be said for the objections of some (Joseph, 2010) that the word patient erroneously conflates clinical psychology with the field of medicine, in which a high degree of objectivity is typically assumed. Some have rightfully pointed out that using medical nomenclature may lead psychological practitioners to assume similar objectivity where none actually exists. We may “diagnose” mental disorders, but most DSM disorders can’t be seen through a microscope. As a psychoanalytic therapist, I don’t believe I have a premium on “the truth.” Meaning is created jointly, and I can imagine few circumstances in which I would claim to know what is right or best for my patient. However, I don’t believe it is my essential function to know these things, nor do I think knowing them is necessary for the ethical and effective treatment of psychological distress. I believe I can use the term patient without assuming objective knowledge about what is best for the people in my care.
I think there is room for us to be doctors to our patients regardless of theoretical orientation, as long as we take seriously the considerable risks and benefits of the therapeutic relationship. Just as we have the ability to heal those in our care, we also have the power to cause further harm. Using the word patient reminds me of this fact – this responsibility – on a daily basis.
Hoofnagle, M. (2008, April 23). Do I have clients or patients? [Web log post]. Retrieved Januar6, 2014, from http://scienceblogs.com/denialism/2008/04/23/do-i-have-clients-or-patients/
Joseph, S. (2013, August 4). Patients or Clients? What word should psychologists use to describe the people they help? [Web log post]. Retrieved January 6, 2014, from http://www.psychologytoday.com/blog/what-doesnt-kill-us
Raphael B, Emmerson B. (1991). Are patients clients or people? Medical Journal of Australia, 154, 183-4.
Rogers, Carl (1951). Client-Centered Therapy. Cambridge Massachusetts: The Riverside Press.
Shedler, J. (2006). That was then, this is now: An introduction to contemporary Psychodynamic Theory [PDF File]. Retrieved January 6, 2014, from http://www.jonathanshedler.com/PDFs/Shedler%20%282006%29%20That%20was%20then,%20this%20is%20now%