How else can we conceive of caring relationships that retain the fullest expression of dignity and partnership for the people involved?
Each of us is here now because in one way or another we share a commitment to language and to the power of language, and to the reclaiming of that language which has been made to work against us. In the transformation of silence into language and action, it is vitally necessary for each one of us to establish or examine her function in that transformation and to recognize her role as vital within that transformation. Audre Lorde, Sister Outsider (1984, p. 43)
The word ‘client’ has always bothered me. It calls up the image of a business transaction. It is not business itself that bothers me but the professionalization of care and the pervasive reduction of human interaction to the roles of consumer and producer. The word ‘client’ smacks of free market capitalism where one’s labor is purchased and exploited for the profit of another often without personal accountability. Of course, this is not the intention in the context of psychotherapy. But this is about the space between intention and impact.
In the context of psychotherapy, the word “client” reflects how we think about the help we offer.
However, as any narrative therapist or drama therapist might argue, the words we use and the stories we tell about ourselves and others reflect and influence how we think. In the context of psychotherapy, the word “client” reflects how we think about the help we offer. As Julie Neuberger remarked in a clinical commentary for the British Medical Journal entitled “Let’s do away with the word ‘patients,’”
The word ‘patient’ conjures up a vision of quiet suffering, of someone lying patiently in a bed waiting for the doctor to come by and give of his or her skill, and of an unequal relationship between the user of healthcare services and the provider. The user is described simply as suffering, while the healthcare professional has a title, be it nurse or doctor, physiotherapist or
phlebotomist. (1999, pg. 1756)
Language changes precisely because language matters. Like any form of cultural expression, language is imbued with the values of the dominant narratives from which it arises. The word “user” is not much better and most would likely think it worse. However, her point remains useful. The word “patient” puts the therapist in the position of the expert and the person they are helping in the position of the damaged recipient (see Foucault, 1964).
There is, of course, a legitimate need that compels one to seek out professional support and there are specific skills that a therapist can offer. In fact, the word ‘client’ was initially introduced to reject an overly medicalized model and replace it with more humanistic language in which the person seeking services consented to treatment and had expertise on what was best for them. From this perspective, “Psychological problems are not illnesses to be cured but states of self and social alienation... therapy is not about curing illness but about helping people to find solutions and new directions in life for themselves” (Joseph,2013, p.1).
However, the word ‘client’ also has a downside in that, here, clients are paying customers for clinicians who provide a service - a service that colleague Christine Mayor described as frequently being “neither determined by the client or clinician, but by insurance companies or for-profit therapy settings” (personal communication, Sept. 28, 2018). This is where it gets troublesome. As Frantz Fanon (1963) argued, the illusion of free choice often masks capitalist motives and actions. Indeed, as Jean-Paul Sartre wrote in the introduction to Fanon’s Wretched of the Earth, a colonial system produces and profits from inequality, slavery and racism. It maintains instability and contributes to the division and competition between social groups. In a market in which care is managed by decentralized and increasingly deregulated insurance companies, we have to remain vigilant of what we may be inadvertently consenting to.
How else can we conceive of caring relationships that retain the fullest expression of dignity and partnership
for the people involved? What is gained in the use of the term ‘client’ and what is lost?
As for myself, I have alternated between the words participant, client, and patient depending on context. I have also found that, in most cases, it is perfectly fine to ask the people you work with about what they prefer. As colleague Britton Williams remarked “this disrupts the notion that the therapist is the "expert" definer of the relationship and makes room for a collaborative defining of roles within the relationship” (personal communication, Sept. 30, 2018). Try asking your colleagues and the people who seek you out for support. Depending on their own life experience, they may have different associations to these words or offer their own preferences. The whole concept of therapy is culturally variable after all (see Jacob, 2013).
Of course, we may come up empty. As colleague Adam Reynolds stated “when conversations happen with clients, I find they feel a bit bereft of ideas or language about what to suggest or say, which I think is directly connected to not seeking support and assistance.” (personal communication, Sept. 30, 2018). The absurdity of feeling an absence of alternatives in an environment that never seems to tire of flaunting individual choice may be the very paradox of capitalism that produces contemporary malaise and maintains social control (see Deleuze & Guattari, 2003).
The point is not to stabilize language which will continue to change but to question what arrangements between us hold the greatest potential for equity, partnership, and dignity. How might our practices allow us to explore this very question?
In closing, this is the 200th anniversary of the birth year of Karl Marx. We have an opportunity to revisit how capitalism and neoliberal ideas influence our everyday interactions and approaches to caring for each other as a society. Is our profession marked by transactions between customers/clients and professionals, users/consumers and providers, or some yet undefined possibility? The point is not to stabilize language which will continue to change but to question what arrangements between us hold the greatest potential for equity, partnership, and dignity. How might our practices allow us to explore this very question?
Dr. Nisha Sajnani , RDT-BCT is the Director of the Drama Therapy Program at NYU Steinhardt and on the faculty of the Rehabilitation Sciences Ph.D. and Educational Theatre Ed.D and Ph.D. program. She is the director of the Theatre & Health Lab where her primary research areas of interest include the health benefits of theatre-making as it relates to social determinants of health, stigma, and social inclusion/exclusion, relational aesthetics in therapeutic theatre, scalable storytelling based interventions in schools, and sustainable mental health care in humanitarian contexts. She has also published in the areas of culturally responsive pedagogy in the arts therapies, embodied and performance research, trauma-informed care, and global mental health. She maintains research partnerships with the Harvard Program in Refugee Trauma, the Foundation for the Arts and Trauma, the Institute for Arts and Health, the Creative Arts Therapies Research Unit (University of Melbourne), and KenVak (European Arts Therapies Research Consortium). Dr. Sajnani is a founding member of the Critical Pedagogy in the Arts Therapies project.
The author would like to thank Christine Mayor, Britton Williams, Adam Reynolds, and Jenni Graham for their inspiration and suggestions.
Deleuze, G., & Guattari, F. (2003). Anti-Oedipus: Capitalism and schizophrenia. London: Continuum.
Fanon, F. (1963). The wretched of the earth. New York: Grove Press.
Foucault, M. (1964). Madness and civilization: A history of insanity in the age of reason. New York: Random House.
Jacob, K.S. (2013). Employing psychotherapy across cultures and contexts. Indian Journal of Psychological Medicine, 35 (4), 323-325.
Joseph, S. (2013). Patients or clients? Psychology Today. Accessed September 28, 2018 from https://www.psychologytoday.com/us/blog/what-doesnt-kill-us/201308/patients-or-clients
Lorde, A. (1984). Sister outsider. Berkeley: Ten Speed Press.
Neuberger, J. (1999). Let’s do away with patients. BMJ, 318 (7200), 1756-1758.