The Practice Notebook of a Psychotherapy Trainee: ‘Client’ or ‘Patient’? and Why Does It Matter?

Contributed by Vicky Nguyen on November 2nd, 2015
Content: The Practice of Psychotherapy

Ask Google to search “client vs. patient” and you will get about 22.5 million search results. The top hits are articles, blogs, and discussions by care providers with passionate arguments for either label. Some writers detest the term “patient” citing paternalism, or the power-over dynamics between the “all-knowing doctor” and the “passive patient”. Supporters of the term “client” believe the term empowers the care-recipient, validating their knowledge and choices. Others argue that the use of “client” de-emphasizes the therapeutic alliance between care provider and care recipient, reducing the exchange to a mere business transaction.

Psychologists and psychotherapists tend to be proponents of pro-client arguments. Physicians tend to be proponents of pro-patient arguments with good reason. Dr. Beverley Raphael and Dr. Bryan Emmerson listed in their essay, published in 1991 in the Medical Journal of Australia, their concerns about the implications of using “client” in physician-provided care because the term does not adequately capture:

1. The biological, psychological, and social dimensions of the majority of human diseases (most notably mental illnesses)
2. The presence of illness that may respond to medical treatment
3. The necessity of the sick role in order to ensure that people with illness have access to care
4. The necessity of guarding against violations and dependency that may arise from the doctor-patient relationship (ie. Using the term “client” denies the existence of imbalanced power dynamics that inevitably arise in any care-providing and care-receiving relationship)
5. The importance of the doctor-patient therapeutic alliance
6. The elements of care and compassion implicit in the term “patient” but not necessarily in the term “client”
7. The necessity of assessing the capacity of the “patient” to participate fully in treatment decisions (for example, a person with severe and disabling mental illness may deny existence of illness and refuse treatment that could save his or her life)

According to Dr. Peter Wing, both terms “client” and “patient” have connotations of dependency on another for protection or patronage. The terms differ in that “patient” acknowledges the existence of suffering while “client” acknowledges the exchange of service for remuneration, which is de-emphasized by the term “patient”.

Furthermore, “client” suggests that the care-recipient is a “customer” with preferences, thoughts, feelings, and wishes that need to be satisfied, thereby making the term implicitly empowering.

Those who responded to the 1991 essay by Drs. Raphael and Emmerson suggested a compromise in which care-recipients in acute-care settings be called “patients” and in other settings (ie. in which the sick role is unnecessary or even harmful) the term “client” be used.

Practically, how do care-recipients prefer to be called?

Dr. Wing conducted an informal survey of 101 people who came to his Orthopedics clinic in Vancouver between June and December asking them which term they would prefer. Three quarters (74 people) would prefer “patient.” Nineteen would prefer “client.” The remaining few surveyed had no preference.

Dr. Michael Ramdass conducted a formal survey of 300 people at the General Hospital at Port-of-Spain, Trinidad to ask which term they would prefer. The majority, 80%, prefer to be called “patients”, 7% prefer “clients” and 6% prefer “customer.” Dr. Ramdass hypothesized that most people may prefer to preserve the doctor-patient relationship suggested by the term “patient” and do not consider health care to be a commodity, as suggested by the term “client” or “customer.”

Nowadays, with “patient-centred care” and “client-centred care” movements in full swing, the wishes of the patient and his or her family are generally not discounted in consent to treatment discussions, despite the limited use of “client” by physicians.

As for me, I have resolved to be mindful to ask people receiving my care whether the term “client” or “patient” is preferred. No doubt the answer to why an individual prefers one term over the other would enrich my understanding of the person receiving my care, and therefore strengthen the therapeutic alliance.

References

1. Raphael B, Emmerson B. Are patients clients or people? Med J Aust. 1991 Feb 4;154(3):183-4.

2. Wing PC. Patient of client? If in doubt, ask. CMAJ. 1997 Aug 1;157(3):287-9. (and references therein)

3. Ramdass MJ, Naraynsingh V, Maharaj D, Badloo K, Teelucksingh S, Perry A. Question of ‘patients’ versus ‘clients’. J Qual Clin Pract. 2001 Mar-Jun;21(1-2):14-5

The views expressed in these blogs are the author’s own and not necessarily reflective of those of Psychotherapy Matters.  Copyright © 2015 PsychotherapyMatters.com

Vicky Nguyen

Vicky is a psychiatrist and recent graduate from the Northern Ontario School of Medicine (NOSM). She completed her PhD and MD training at the University of Toronto. Her research interests are directed at promoting innovative practices and policies to address sub-optimal wait times, access, equity, and quality of health care services for disadvantaged populations in Ontario. She is certified to provide IPT and CBT. She is trained to provide other types of therapy including DBT, and Psychodynamic Psychotherapy.

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