What are you? (Therapy patient? Client?)

If you're like most people I talk to about this topic, you couldn't care less about how we refer to the folks we work with in our NYC therapy office. In fact, the odds are slim that you'd ever be referred to by anything but your first name by your therapist. And so it may surprise you that this is a matter of great controversy and that it is one of great significance to anyone who engages in therapy.

At Tribeca Therapy, we say "therapy patient"

And it's a very intentional choice on our part. Many patients (see, I just did it there) and especially therapists we encounter are surprised. They recognize our therapeutic progressivism, our concern with therapy patients (again!) being an active part of shaping their therapy as co-collaborators (rather than as recipients of the "wisdom" of the therapists) and our concern with the prevalence of diagnosis in therapy. This seems contradictory to the use of the term therapy patient, which can appear reactionary or reductionist.

Patient, in its use in psychotherapy, emerged from the lexicon of medicine (as did the term "therapy," which I hate, but use) and it is the so-called "medical model" in therapy that we fundamentally challenge with our approach. We don't believe that those we work with are sick. We don't believe that we, as therapists, are charged with diagnosing a condition and then, providing treatment (in the tradition of a physician).

So why "patient"?

There are a few answers. First, I deplore the word client in the context of therapy. (And I confess, in moments of excessive self-consciousness in just the right company like a particularly judgmental-seeming NYC therapist, perhaps, I've been known to use it). Client drops the significance of the financial relationship front and center, and genericizes (so to speak) the particulars of the relationship we have here in our therapy office. It's not so much that it's untrue–as therapists, we are contracted to provide a particular set of services to those we work with in therapy. But it seems, by design, to ignore or even, cover up an issue of power.

Clients are customers of a sort who are "served" and have a good deal of power in the relationship (to fire, to make demands, etc.). To be clear, I don't mean to assert that this is untrue in the therapy room. However, the use of the word client seems to ignore that the power dynamic between a therapist and a (err...) client is more complicated. Yes, the... patients/ client/ person engaging in therapy has the power to fire the therapist (and sometimes should!), but the nature of the work is otherwise just not the same. My (stubborn, I know) position on this? We must be honest about it.

Therapists have a lot of power, whether they choose to admit it or not

As therapists, we have power that most contractors (the counterpart to client) don't. We are a certain sort of expert and are considered to have a good deal of privileged insight into the workings of human experience, which casts itself as something of a different sort altogether from the myriad of other sorts of expertise that are engaged in a contractor/ client relationship. We go to special therapy schools and have a special therapy license, and all of that makes us, well, special. I may not like that specialness or may seek to shrug it off in some way. But, independent of my efforts, my status as a therapist is accompanied by a certain undeniable mystique. Before any given therapist ever settles into his or her therapy chair, that mystique is already there and it can't be taken away.

Honesty, first and foremost

The 1970s were a decade when many of the traditional notions of therapy were challenged and the emergence of client as a replacement for patient has its origins there. Psychiatric hospitals ended the practice of long-term in-patient care for most so-called chronically mentally ill patients. Psychotherapy in New York was largely unregulated at the time (so more or less anyone could hang out a shingle and call him/herself a "therapist), and all sorts of folks tried their hand at creating a new sort of therapy. Additionally, social workers, who had traditionally been relegated as clinicians to case management and treatment center therapy, fled managed care and emerged in private practice, bringing a different ethos to the practice of therapy than the psychiatrists and psychologists who had previously dominated the conversation.

Particularly in places like San Francisco and New York, where there was a sizable counterculture, group therapy, especially, overlapped with consciousness-raising, self-reflexive groups of all types. It was a period of time when traditional institutions of all sorts were being challenged and therapy was not immune.

In the aggregate, those changes were good. I'm sure that much of the therapy and pseudo-therapy that was being "practiced" at the time was of poor quality (much of it benignly so, I'd guess, though surely some of it harmful). But let us not forget that much of the therapy practiced before then (and sadly, since) in more traditional contexts was of poor quality and often harmful as well. Whatever the means, the ends were a greater awareness of the coerciveness of traditional mental health treatment through the previously unchecked exercise of power. Therapy needed its hair messed up and the 1970s were nothing if not a decade willing to meet this need. As was the case on college campuses and welfare offices, it was the construction of power that was particularly challenged. Labels more broadly (man, woman; black, white) were up for examination and so were labels most directly related to the therapeutic encounter (sick, well; therapist, patient; depressed; psychotic).

The work isn't done

The 1970s were a step forward and yet, the problematic traditions that preceded that decade continue to express themselves. Psychiatrists (many, not all) still cast spells with prescription pads. Diagnosis, while more frequently derided a cocktail parties, still dominates the course of most therapy from the earliest encounter. Does referring to those I work with as clients, instead of patients, change that fact, or is it my struggle to engage them from the start as active participants in our work, as power creators, that does? Even with those efforts–the transparency and ongoing invitation to see the work differently, we would be arrogant to think that we've changed the imbalance of power. And so we say patient because it serves as an honest reminder that as paradigm-challenging as our work may be, we are still functioning within a very troubled paradigm.

Yeah, you really do need a term

I hate all of the options, therapy patient included, but it turns out there really isn't a way around the need to refer to the body of people with whom one works in some concise way. I like to write about how I see that work, for one, and people I work with in my therapy practice gets a bit cumbersome to write. I also like the fact, though, that every time I write the word patient, I am reminded of the long and complicated history of that word, and of the history of problematic power in my profession. It reminds me: for all the times I may say, with great depth of sincerity, that I am seeking to locate myself outside of this power dynamic, that effort, as meaningful as it is, will always fall short. I don't have the option of simply declaring the history of power abuse in psychotherapy to be dead by virtue of my wish to step outside of it. It doesn't matter what chairs we sit in. If we want to change the nature of power, we have to overthrow the institution that governs it.