We Treat Patients, Not Clients or Consumers

A recent editorial published in the journal Current Psychiatry by the journal's editor, Henry A. Nasrallah, M.D., contends that the de-medicalization of language used to describe psychiatrists and their patients has harmed both the psychiatric profession and those it treats. The article was published earlier this month and is available online here.

The first half of the piece traces the origin of the term "provider" to three entities: Nazi Germany, U.S. federal statutes, and the insurance industry. As for the former, Nasrallah interestingly notes that the Nazi Third Reich stripped from physicians their medical identity and forcibly relabeled them "behandlers" and "providers" in an attempt to demoralize and control them. The second half of the article laments the proliferation of the term "client" on the basis that psychiatric patients suffer from genuine disease like other medical patients. Nasrallah concludes, "This de-medicalization of psychiatrists and our patients must be corrected and reversed so that the public understands that treating mental illness is not a business transaction between a 'provider' and a 'client.'"

Source: Mark L. Ruffalo, D.Psa., L.C.S.W.

I wish to second Dr. Nasrallah's opinion and extend it beyond psychiatry to the realms of psychotherapy and psychoanalysis, particularly as it applies to the designation of those we treat.

What is implied when those treated in psychotherapy are called "clients" or "consumers" rather than "patients"? The implication is that those in psychotherapy are not really ill and that psychotherapy is not really a form of treatment. In a linguistic sleight-of-hand, proponents of terms like "client" and "consumer" have transmogrified psychotherapy from a specialized form of medical treatment delivered by a trained professional to an unspecified service offered by a mere provider. This, in essence, serves to de-medicalize psychotherapy, as Nasrallah notes when it comes to psychiatry more generally.

Yet, one need only to conduct a quick literature search to find evidence that psychotherapy is, in fact, a treatment for disease and not a service akin to plumbing or accounting. Phrases such as "the psychotherapy of borderline personality disorder" or "the psychotherapy of schizophrenia" demonstrate the medical nature of psychotherapy as a form of treatment. Likewise, phrases such as "the pharmacotherapy of schizophrenia" indicate the medical nature of psychiatric interventions.

This trend towards the de-medicalization of psychotherapy is nothing new. Freud insisted that psychoanalysis is squarely a medical endeavor and form of treatment for psychiatric disease, specifically comparing it to surgical technique; however, since the 1970s, there has been a trend away from this conceptualization within analysis and psychotherapy more broadly. As I have noted elsewhere, this aligns historically with the decline of psychoanalysis within American psychiatry. As psychiatry grew more biological, psychoanalysis and psychotherapy were adopted by nonphysicians and, often, promoted as something other than medical treatment.

But the reality remains. Many of the patients I see in psychotherapy are ill in the literal sense, and psychotherapy is a particular treatment for their mental illness. It is true, of course, that some patients who present for psychotherapy are not ill; however, the same is true in medicine—some patients who visit physicians are not sick. This fact does not mean that psychotherapists do not treat patients any more than it means that doctors do not treat patients.

While it may seem pedantic to challenge the use of conventional terminology, the language we use matters. If mental illness is to be taken seriously as a medical and social problem of the highest magnitude, then we ought to use language that accurately reflects the work we do. Redefining psychotherapy as something other than treatment will only serve to limit access to an intervention shown to be effective for a variety of illnesses, from depression to personality disorder to severe mental disorders like schizophrenia.

As Dr. Nasrallah points out, the public must be informed that those individuals we treat are not contracting for a service but are undergoing treatment for their mental, and thus medical, illness. This is true for psychotherapy, as it is for psychiatry.