We Believe How We Refer To Those Who Seek Therapy Matters
At Tribeca Therapy, we believe that words matter and that the most foundational words matter the most. Nowhere is there more variation (and disagreement) about nomenclature than in how to refer to someone who seeks psychotherapy services.
The term patient is historically standard. Borrowing from medicine, as many of the first psychotherapists were trained as physicians, patient was initially uncontroversial and reflected the station of early psychiatry as a subset of medicine equivalent in form (if not in stature) to cardiology or surgery. Patient carries with it many of these medical associations–the patient as sick, the doctor as expert, and the model of treatment as medical (i.e. following the methodology of medicine, starting with assessment, followed by a diagnosis, and then delivering empirically-based treatment).
In consideration of the many problems of that medical framework, the term client became increasingly prominent beginning in the 1970s, particularly by social workers who were representing a larger and larger portion of private-practice therapists, as well as psychologists who were interested in casting themselves as more progressive and less authoritarian than their forebears.
Since then, client has moved into prominence and become the standard, especially among these groupings. In some settings, particularly social services settings, those that provide a mental health component adjacent to other services like housing, and programs that serve those with so-called “chronic mental illness” such as day-treatment programs, the word consumer has emerged as an alternative to client.
The Terms Client and Consumer Aim To Relocate Power Without Actually Disrupting the Power Structures That Underlie Them
Both client and consumer are a clear attempt at relocating power, namely away from the “doctor” (therapist, social worker) by emphasizing a therapy-seeker’s status as a customer. Whereas patient is cast as subservient to an “expert’s” knowledge and skill, customers, like clients and consumers, are seen as having authority based on their purchasing power and their discretion in choosing to use it elsewhere. One is reminded of an unhappy customer proclaiming in that very American of ways, “You have LOST my business!”
It is important to not understate the profound importance of the question of consumer choice in selecting a psychotherapy provider. It’s also equally important to point out the irony that the word client (and even more often, consumer) is used most frequently in settings where there is the least choice by virtue of a program or service being the only one available, being tied to a service like housing or social security benefits, or simply by virtue of poor quality and diversity of offerings based on a therapy-seeker’s financial constraints or the preferences of their insurance company. These are also the therapy-seekers most likely to be offered off-the-shelf, “short-term,” structured interventions such as Cognitive Behavioral Therapy as opposed to more rigorous, relational, and creative (and expensive and difficult to master) offerings.
This irony betrays the insincerity behind the use of the word client (and similar shifts in nomenclature), revealing a sort of Orwellian double-speak: an attempt at changing words without actually touching the authoritarian power structures that underlie them. It is not a change in language that disrupts problematic power structures, but access to a just healthcare system, high-quality training of providers, and humanistic settings where therapy-seekers are truly given input into their treatment.
Our greatest objection to the word client is simply that it is dishonest. Power imbalances cannot be willed away through rhetorical maneuvering. Therapy-seekers need real power–not simply new terms. Until healthcare is seen as a right in this country, as it is in other wealthy countries, the true power in its delivery will be with the insurance companies. For those who cannot afford out-of-network treatment, the true client will always be these corporations.
We Use Patient To Be Honest About The Realities of Both Suffering And Power
And so we use the word patient, not without reluctance, because we find it to be the most honest term for a few reasons. First, the etymology of patient is often misrepresented as “one who is sick.” But, in fact, the Latin origin is more accurately translated as “one who suffers.” While understanding someone in psychotherapy as sick is worth examining (and is understandably off-putting to many), their status as sufferers cannot be in doubt. Those who seek therapy are suffering.
To be clear, that suffering may not be psychically pathological. Grief, for example, is not pathological but can cause great suffering and lead one to benefit from good therapy. Economic inequality, racism, and injustice are further examples, alongside historical trauma or disorders of mental health that have a component of biology in their origin. What unifies these experiences is that they may cause suffering of the sort that might compel the sufferer to seek psychotherapy. We wish to be honest about that suffering.
The second reason we find patient to be the most honest is related to power. We concede (and are concerned) that “doctors,” whether physicians, therapists, or other health professionals, are given too much power. The determinations they make, including the diagnoses they apply, can be hugely determinant for those who seek their help. Their opinions about treatment are often above reproach even when clearly creating harm.
With this awareness, we seek to orient our practice, both in its clinical and structural organization, to disrupt that power, finding ways of giving therapy-seekers power through choice. We encourage therapy-seekers’ choice in whether to receive therapy with us or elsewhere, in which provider they work with, in how the therapy is structured, in the methodological organization of their treatment, and in participation. Our model of non-diagnostic, collaborative therapy is designed to actively engage therapy-seekers in the work of the therapy.
But we also recognize that the power given to doctors and therapists cannot merely be foregone through a change in language or a profound shift in methodology. Even with our efforts to engage in new, collaborative approaches with those who seek therapy from us, millennia of history and an entire industry of healthcare cannot be cast aside merely by our desire to do so, just as a white person, however well-intentioned, cannot forgo the privilege endowed by white skin and white identity by declaring they’re not white or by working to adapt the ways they express the privilege therein. To do so would be an ill-conceived attempt at hiding power, not a reorganization of power at all.
We understand these forces are much larger than us. What we can do is continually seek to develop new ways of collaborating, but we must first and always acknowledge the presence of those dynamics of power.